‘Nudges’ could increase appropriate statin prescription in primary care practice
Click Here to Manage Email Alerts
Physician “nudges” via electronic health record prompts and peer comparison feedback improved statin prescription in the primary care setting for eligible patients compared with usual care, researchers reported.
The rate of statin prescription increased further when the physician nudges were combined with nudges sent via text message to patients in the days leading up to their appointment; however, the patient nudges alone had no significant effect on statin prescription, according to the results of a cluster-randomized trial published in JAMA Cardiology.
Source: Adobe Stock
“Statins ... significantly reduce the risk of major adverse cardiovascular events, including coronary events and stroke, across a wide range of ages and cardiovascular risk,” Srinath Adusumalli, MD, MSHP, MBMI, assistant program director of the cardiovascular disease fellowship, assistant chief medical information officer of connected health strategy and applications and adjunct assistant professor of medicine in the Penn Medicine Primary Cardiology program, and colleagues wrote. “Despite these benefits, less than 50% of Americans who meet guideline indications for a statin are actively prescribed this medication. In addition, appropriate statin prescription varies across practice sites and patient racial and demographic characteristics.”
Therefore, Adusumalli and colleagues conducted a cluster-randomized clinical trial to evaluate the effects of a statin prescribing nudge in a cohort of 158 clinicians from 28 primary care practices including 4,131 patients in suburban Pennsylvania and New Jersey (mean age, 66 years; 51% men; 29% Black; 23% with atherosclerotic CVD).
Patients were enrolled if they were eligible for statin therapy based on the U.S. Preventive Services Task Force guidelines for primary prevention or had presence of clinical ASCVD or a history of familial hyperlipidemia and no prior statin prescription.
The nudge intervention
The study included a 12-month preintervention period followed by a 6-month intervention period.
Participants were randomly assigned to one of four groups: usual care with no nudges; patient nudge only; physician nudge only; and combined patient/physician nudges.
Patient nudges consisted of text messages sent 4 days before their appointment, reminding them of the upcoming appointment. After the patient replied confirming their willingness to communicate via text, they were told “guidelines indicate you should be taking a statin to reduce the chance of a heart attack” and informed of the benefits of lowering cholesterol, as well as the rare statin-related adverse effects that go away upon cessation.
Physician nudges consisted of an active choice prompt in the EHR — triggered when a clinician entered the EHR ordering section — as well as a monthly peer comparison feedback showing their 3-month average of the percentage of their eligible patients prescribed a statin compared with peer clinicians at Penn Medicine.
“It is important to recognize that approximately 70% of primary care patients eligible for statins in these practices already had the medication prescribed,” the researchers wrote. “This trial targeted the remaining cohort of patients.”
Nudges to improve statin prescription
Among patients who received a text message nudge, 33.5% consented to receive the intervention message. Among those patients, 13.8% responded that they were interested in taking a statin.
During the intervention, statins were prescribed to 7.3% of patients in the usual care group; 8.5% in the patient nudge only group; 13% in the clinician nudge only group; and 15.5% in the combined patient/physician nudge group.
In adjusted analyses, the clinician only nudges increased statin prescription by 5.5 percentage points (95% CI, 3.4-7.8; P = .01) and the combined patient/physician nudges increased prescription by 7.2 percentage points (95% CI, 5.1-9.1; P = .001) compared with usual care.
The patient nudge alone did not result in any significant change in statin prescribing compared with usual care (P = .32).
“In this cluster randomized clinical trial, a clinician nudge alone and when combined with a patient nudge significantly increased initiation of a statin prescription during primary care visits. Nudges to patients alone were not effective,” the researchers wrote. “These findings demonstrate the potential benefit and scalability of using nudges to change prescribing behavior through automated processes within the EHR.”
Collapse
Click Here to Manage Email Alerts