Personalized Letter From Doctor Improves Cholesterol Control

Patients who received a description of their cardiovascular risk factors were more likely to start taking statins and to significantly reduce their LDL cholesterol levels.

Patients at high risk of cardiovascular disease (CVD) are more likely to start taking cholesterol-lowering medication and to significantly reduce their LDL cholesterol level if they receive a personalized letter from their physician detailing their CVD risk factors, according to the results of a study published online on November 11, 2012, in the Journal of General Internal Medicine.

Researchers at Northwestern University recruited 29 internal medicine primary care physicians at a large practice affiliated with an academic medical center to participate in the study. Patients of these physicians were included in the study if they were aged 40 to 79 years, did not have established CVD or diabetes, had a Framingham Risk Score of at least 5%, had LDL cholesterol higher than the guideline threshold for drug treatment, and had not been prescribed a lipid-lowering medication. Information on patients’ risk factors was drawn from their electronic health records (EHRs).

The researchers randomized 14 physicians with 218 participating patients to the intervention group and 15 physicians with 217 participating patients to the control group, which received usual care. The average age of the patients was 60.7 years and 77% were male. Patients in the intervention group each received an individualized message from their physician with information on their personal CVD risk factors, in written and graphical form, and an estimate of how much their risk could be reduced by taking a statin. Those who smoked or had hypertension received information on the benefits of modifying these risk factors as well. In addition, the mailing encouraged patients to discuss options for reducing their CVD risk with their physician.

The initial study period lasted 9 months, from February to November 2011. At the end of this period, there was no difference in the portion of patients in the intervention group compared with that in the control group whose LDL cholesterol levels were reduced by at least 30 mg/dl (11.0% vs. 11.1%). However, patients in the intervention group were twice as likely to receive a prescription for a lipid-lowering medication during this period (11.9% vs. 6.0%, odds ratio of 2.13). In an extended 18-month follow-up, patients in the intervention group were significantly more likely to have their LDL cholesterol levels reduced by at least 30 mg/dl (22.5% vs. 16.1%, odds ratio of 1.59).

Among participants with hypertension, prescribing additional antihypertensive agents was more common and blood pressure was lower in the intervention group, and among those not taking aspirin at baseline, initiation of aspirin therapy was more common in the intervention group. In these cases, however, sample sizes were small and the differences between groups were not statistically significant. Overall, the researchers report, their efforts to detect differences between the groups were hindered by the fact that most participants did not have a follow-up LDL cholesterol test performed during the study’s initial 9 months.

The researchers note that even in the intervention group a relatively small portion of patients received lipid-lowering medications. However, they point out that this small effect should be considered in the context of the limited resources required to carry out the intervention and the fact that only 1 message was sent to patients. In addition, patients may not have considered their risk to have been very high; the mean 10-year risk for any CVD event among participating patients was 24%. The researchers conjecture that focusing on patients’ lifetime risk and sending multiple messages might be more effective.