Electronic Health Record-Based Patient Identification and Individualized Mailed Outreach for Primary Cardiovascular Disease Prevention: A Cluster Randomized Trial

Abstract

BACKGROUND: Many individuals at higher risk for cardiovascular disease (CVD) do not receive recommended treatments. Prior interventions using personalized risk information to promote prevention did not test clinic-wide effectiveness. OBJECTIVE AND DESIGN: To perform a 9-month cluster-randomized trial, comparing a strategy of electronic health record-based identification of patients with increased CVD risk and individualized mailed outreach to usual care. PARTICIPANTS: Patients of participating physicians with a Framingham Risk Score of at least 5 %, lowdensity lipoprotein (LDL)-cholesterol level above guideline threshold for drug treatment, and not prescribed a lipid-lowering medication were included in the intention-to-treat analysis. INTERVENTION: Patients of physicians randomized to the intervention group were mailed individualized CVD risk messages that described benefits of using a statin (and controlling hypertension or quitting smoking when relevant). MAIN MEASURES: The primary outcome was occurrence of a LDL-cholesterol level, repeated in routine practice, that was at least 30 mg/dl lower than prior. A secondary outcome was lipid-lowering drug prescribing. Clinicaltrials.gov identifier: NCT01286311. KEY RESULTS: Fourteen physicians with 218 patients were randomized to intervention, and 15 physicians with 217 patients to control. The mean patient age was 60.7 years and 77% were male. There was no difference in the primary outcome (11.0 % vs. 11.1 %, OR 0.99, 95 % CI 0.56-1.74, P=0.96), but intervention group patients were twice as likely to receive a prescription for lipid-lowering medication (11.9 %, vs. 6.0 %, OR 2.13, 95 % CI 1. 05-4.32, p=0.038). In post hoc analysis with extended follow-up to 18 months, the primary outcome occurred more often in the intervention group (22.5 % vs. 16.1 %, OR 1.59, 95 % CI 1.05-2.41, P=0.029). CONCLUSIONS: In this effectiveness trial, individualized mailed CVD risk messages increased the frequency of new lipid-lowering drug prescriptions, but we observed no difference in proportions lowering LDL-cholesterol after 9 months. With longer follow-up, the intervention's effect on LDL-cholesterol levels was apparent.

Predictors of cholesterol treatment discussions and statin prescribing for primary cardiovascular disease prevention in community health centers

“…(24) In that trial, randomization to an individualized mailed CVD risk message intervention led to greater odds of receiving a lipid-lowering medication (OR 2.13, 95%CI 1.05-4.32). However, there are key differences between the two trials.…”

Individualized Risk Communication and Outreach for Primary Cardiovascular Disease Prevention in Community Health Centers

“…25 Several studies completed because this review have also demonstrated significant improvements in risk factor levels, and increased the use of preventive medication. 15,26,27 One difference between this study and most previous trials is that we used a pragmatic design with a waiver of informed consent that included all eligible patients receiving care at participating sites. Therefore, our findings may be more indicative of how this type of intervention performs in a general population rather than one limited to volunteer participants.…”

“…Another potential explanation for our observed findings is that this intervention led patients to discuss CVD prevention with clinicians but did not overcome some patients' reluctance to initiate drug therapy. The increase in patients who refused [12][13][14][15] and applies it to an entire population of patients receiving care in CHCs. Previous studies showed that providing individualized CVD risk information to patients has effects on patients' knowledge, attitudes, and some health behaviors, but the impact on CVD risk factors has been inconsistent, and the impact on health outcomes is not known.…”

“…[12][13][14] Outreach interventions focused on addressing this risk could increase the number of high-risk patients who seek out treatment. 15 Implementing population health management strategies in settings that serve large numbers of patients from low income and minority populations may be an effective way to reduce disparities. 16,17 In addition, testing strategies in safety net settings will help ensure that the study findings are applicable to low income and minority populations.…”

Capsule Commentary on Persell et.al., Electronic Health Record-Based Patient Identification and Individualized Mailed Outreach for Primary Cardiovascular Disease Prevention: a Cluster Randomized Trial

“…T his trial by Persell et al 1 tested an intervention that leveraged electronic health records to identify patients with risk factors for cardiovascular disease but not receiving statin treatment. The investigators provided a list of patients meeting these criteria to clinicians and mailed personalized letters to the patients on the list, offering advice regarding the benefit of statin treatment, controlling hypertension or quitting smoking.…”