Tyler Gallo

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Scholarly Contributions

Chapters

• Gallo, T. (2024). A computerized scoring system to improve assessment of heparin-induced thrombocytopenia risk. In Comprehensive Precision Medicine(pp 443-457). Elsevier. doi:10.1016/b978-0-12-824010-6.00002-2

Journals/Publications

• Gallo, T., Curry, S. C., Heise, C. W., Antonescu, C. C., & Raschke, R. A. (2023). Clinical decision support to reduce unnecessary diagnostic testing for heparin-induced thrombocytopenia. British journal of haematology, 202(5), 1011-1017.
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  Appropriate evaluation of heparin-induced thrombocytopenia (HIT) is imperative because of the potentially life-threatening complications. However, overtesting and overdiagnosis of HIT are common. Our goal was to evaluate the impact of clinical decision support (CDS) based on the HIT computerized-risk (HIT-CR) score, designed to reduce unnecessary diagnostic testing. This retrospective observational study evaluated CDS that presented a platelet count versus time graph and 4Ts score calculator to clinicians who initiated a HIT immunoassay order in patients with predicted low risk (HIT-CR score 0-2). The primary outcome was the proportion of immunoassay orders initiated but cancelled after firing of the CDS advisory. Chart reviews were conducted to assess anticoagulation usage, 4Ts scores and the proportion of patients who had HIT. In a 20-week period, 319 CDS advisories were presented to users who initiated potentially unnecessary HIT diagnostic testing. The diagnostic test order was discontinued in 80 (25%) patients. Heparin products were continued in 139 (44%) patients, and alternative anticoagulation was not given to 264 (83%). The negative predictive value of the advisory was 98.8% (95% CI: 97.2-99.5). HIT-CR score-based CDS can reduce unnecessary diagnostic testing for HIT in patients with a low pretest probability of HIT.
• Maghari, S., Gallo, T., Rivas, S., German, A., Nguyen Le, M. Q., Abbaszadegan, H., Zubriski, M. A., Heise, C. W., & Landas, N. D. (2023). Prescription medications with actionable pharmacogenomic recommendations in Veterans Health Administration patients. Pharmacogenomics, 24(9), 501-508.
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  To evaluate the prevalence of medications with actionable pharmacogenomic (PGx) safety and efficacy recommendations in patients receiving care from the Veterans Health Administration. Outpatient prescription data from 2011 to 2021 and any documented adverse drug reactions (ADRs) were reviewed for those who received PGx testing at one Veterans Administration location between November 2019 and October 2021. Among the reviewed prescriptions, 381 (32.8%) were associated with an actionable recommendation based on the Clinical Pharmacogenetics Implementation Consortium (CPIC) prescribing guidelines, with 205 (17.7%) for efficacy concerns and 176 (15.2%) for safety concerns. Among those with a documented ADR for a PGx-impacted medication, 39.1% had PGx results that aligned with CPIC recommendations. Medications with actionable PGx recommendations for safety and efficacy concerns are received with similar frequency, and most patients who have undergone PGx testing at the Phoenix Veterans Administration have received medications that may be impacted by PGx testing.
• Gallo, T., Gallo, T., Heise, C. W., Heise, C. W., Woosley, R. L., Woosley, R. L., Tisdale, J. E., Tisdale, J. E., Antonescu, C. C., Antonescu, C. C., Gephart, S. M., Gephart, S. M., Malone, D. C., & Malone, D. C. (2022). Clinician Satisfaction With Advanced Clinical Decision Support to Reduce the Risk of Torsades de Pointes.. Journal of patient safety, 18(6), e1010-e1013. doi:10.1097/pts.0000000000000996
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  Clinical decision support (CDS) can potentially help clinicians identify and manage patients who are at risk for torsades de pointes (TdP). However, computer alerts are often ignored and might contribute to alert fatigue. The goals of this project were to create an advanced TdP CDS advisory that presents patient-specific, relevant information, including 1-click management options, and to determine clinician satisfaction with the CDS..The advanced TdP CDS was developed and implemented across a health system comprising 29 hospitals. The advisory presents patient-specific information including relevant risk factors, laboratory values, and 1-click options to help manage the condition in high-risk patients. A short electronic survey was created to gather clinician feedback on the advisory..After implementation, an email invitation to complete the anonymous advisory-related survey was sent to 442 clinicians who received the advisory. Among the 38 respondents, feedback was generally positive, with 79% of respondents reporting that the advisory helps them care for their patients and 87% responding that alternative actions for them to consider were clearly specified. However, 46% of respondents indicated the alert appeared too frequently..Advanced TdP risk CDS that provides relevant, patient-specific information and 1-click management options can be generally viewed favorably by clinicians who receive the advisory.
