‘People voted with their clicks’: Automated referrals boosted statin prescriptions
Click Here to Manage Email Alerts
Key takeaways:
- Automatic referrals to a centralized pharmacy placed for cosign increased prescriptions of any statin by 16 percentage points vs. usual care.
- An EHR notification strategy had a smaller effect.
PHILADELPHIA — Automatic referrals of eligible patients not already prescribed statins to a centralized pharmacy service via email increased prescriptions of any statin by 16 percentage points compared with usual care, a speaker reported.
The asynchronous strategy of automated statin orders, which was not visit-based, was more successful than an interruptive, pop-up electronic health record notification strategy that was visit-based, which only increased prescriptions of statins by about 3% to 5%, Alexander C. Fanaroff, MD, MHS, an assistant professor of cardiovascular medicine at the Perelman School of Medicine at the University of Pennsylvania, said during a late-breaking science presentation at the American Heart Association Scientific Sessions. As part of the SUPER LIPID clinical program, researchers conducted two parallel randomized controlled trials of electronic “nudges” to assess the ideal method to encourage referrals to centralized pharmacy services for evidence-based statin initiation for high-risk patients.
Image: Adobe Stock
“When you have a [best practice alert] that pops up and says, ‘This is your patient and they are not on the medicine that they are supposed to be on, fix it,’ you are identifying a problem for clinicians ... and putting a burden on them,” Fanaroff told Healio. “Whereas the asynchronous model says, ‘I found this problem and I solved it for you. All you have to do is sign off and I have taken statins off of your plate.’”
Comparing notification strategies
For the first study, Fanaroff and colleagues assessed the use of an interruptive, pop-up notification EHR strategy at one primary care practice. Researchers randomly assigned eligible patients at the level of the primary care provider to the EHR notification during a visit recommending referral to a centralized pharmacy for consideration of statin initiation or to usual care. If pharmacists received a referral, they confirmed statin eligibility and then called patients to discuss statin initiation. If the patient agreed, the pharmacist prescribed the statin and ordered follow-up labs as indicated.
PCPs saw the notification an average 11.5 times per month; overall, the notification fired 3,579 times for 913 patients over 6 months, Fanaroff said. An order was entered in response to the notification 165 times, or for 4.6% of all notification firings for 18% of all patients.
“So, most of the time PCPs ignored it; they just hit ‘cancel,’” Fanaroff said during an interview after the presentation. “There are so many notifications that providers see. It’s another ‘click’ to get through. PCPs are too busy. What we showed in that trial was the notification increased prescriptions of statins by about 3% to 5%, and increased prescriptions of appropriate-dose statins by about 1% to 3%. A small effect but consistent with what you see with other EHR-based notification studies.”
In the second cluster-randomized trial, Fanaroff and colleagues analyzed data from 1,950 patients from 10 primary care practices affiliated with the Penn Medicine Lancaster General Health System who were candidates for but not already prescribed statin therapy by their clinicians. Researchers randomly assigned 975 patients to automated referral to a centralized pharmacy service and 975 patients to usual care. For the automated referral arm, pharmacists subsequently contacted appropriate patients, discussed their personalized risks and the benefits of statin initiation and initiated therapy when appropriate.
“We did not give the pharmacists a protocol; we did not tell them what to say to patients,” Fanaroff told Healio. “That makes this more of a real-world trial.”
The primary goal was to assess the proportion of patients prescribed statins. Secondary outcomes included the proportion of prescribed statins at guideline-recommended doses.
Within the cohort, 86.4% of eligible patients were not prescribed any statins at baseline, with the rest prescribed inappropriately low doses. Patients in the intervention arm practices had a significant increase in statin prescription rates, with 31.6% prescribed a statin vs. 15.2% in usual care practices.
Additionally, 24.8% of patients at intervention arm practices were prescribed a statin at the guideline-recommended dose during the study period vs. 7.7% of patients at usual care practices.
“The order appears in the inbox, the provider clicks ‘sign’ and the patient gets referred to the centralized pharmacy services,” Fanaroff said. “About 75% of the orders got signed, so there was high uptake as compared with the synchronous version. Of the patients referred, about 20% were put on an appropriate-dose statin. The upshot of this is that compared with usual care, there was a 16 percentage point increase in the proportion of patients who were prescribed a statin, from 15% to 32%.”
Fanaroff said most clinicians preferred automated referrals.
“A minority of physicians said, ‘These are my patients, I don’t want a pharmacist managing them for me,’” Fanaroff told Healio. “The other 75% clicked through and signed it. This is the type of study where it is good to have people’s perceptions, but people voted with their clicks. This was effective at increasing statin prescriptions by a substantial amount, but there is still room to grow.”
Fanaroff noted several limitations for the two studies. The visit-based trial did not reach the enrollment goal and randomization at the level of practice and physician led to an imbalance between groups. Researchers also did not collect data on statin adherence or assess effects on longer-term CV event rates.
“This is a model that works,” Fanaroff told Healio. “The question is, does it have to be pharmacists? We don’t know. Could this be done with patient navigators, nurses or nurse practitioners? This model of having a nonphysician from the care team call and speak with a patient, with the supervision of a physician, is scalable in multiple centers. It is not a heavy administrative lift. This is an intervention health systems could and should deploy to do better by their patients.”
‘You do get what you pay for’
In discussing the study findings, Benjamin M. Scirica, MD, MPH, FAHA, associate professor of medicine at Harvard Medical School and director of quality initiatives at Brigham and Women’s Hospital’s cardiovascular division, said the best practice alert via the EHR is a low-cost, easily scalable intervention, but minimally effective, and could potentially cause alarm fatigue or alarm annoyance for providers.
The pharmacist-based intervention, although more complicated and costly, was “much more effective” and could allow health systems to personalize treatment at scale, Scirica said.
“In general, you do get what you pay for,” Scirica said. “Lower-cost solutions will not result in the changes that you see with more complex solutions, and we need to align our incentives across organizations and systems for true and lasting change.”
Collapse
Fanaroff A, et al. LBS.07. From local to global: Achieving equity in prevention. Presented at: American Heart Association Scientific Sessions; Nov. 11-13, 2023; Philadelphia.
Click Here to Manage Email Alerts