Statin therapy reduces major adverse cardiovascular events in patients at risk for atherosclerotic cardiovascular disease (ASCVD) but remains underutilized. A recent study shows that electronic health record (EHR)-based nudges to clinicians and patients increase statin prescription rates.1
Statins are a cornerstone of both primary and secondary ASVCD prevention in addition to healthy lifestyle measures.2 Statin therapy lowers relative CVD risk by about 30% regardless of baseline low density lipoprotein cholesterol (LDL-C), with absolute benefit related to baseline CVD risk. Despite these benefits, statins remain underprescribed and underutilized, likely driven by both clinician and patient related factors. Effective strategies to improve evidence-based statin utilization could have meaningful impact on population outcomes.
Adusumalli and colleagues investigated whether EHR-based nudges to clinicians and/or patients might improve statin utilization. They performed a cluster randomized clinical trial including 158 clinicians and 4,131 patients across 28 primary care practices studied over a 12-mongh preintervention period and a 6-month intervention period. In the intervention group, clinician nudges were combined with an active choice prompt during the patient visit in addition monthly feedback on personal prescription patterns compared with peers. Patients received nudges in the form of an interactive text message delivered 4 days prior to their visit. The combined nudge included both clinician and patient nudges. The usual care group received no nudges.
The study included 4,131 patients with mean (SD) age 65.5 (10.5) years – 51.3% male, 29.3% Black, 2.6% Hispanic, 66.1% White, and 2% “other race or ethnicity.” Established ASCVD was present in 22.6% of patients for whom high intensity statin therapy would be strongly recommended for secondary prevention with the aim of reducing LDL-C by at least 50% (Class 1, 2018 American guidelines).2 Despite this, a small minority of patients were prescribed statin therapy during the preintervention period: 5.6% in the usual care group, 4.8% in the patient nudge group, 6.0% in the clinician nudge group, and 4.7% in the combined group. When compared with the usual care group during the intervention period, stain prescriptions rates significantly increased in the clinician nudge arm (5.5 percentage points; 95% CI, 3.4 to 7.8 percentage points; P = 0.01) and in the combined nudge group (7.2 percentage points; 95% CI, 5.1 to 9.1 percentage points; P = 0.001). Notably, nudging the patient alone did not change statin prescribing behavior compared with usual care (0.9 percentage points; 95% CI, −0.8 to 2.5 percentage points, P = 0.32).
The baseline statin usage is alarming. In this cohort, nearly a 1 in 4 of patients had established ASCVD and yet only about 5% overall were prescribed a statin (~1 in 20 patients!) during the preintervention period. There was a significant rise in statin prescriptions with clinician or clinician combined with patient nudges, speaking to the value of HER-based just in time reminders and personal performance feedback relative to peers. However, even with the combined nudges, the during-intervention statin prescription only rose to 15.5%, again in a population with 22.6% of persons having established ASCVD.
The data are promising and advocate for innovative EHR-based strategies to improve outcomes. However, rates of statin prescription remained relatively low, and the efficacy of this strategy may wane with time and user-fatigue or desensitization. Reasons for persistently low rates are probably multifactorial spanning clinician, patient, and systems-level variables. A multipronged approach including education, improved access, and availability of non-statin adjunctive therapies will be needed for continued improvements in ASCVD outcomes.
Nudges are often directed to only patients or doctors, but shared decision-making includes both. In a new study in @JAMACardio we found nudges to patients AND doctors tripled statin prescribing and worked better than nudges to either group alone. https://t.co/743fHBFppP @sri_adu
— Mitesh Patel (@miteshspatel) December 1, 2022
- Adusumalli S, Kanter GP, Small DS, Asch DA, Volpp KG, Park SH, Gitelman Y, Do D, Leri D, Rhodes C, VanZandbergen C, Howell JT, Epps M, Cavella AM, Wenger M, Harrington TO, Clark K, Westover JE, Snider CK, Patel MS. Effect of Nudges to Clinicians, Patients, or Both to Increase Statin Prescribing: A Cluster Randomized Clinical Trial. JAMA Cardiol. 2023;8:23–30.
- Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, Braun LT, de Ferranti S, Faiella-Tommasino J, Forman DE, Goldberg R, Heidenreich PA, Hlatky MA, Jones DW, Lloyd-Jones D, Lopez-Pajares N, Ndumele CE, Orringer CE, Peralta CA, Saseen JJ, Smith SC, Sperling L, Virani SS, Yeboah J. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol [Internet]. 2019;73:3168–3209. Available from: http://dx.doi.org/10.1016/j.jacc.2018.11.002