Efficacy of a clinical decision support tool to promote guideline concordant evaluations in patients with high-risk microscopic hematuria: a cluster randomized quality improvement project.

Purpose: We aimed to determine whether implementation of clinical decision support (CDS) tool integrated into the electronic health record (EHR) of a multi-site academic medical center increased the proportion of patients with American Urological Association (AUA) "high risk" microscopic hematuria (MH) who receive guideline concordant evaluations.

Materials And Methods: We conducted a two-arm cluster randomized quality improvement project in which 202 ambulatory sites from a large health system were randomized to either have their physicians receive at time of test results an automated CDS alert for patients with 'high-risk' MH with associated recommendations for imaging and cystoscopy (intervention) or usual care (control). Primary outcome was met if a patient underwent both imaging and cystoscopy within 180 days from MH result. Secondary outcomes assessed individual completion of imaging, cystoscopy or placement of imaging orders.

Results: There were 917 patients randomized to intervention (n=476) or control (n=441) arms between October-December 2021. The percentage of eligible patients for whom the alert correctly triggered in the intervention arm was 83%. Primary outcome was achieved in 0.6% vs. 0.9% (RR: 0.69; 95% CI 0.15, 3.10) of patients in the intervention and control arms, respectively. Patients in the intervention and control groups had similar rates of completed imaging (17.7% vs. 14.7%) and cystoscopy (1.5% vs. 0.9%). Those in the intervention arm had a higher likelihood of CT urogram order (5.5% vs. 1.1%, p=0.003) and a non-significant increase in urology evaluation (11.1% vs. 7.5%, p=0.09).

Conclusion: Implementing an EHR-integrated CDS tool to promote evaluation of patients with high-risk MH did not lead to improvements in patient completion of a full guideline-concordant evaluation. The development of an algorithm to trigger a CDS alert was demonstrated to be feasible and effective. Further multi-level assessment of barriers to evaluation are necessary to continue to improve the approach to evaluating high risk patients with MH.