• Gallo, T., Heise, C. W., Woosley, R. L., Tisdale, J. E., Tan, M. S., Antonescu, C. C., Gephart, S. M., & Malone, D. C. (2022). Clinician Responses to a Clinical Decision Support Advisory for High Risk of Torsades de Pointes. Journal of the American Heart Association, 11(11). doi:10.1161/jaha.122.024338
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  Background Torsade de pointes (TdP) is a potentially fatal cardiac arrhythmia that is often drug induced. Clinical decision support (CDS) may help minimize TdP risk by guiding decision making in patients at risk. CDS has been shown to decrease prescribing of high‐risk medications in patients at risk of TdP, but alerts are often ignored. Other risk‐management options can potentially be incorporated in TdP risk CDS. Our goal was to evaluate actions clinicians take in response to a CDS advisory that uses a modified Tisdale QT risk score and presents management options that are easily selected (eg, single click). Methods and Results We implemented an inpatient TdP risk advisory systemwide across a large health care system comprising 30 hospitals. This CDS was programmed to appear when prescribers attempted ordering medications with a known risk of TdP in a patient with a QT risk score ≥12. The CDS displayed patient‐specific information and offered relevant management options including canceling offending medications and ordering electrolyte replacement protocols or ECGs. We retrospectively studied the actions clinicians took within the advisory and separated by drug class. During an 8‐month period, 7794 TdP risk advisories were issued. Antibiotics were the most frequent trigger of the advisory (n=2578, 33.1%). At least 1 action was taken within the advisory window for 2700 (34.6%) of the advisories. The most frequent action taken was ordering an ECG (n=1584, 20.3%). Incoming medication orders were canceled in 793 (10.2%) of the advisories. The frequency of each action taken varied by drug class ( P
• Salgado, T. M., Ngo, P. Q., Holdford, D. A., Hincapie, A. L., Gallo, T., Clauson, K. A., & Bajaj, S. K. (2022). Characterization of doctor of pharmacy/health informatics dual degrees in the United States. Currents in Pharmacy Teaching and Learning. doi:10.1016/j.cptl.2022.02.001
• Tan, M. S., Heise, C. W., Gallo, T., Tisdale, J. E., Woosley, R. L., Antonescu, C. C., Gephart, S. M., & Malone, D. C. (2022). Relationship between a risk score for QT interval prolongation and mortality across rural and urban inpatient facilities. Journal of electrocardiology, 77, 4-9.
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  To evaluate the relationship between a modified Tisdale QTc-risk score (QTc-RS) and inpatient mortality and length of stay in a broad inpatient population with an order for a medication with a known risk of torsades de pointes (TdP).
• Gallo, T., Curry, S. C., & Raschke, R. A. (2021). Computerised risk scores to guide recognition and diagnosis in patients with possible heparin-induced thrombocytopenia. British journal of haematology, 192(1), 146-150.
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  The heparin-induced thrombocytopenia computerised risk (HIT-CR) score is designed to aid in the diagnosis of HIT. We sought to evaluate its potential clinical utility. In this retrospective cohort study, we collected HIT-CR scores on all inpatients receiving heparin over a 4-month period and performed chart reviews on the subset who independently underwent clinical diagnostic testing for HIT to identify patients with HIT. In all, 34 342 patients received heparin, 1744 had high-risk HIT-CR scores of ≥3 and 220 had the maximal risk score of 4. Only 6% of high-risk and 10% of maximal-risk patients underwent testing for HIT. Conversely, among all 317 patients who underwent independent testing for HIT, 67% had low-risk HIT-CR scores (
• Gephart, S., Woosley, R. L., Gallo, T., Heise, C. W., Tisdale, J. E., Tan, M., Antonescu, C., & Malone, D. (2021). Abstract 12172: Relationship Between Increased QTc Risk Score and In-Hospital Mortality. Circulation, 144(Suppl_1). doi:10.1161/circ.144.suppl_1.12172
• Raschke, R. A., Stoffer, B., Assar, S., Fountain, S., Olsen, K., Heise, C. W., Gallo, T., Padilla-Jones, A., Gerkin, R., Parthasarathy, S., & Curry, S. C. (2021). The relationship of tidal volume and driving pressure with mortality in hypoxic patients receiving mechanical ventilation. PloS one, 16(8), e0255812.
