Automatic alerts to aid clinical decision making are designed with the best of intentions, but can be easy to ignore or overlook. but a random test Testing such electronic alerts or “nudges” to promote statin prescriptions may have identified some design features that help their success, the researchers say.
In the main finding of the trial, for example, reminders displayed to primary care physicians in the electronic health record (EHR) worked better when the system also communicated with the patient.
Physician-only reminders also prompted statin prescribing, but not as much, and nudges did not work at all compared to a no-nudge approach to care. The patient-only notices consisted of text messages explaining why a statin prescription might be listed in your next appointment.
Importantly, the notices to doctors were more than just reminders to consider a statin prescription, said Mitesh S. Patel, MD, MBA, Ascension Health, St. Louis, Missouri. elcorazon.org | Medscape Cardiology. They also showed the patient atherosclerotic cardiovascular disease (ASCVD) 10-Year Risk Score and Explanation why a statin may be appropriate. He thinks the information, which is often left out of such clinical decision support alerts, increases clinicians’ confidence in them.
In another key feature, Patel said, the EHR notices themselves were actionable—that is, they were functional in ways that streamlined the prescribing process. In particular, they include checkbox shortcuts for prescribing statins in the appropriate doses specific to the patient, making the whole process “quicker and easier,” said Patel, who is the lead author of the paper. published study November 30 in NEVER Cardiology with lead author Srinath Adusumalli, MD, University of Pennsylvania, Philadelphia.
Timing can also be important, he noted. In previous iterations from the study’s EHR prompt system, the prompt would appear “on opening the chart,” he said. “Now, that’s when you go to the ordering section, which is when you’re going to be in the mindset of ordering prescriptions and testing.”
Prescription rates were higher with doctor-patient nudges than with the doctor-only approach, Patel speculates, largely because the decision process for initiating statins is shared. “The most effective intervention is going to recognize that and try to bring the two groups together.”
two text messages
The trial, involving 158 participating physicians in 28 primary care practices, randomly assigned 4,131 patients to three intervention groups and one control group. Notices were sent only to the doctor, only to the patient, or to the doctor and the patient; and there was a usual care pool with no jostling.
The notices to the patients consisted of two text messages, one 4 days and the other 15 minutes before the appointment, announcing that they would discuss with the doctor the prescription of a statin “to reduce the possibility of a heart attack.” , according to the report.
Statins are very underprescribed nationally, he notes, and that was reflected in the prescription rates seen during the study’s initial 12-month, no-intervention observation period. Rates ranged from only 4.7% to 6% of patients in the four allocation groups.
However, during the subsequent 6-month intervention period, rates increased in the physician-only and physician-plus-patient support groups compared with usual care, by 5.5 (P = .01) and 7.2 (P = .001) absolute percentage points, respectively.
The mean age of the overall cohort was 65.5 years; approximately half were men, 29% were black, 66% were white, and 22.6% already had a diagnosis of cardiovascular disease. The analysis was adjusted for calendar months and pre-intervention statin prescription rates. Additional adjustment for demographics, type of insurance, family income, and comorbidities yielded similar results to the main analysis, the report states.
The results in context
“Although the differences in the combined physician-patient and physician-only arms were small, this result should be interpreted in the context of the population in which the study was conducted,” a accompanying editorial says the published report.
For example, “the majority of untreated patients were candidates for primary, not secondary, prevention, making this group of patients particularly difficult to see large effect sizes of interventions.”
In addition, “There was a high initial statin prescription rate in the statin-eligible population (approximately 70%) and a high rate of established patients,” write Faraz S. Ahmad, MD, and Stephen D. Persell, MD, of Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Among the approximately 30% of patients who had not previously been prescribed statins, the true target of boost interventions, the published trial report states, around 98% were not visiting their doctor for the first time.
So “this may not have been the first opportunity to discuss statins,” they write. “It is possible that many of these patients were resistant to statins in the past, which could have created a ceiling effect in prescription rates.”
Patel reports that he owns and receives personal fees from Catalyst Health; and serving on an advisory board and receiving personal honoraria from Humana. Adusumalli reports being an employee of CVS Health. Ahmad reports receiving consulting fees from Teladoc Livongo and Pfizer. Persell reveals having received grants from Omron Healthcare.