EFFECT OF AN EXOCRINE PANCREATIC INSUFFICIENCY ORDERSET AND BEST PRACTICE ALERT ON MANAGEMENT OF PANCREATIC DISORDERS.

BACKGROUND: Exocrine pancreatic insufficiency (EPI) is common in chronic pancreatitis (CP), pancreatic cancer (PDAC), and post pancreatic resection. Only about 1/3 of these patients are prescribed pancreatic enzyme replacement therapy (PERT), often at an inadequate dose. There is increasing evidence that this leads to increased morbidity and mortality. The aim of this study was to identify practice patterns of EPI treatment , develop and implement an EPIC-based best practice alert (BPA) and smart order set with goal of improving management of EPI.

METHODS: All patients with ICD-10 codes of EPI, CP, and PDAC or CPT code for pancreatic resection, who were seen in either an outpatient or inpatient setting at a tertiary care center from Feb-2018 to June-2022 were included. Appropriate use of PERT was defined as > 40,000 USP units of lipase with each meal. The initial retrospective analysis was conducted prior to implementation of the BPA and smart set from feb-2018 to feb-2020. The BPA and smart set were implemented on Feb-2020 and another analysis was done on patients from feb-2020 to June 2022.

RESULTS: The baseline analysis identified 1,464 patients carrying an ICD-10 code for CP, EPI, PDAC or a CPT code for pancreatic resection whose diagnosis was confirmed by manual chart review . Overall, 837 (57.2%) patients were prescribed PERT. Of those prescribed enzymes, 518 (61.9%) were on a less than minimum therapeutic dose. Overall, 299 (20.4%) patients had a pancreatic elastase checked, 453 (30.9%) had a vitamin D level measured, 156 (10%) had a DEXA ordered, and 801 (54.7%) had a hemoglobin A1c level checked. An order set was designed, with an associated BPA tied to any of these diagnoses or to any order for PERT (Figure 1).The BPA and order set were incorporated into our EPIC system and are now in active use.

A statistically significant increase in the proportion of patients on minimum therapeutic dose of PERT from 61.9 to 72.9% (P=<0.001) was observed. Ordering of pancreatic elastase, A1c, vitamin D, and DEXA increased from 20.4 to 29.9% (P<0.001), 54.7 to 62.1% (P=0.001), 30.9 to 48.1% (P<0.001) and 10 to 18% (P<0.001), respectively after initiation of BPA and smart set. An increase in vitamin D supplementation from 25.5 to 33.4% (P<0.001) and a decrease in the proportion of patients with unknown metabolic bone disease status from 86.8 to 76.8% (P<0.001) was observed.

CONCLUSIONS: The implementation of a BPA and smart set for the management of exocrine pancreatic insufficiency was associated with an improvement in management and monitoring noted by an increase in proportion of patients on minimum therapeutic dose of enzyme as well as by an increase in ordering of pancreatic elastase, A1c, vit D, DEXA scan to monitor disease related complicatons