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  To determine whether tidal volume/predicted body weight (TV/PBW) or driving pressure (DP) are associated with mortality in a heterogeneous population of hypoxic mechanically ventilated patients.
• Gress, K. L., Gallo, T., Urits, I., Geng, X., Viswanath, O., Kaye, A. D., & Woosley, R. L. (2020). Investigating the Impact of Gadolinium-Based Contrast Agents on the Corrected QT Interval. Cureus, 12(8), e9668.
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  Introduction The manufacturing labels for all currently marketed gadolinium-based MRI contrast agents describe adverse cardiac events reported during post-market use. The goal of this study was to determine prolongation of the rate-corrected QT interval occurs in the immediate setting after gadolinium-based MRI contrast agent injection. Methods This study enrolled adults scheduled to have a gadolinium-based MRI contrast agent injection as part of a diagnostic MRI. A single-lead electrocardiogram was recorded using the AliveCor Kardia® ECG (Mountain View, CA) device before and after injection. The rate-corrected QT interval was subsequently measured by two independent investigators. The QT interval was corrected for rate using the two most common formulas, originally cited by Bazett and Fridericia. These rate-corrected QT intervals from before and after gadolinium-based MRI contrast agent injection were compared using the Wilcoxon signed-rank test paired analysis. Results A total of 24 consenting adults had electrocardiogram that were free of motion artifact. The mean age of the final patient cohort was 59.4 years. There was an equal split of 12 men and 12 women. The mean pre-injection, rate-corrected QT interval, corrected using Bazett's formula, was 395 msec. The mean post-injection, rate-corrected QT interval, corrected using Bazett's formula, was 396 msec. The corrections using Fridericia's formula were 384 and 381 msec, respectively. There was no statistically significant change in Bazett-corrected QT interval (QTc-B) when pre-injection and post-injection values were directly compared. Discussion The results of the present investigation support the conclusion that gadolinium-based MRI contrast agents do not commonly affect rate-corrected QT interval in routine clinical use. While the frequency of rate-corrected QT interval prolongation might be overstated, the severity of adverse events is definitively not. A role for concomitant rate-corrected QT interval-prolonging drugs or unidentified rare factors such as genetic predisposition cannot be ruled out. The limitations of this study include its relatively small size and the implementation of a single-lead electrocardiogram to measure rate-corrected QT interval. Conclusion The present investigation revealed that significant rate-corrected QT interval prolongation, while previously reported in as many as 55% of patients after gadolinium-based MRI contrast agent injection, is not a common occurrence in the routine clinical setting.
• Heise, C. W., Gallo, T., Curry, S. C., & Woosley, R. L. (2020). Identification of populations likely to benefit from pharmacogenomic testing. Pharmacogenetics and genomics, 30(5), 91-95.
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  Pharmacogenomic testing (PGX) implementation is rapidly expanding, including pre-emptive testing funded by health systems. PGX continues to develop an evidence base that it saves money and improves clinical outcomes. Identifying the potential impact of pre-emptive testing in specific populations may aid in the development of a business case.
• Gallo, T., Gallo, T., Curry, S. C., Curry, S. C., Padilla-jones, A., Heise, C. W., Ramos, K. S., Woosley, R. L., Raschke, R. A., & Raschke, R. A. (2019). A computerized scoring system to improve assessment of heparin-induced thrombocytopenia risk.. Journal of thrombosis and haemostasis : JTH, 17(2), 383-388. doi:10.1111/jth.14359
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  Essentials Current risk scores for heparin-induced thrombocytopenia (HIT) are not computer-friendly. We compared a new computerized risk score with the 4Ts score in a large healthcare system. The computerized risk score agrees with the 4Ts score 85% of the time. The new score could potentially improve HIT diagnosis via incorporation into decision support. SUMMARY: Background (HIT) is an immune-mediated adverse drug event associated with life-threatening thrombotic complications. The 4Ts score is widely used to estimate the risk for HIT and guide diagnostic testing, but it is not easily amenable to computerized clinical decision support (CDS) implementation. Objectives Our main objective was to develop an HIT computerized risk (HIT-CR) scoring system that provides platelet count surveillance for timing and degree of thrombocytopenia to identify those for whom diagnostic testing should be considered. Our secondary objective was to evaluate clinical management and subsequent outcomes in those