Clinical Decision Support Systems Could Improve Low Vision Care Utilization


Data indicate 2 out of 5 patients utilized LVR services among those who received a referral recommendation during the CDSS active phase, while onsite LVR service provision increased utilization rates.

Judith Goldstein, OD

Judith Goldstein, OD

An analysis of a quality improvement study investigating a clinical decision support system (CDSS) found patients were more inclined to utilize low vision referral (LVR) services following a referral recommendation by an ophthalmologist.1

Service utilization occurred in approximately 43% of patients who received a referral recommendation during the study’s electronic health record (EHR)-related CDSS active phase. Investigators from the Wilmer Eye Institute at Johns Hopkins noted clinic locations with onsite LVR services increased these rates.

“Patients who may benefit from LVR are largely unaware or may hold misconceptions of the service until their ophthalmologist, optometrist, neurologist, or other clinicians introduces the idea and recommends a referral,” investigators wrote. “Thus, clinician endorsement and advocacy play an essential role in LVR service delivery.”1

Reports indicate that fewer than 10% of individuals in need of LVR care utilize the service, as leading ophthalmology and optometry associations aim to improve the delivery of these services. A team led by Judith E. Goldstein, OD, developed and tested an EHR-based ophthalmology CDSS following a care pipeline by identifying patients who may benefit from these services. When patients met referral criteria in the original quality improvement study, clinicians received an EHR-generated alert and documented their response to the LVR referral recommendations.

For the primary analysis of the current study, investigators characterized patients who utilized LVR services after receiving a referral recommendation from their ophthalmologist according to the CDSS alert between November 2017 and October 2019. In a secondary analysis, they assessed the LVR service utilization rate from September 2016 to April 2021 based on CDSS implementation.

The study included a convenience sample of 15 ophthalmologists from 8 ophthalmology subspecialties and 6 referral locations. To compare the service utilization rate among patients who would have met CDSS criteria between active and inactive alert periods, investigators classified patients as having utilized LVR services when best-documented visual acuity (BDVA) was worse than 20/40. Investigators extracted data from the EHR on patient demographics and encounter characteristics.

Overall, the study indicated 429 patients (median age, 71 years; 233 female [54%]) received at least 1 LVR referral recommendation from the 15 participating ophthalmologists when they had BDVA worse than 20/40. Of this population, 184 (42.9%) utilized LVR service, with a median time after referral recommendation of 73 days.

Compared with patients who did not utilize LVR, those who utilized LVR were more likely to have received at least 2 referral recommendations (12.5% vs. 6.1%; P = .02) and were more likely to have received referral recommendations from a location with onsite service (87.5% vs. 78.0%; P = .01), according to the results.

After multivariable regression, the data show clinic locations with onsite LVR services remained the only statistically significant factor associated with service utilization (odds ratio [OR], 2.06; 95% CI, 1.18 to 3.61; P = .01) after adjusting for patient demographics and other referral characteristics. Upon further analysis, among patients with BDVA worse than 20/40, the LVR service utilization rate was 6.1% before, 13.8% during, and 7.5% after the CDSS active alert regardless of referral status.

Moreover, of the 2227 patients who had BDVA worse than 20/40 during the active alert, the LVR service utilization rate was significantly higher among the 387 patients who received a referral recommendation than the 1840 patients who did not (41.6% vs. 8.0%).

Investigators note how these findings highlight the vital role of ophthalmologists in driving LVR utilizations.

“As 85% of the participating ophthalmologist users found the alert to be useful in identifying candidates for referral, and given that utilization of LVR was significantly less when the alert was inactive, implementing CDSS in ophthalmology may offer a new and sustainable approach to meeting clinical guidelines and standardizing LVR delivery practices,” they wrote.1


1. Guo X, Boland MV, Swenor BK, Goldstein JE. Low Vision Rehabilitation Service Utilization Before and After Implementation of a Clinical Decision Support System in Ophthalmology. JAMA Netw Open. 2023;6(2):e2254006. doi:10.1001/jamanetworkopen.2022.54006

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