Effect of Clinical Decision Support at Community Health Centers on the Risk of Cardiovascular Disease

Abstract

IMPORTANCE Management of cardiovascular disease (CVD) risk in socioeconomically vulnerablepatients is suboptimal; better risk factor control could improve CVD outcomes. OBJECTIVE To evaluate the impact of a clinical decision support system (CDSS) targeting CVD risk in community health centers (CHCs). DESIGN, SETTING, AND PARTICIPANTSThis cluster randomized clinical trial included 70 CHC clinics randomized to an intervention group (42 clinics; 8 organizations) or a control group that received no intervention (28 clinics; 7 organizations) from September 20, 2018, to March 15, 2020. Randomization was by CHC organization accounting for organization size. Patients aged 40 to 75 years with (1) diabetes or atherosclerotic CVD and at least 1 uncontrolled major risk factor for CVD or (2) total reversible CVD risk of at least 10% were the population targeted by the CDSS intervention. INTERVENTIONS A point-of-care CDSS displaying real-time CVD risk factor control data and personalized, prioritized evidence-based care recommendations. MAIN OUTCOMES AND MEASURES One-year change in total CVD risk and reversible CVD risk (ie, the reduction in 10-year CVD risk that was considered achievable if 6 key risk factors reached evidence-based levels of control). RESULTS Among the 18 578 eligible patients (9490 [51.1%] women; mean [SD] age, 58.7 [8.8] years), patients seen in control clinics (n = 7419) had higher mean (SD) baseline CVD risk (16.6% [12.8%]) than patients seen in intervention clinics (n = 11 159) (15.6% [12.3%]; P < .001); baseline reversible CVD risk was similarly higher among patients seen in control clinics. The CDSS was used at 19.8% of 91 988 eligible intervention clinic encounters. No population-level reduction in CVD risk was seen in patients in control or intervention clinics; mean reversible risk improved significantly more among patients in control (−0.1% [95% CI, −0.3% to −0.02%]) than intervention clinics (0.4%[95% CI, 0.3% to 0.5%]; P < .001). However, when the CDSS was used, both risk measures decreased more among patients with high baseline risk in intervention than control clinics; notably, mean reversible risk decreased by an absolute 4.4% (95% CI, −5.2% to −3.7%) among patients in intervention clinics compared with 2.7% (95% CI, −3.4% to −1.9%) among patients in control clinics (P = .001). CONCLUSIONS AND RELEVANCEThe CDSS had low use rates and failed to improve CVD risk in the overall population but appeared to have a benefit on CVD risk when it was consistently used for patients with high baseline risk treated in CHCs. Despite some limitations, these results provide (continued) Key Points Question Does a clinical decision support system (CDSS) proven to reduce cardiovascular risk in integrated care settings also reduce cardiovascular risk in community health centers? Findings In this cluster randomized clinical trial of 18 578 eligible patients, although CDSS adoption rates were low, CDSS use was associated with significantly improved reversible risk of cardiovascular disease among patients with the hig...

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“…In JAMA Network Open , Gold et al share results from their cluster randomized clinical trial assessing the impact of CV Wizard, an electronic health record (EHR)–embedded clinical decision support system (CDSS), on cardiovascular risk reduction in patients served by community health centers (CHCs). By implementing a previously validated CDSS in underresourced health care facilities that predominantly serve socioeconomically vulnerable patients, the authors generated 2 particularly important findings.…”

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