identified as being at risk for HIT. Methods We retrospectively analyzed data from a stratified sample of 150 inpatients treated with heparin to compare the performance of the HIT-CR scoring system with that of a clinically calculated 4Ts score. We took a 4Ts score of ≥ 4 as the gold standard to determine whether HIT diagnostic testing should be performed. Results The best cutoff point of the HIT-CR score was a score of 3, which yielded 85% raw agreement with the 4Ts score and a kappa of 0.69 (95% confidence interval 0.57-0.81). Ninety per cent of patients with 4Ts score of ≥ 4 failed to undergo conventionally recommended diagnostic testing; 38% of these experienced persistent, unexplained thrombocytopenia, and 4% suffered life-threatening thrombotic complications suggestive of undiagnosed HIT. Conclusion The HIT-CR scoring system is practical for computerized CDS, agrees well with the 4Ts score, and should be prospectively evaluated for its ability to identify patients who should be tested for HIT.
• Martin, L. G., Warholak, T. L., Hincapie, A. L., Gallo, T., Kjos, A. L., & Task Force On Informatics, A. J. (2019). Health Informatics Competencies for Pharmacists in Training. American journal of pharmaceutical education, 83(2), 6512.
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  To gather feedback from focus groups regarding health informatics competencies that should be taught in a Doctor of Pharmacy (PharmD) curricula and to revise the competencies based on this feedback. The pharmacy informatics task force of the American Association of Colleges of Pharmacy (AACP) used 11 sources to create a list of pharmacy informatics competencies. Subsequently, faculty feedback about the competency list was obtained via two synchronous online focus groups in August 2015. The list was then revised based on the feedback. Eight people (a department chair, six faculty members and a graduate student) participated in the focus groups (six were from private and two were from public institutions). Participants felt the list had too many competencies to be covered in a timely manner and some indicated that basic computer and Internet competencies should be considered pre-requisites. Participants also recommended that competencies be split by proposed curricular placement (eg, prerequisite, required, elective, didactic, experiential) for each objective. The competency list was revised in response to focus group feedback. The proposed curriculum aligns with the new Accreditation Council for Pharmacy Education (ACPE) standards requiring that professional pharmacy curricula cover multiple aspects of health informatics. The proposed competencies list can serve as a reference to assist in the development of the curriculum and ensure compliance with the new standards.
• Woosley, R. D., Romero, K., Heise, C. W., Gallo, T., Tate, J., & Woosley, R. L. (2019). Summary of Torsades de Pointes (TdP) Reports Associated with Intravenous Drug Formulations Containing the Preservative Chlorobutanol. Drug safety, 42(7), 907-913.
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  Drug-induced torsades de pointes (TdP) is a potentially lethal ventricular arrhythmia that is associated with drugs that prolong the QT interval on the electrocardiogram (ECG) due to their interference with the cardiac potassium current, I. Intravenous (IV) formulations of methadone have been associated with TdP and contain the preservative chlorobutanol, which, like methadone, blocks I. The combinations of chlorobutanol with methadone or terfenadine, another I blocker, produce synergistic I block.
• Woosley, R., Heise, C., Tate, J., Gallo, T., Woosley, D., & Romero, K. (2019). Drug labels, QT prolongation and ECG recommendations. Cardiology Today.
• Gallo, T., Curry, S. C., Padilla-Jones, A., Heise, C. W., Ramos, K. S., Woosley, R. L., & Raschke, R. A. (2018). A Computerized Scoring System to Improve Assessment of Heparin-induced Thrombocytopenia Risk. Journal of thrombosis and haemostasis : JTH.
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  Heparin induced thrombocytopenia (HIT) is an immune-mediated adverse drug event associated with life-threatening thrombotic complications. The four T's (4Ts) score is widely used to estimate the risk for HIT and guide diagnostic testing, but it is not easily amenable to computerized clinical decision support (CDS) implementation.
• Gallo, T., Malone, D., Beck, J., & Clark, D. (2017). Feasibility of measuring QT intervals with a portable device. American Journal of Health-System Pharmacy, 74(22), 1850-1851. doi:10.2146/ajhp170252
• Warkentin, T. E., Whiting, T., Gallo, T., Raschke, R. A., Curry, S. C., Padilla-Jones, A., & Puri, A. (2017). Clinical effectiveness of a Bayesian algorithm for the diagnosis and management of heparin-induced thrombocytopenia. Journal of Thrombosis and Haemostasis, 15(8), 1640-1645. doi:10.1111/jth.13758

