Impact of an electronic best practice advisory on fertility preservation referral and consultation rates in pediatric oncology: A pre–post implementation study.

Abstract

e13529 Background: Fertility preservation (FP) counseling is recommended as standard of care for pediatric oncology patients receiving gonadotoxic therapy, yet adherence to guidelines remains suboptimal. At our institution, historical data demonstrated low rates of pre-treatment FP counseling and referral. To improve access to FP services, an electronic medical record (Epic) Best Practice Advisory (BPA) was implemented to prompt FP referral at the time of new cancer diagnosis. Methods: A BPA identifying patients assigned female at birth with a new cancer diagnosis and planned gonadotoxic therapy was implemented on January 25, 2023. We conducted a retrospective chart review of all eligible patients for whom a BPA was triggered between January 25, 2023 and December 31, 2025. Outcomes included FP referral rates, FP/gynecology consultation rates, and time to referral and consultation. These outcomes were compared to a historical pre-BPA group (January 2018–January 2021) previously evaluated at our institution. Research ethics approval was obtained. Results: Eighty-seven patients met inclusion criteria in the post-BPA cohort (mean age 7.6±5.5 years; 59.3% prepubertal). The number of pre-treatment FP/gynecology consultations were 32.6% (29/89) and 32.2% (28/87) with the number of referrals to fertility specialists being 13% (12/29) and 10.7% (3/28) and the uptake of FP procedure was 3.4% (1/29) and 3.6% (1/28), in the pre- versus post- BPA groups, respectively. Following BPA implementation, the consultations occurred a median of 5 days after diagnosis and 1 day after referral. Only 42.9% of the FP/gynecology referrals (12/28) were initiated through the BPA, indicating partial uptake of the tool. Conclusions: Despite implementation of an electronic BPA, overall consultation rates, speciality referral, and FP treatment, remained the same. These findings suggest that passive electronic prompts alone are insufficient to achieve guideline-level FP integration which is also reflected in the fact that half of the referrals occurred through other pathways than the BPA. Future work will focus on embedding FP referral into standardized oncology order sets, using a default referral strategy and testing a workflow-anchored hard stop to improve referral reliability while minimizing workflow burden.