Research Finds Targeted Reminders Increase Prescriptions for High-Intensity Statins

Clinicians were more likely to prescribe guideline-recommended high-intensity statin therapy if they were sent an automated reminder with information about the patient’s cardiovascular disease history, prior statin use, and history of statin-associated adverse effects (AEs), according to research presented at the American College of Cardiology 2023 Scientific Session.

Statins are highly effective at preventing premature death in patients with cardiovascular disease-related clogged arteries, as well as reducing the likelihood of serious cardiac events in individuals with a high risk for heart disease or stroke. Although current guidelines recommend high-intensity statin treatment for nearly all patients with established cardiovascular disease, earlier research has found that rates of guideline compliance are low.

In the study, researchers developed a reminder system for clinicians using machine learning algorithms to parse clinicians’ notes for evidence of statin-associate AEs, which are often a cause of low guideline compliance. The system generated summaries of patients’ cardiovascular disease history, history of statin use, and any reported AEs. The researchers conducted interviews with patients and clinicians to understand the contexts in which reminders presenting patient-specific summaries alongside general statin guidelines would be most useful.

“We found that if you’re able to send reminders that have information that is personally relevant to the patient, it works,” said Salim Virani, MD, PhD, a staff cardiologist at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, in a press release. “Our data also show that it is important to be mindful of how reminders fit in with the clinical workflow to avoid creating alert fatigue.”

To test the system, investigators randomly assigned 14 clinics with a total of 117 clinicians and 18,427 patients to implement reminders for a 15-month period, as well as 13 clinics with a total of 128 clinicians treating 18,214 patients to continue their usual care practices. All clinics received basic education on statin guidelines before the study began, and all clinicians had access to a dashboard with detailed information on statin therapy use in their patients with cardiovascular disease throughout the study.

Among clinics implementing the reminders, approximately 27% of the reminders were sent synchronously, meaning they were sent within 2 to 7 days before the clinician saw the patient, and the rest were sent asynchronously at other points during the study. The system was designed to not send reminders to clinicians who had more than 3 unsigned reminders in a row.

According to the study results, the intervention arm had 4928 reminders sent in total on 4532 unique patients. This was only about half of the cohort that was eligible for reminders due to the protocols built into the study algorithm to minimize alert fatigue. The proportion of patients prescribed high-intensity statin therapy increased by 3.8% across all clinics in the intervention arm compared with the usual care arm, and that proportion increased by 10.1% among the subset of patients who were featured a reminder in the intervention arm.

“A 10% increase in high-intensity statin use is very meaningful at a health care system level given the challenges associated with this issue as shown in several studies,” Virani said in the press release. “Our results show that for every 10 reminders sent, health care systems can expect 1 patient with cardiovascular disease to be initiated or titrated to high-intensity statin therapy.”

Patients featured in asynchronous reminders were slightly more likely to receive high-intensity statin therapy, as well as patients who had not previously reported a statin-associated AE. However, the study showed a 9% increase in high-intensity statin use even among patients with statin-associated AEs in the subset of patients featured in a reminder in the intervention arm.

“This is important as these patients are the toughest to treat given their prior history of statin associated side effects,” Virani said in the press release.

Additionally, statin adherence as measured by prescription refill data was 2.8% higher among patients in the intervention group. The total proportion of patients prescribed any statins (not only high-intensity therapy) declined slightly in both groups, but this attrition was lower among patients in the intervention group.

Despite the benefits of the alerts, Virani said approximately 30% of the clinicians in the study opted out of the trial, highlighting the challenge of creating alerts that can attract clinicians’ attention without overwhelming them. He noted that the study was conducted at a time when workflows were changing rapidly due to waves of COVID-19, which may have impacted the results.

The investigators plan to do further analyses to understand why some clinicians opted out of the reminders. Clinicians were unable to click directly from the reminder to initiate a prescription, which may have limited its use as a clinical decision support tool.

REFERENCE

Targeted Reminders Increase Prescriptions for High-Intensity Statins. News release. American College of Cardiology 2023 Scientific Session. March 5, 2023. Accessed March 8, 2023.