Presentations

• Gallo, T., Raschke, R. A., & Curry, S. (2019, May). Heparin-induced thrombocytopenia computerized risk score in laboratory-tested patients. ABRC Research Conference. Phoenix, AZ.

Poster Presentations

• Gallo, T., Maghari, S., Heise, C., Rivas, S., Nguyen, M., & Mark, Z. (2023, June). Medications with actionable safety and efficacy pharmacogenomic recommendations in Veteran patients. PGRN 2023 Annual Scientific Meeting. Memphis, TN.
• Gallo, T. (2021). Clinician satisfaction with clinical decision support to reduce the risk of torsades de pointes. AMIA Clinical Informatics Conference.
• Gallo, T. (2021). Medications Evoking Torsade de Pointes Clinical Decision Support and Clinician Response to the Advisory. American College of Clinical Pharmacy Annual Meeting.
• Gallo, T. (2020, October). Initial characteristics of one site’s experience with implementation of the Pharmacogenomic Testing for Veterans (PHASER) program. Pharmacogenomics Research Network Annual Meeting.
• Gallo, T., Heise, C., & Curry, S. (2019, Nov). Identifying target populations for pharmacogenomic testing implementation using a benefit tool. Re-imagine Health: Is my fate in my genes. Phoenix, AZ.
• Bhattacharjee, S., Gallo, T., Patel, J. G., & Harrison, D. J. (2018, May). Caregiver Burden among Individuals Providing Informal Caregiving to Survivors of Major Adverse Cardiac Event (Mace): A Systematic Review. ISPOR 23rd Annual International Meeting. Baltimore, MD, USA: ISPOR.