Personalized Physician Reminders Increase the Use of High-Intensity Statins in Patients with ASCVD

While statins are a key pillar in the treatment of patients with any type of atherosclerotic cardiovascular disease (ASCVD), including ischemic heart disease, peripheral arterial disease, or ischemic stroke, their use remains sub-optimal. In recent claims data from a large U.S. commercial health plan, only 22.5% of patients with established ASCVD were on a high-intensity statin [1]. Effective implementation of statins, along with other guideline-directed medical therapies, is necessary to reduce risk of future adverse cardiovascular events.

In the cluster, randomized PCDS Statin trial conducted in the Department of Veterans Affairs, Dr. Virani and colleagues evaluated the effectiveness of personalized reminders sent to primary care clinicians either synchronously (2-7 days prior to patient visit) or asynchronously (not timed to a visit) [2]. Twenty-seven primary care clinics were randomized to intervention versus usual care from August 2021 – November 2022. Personalized reminders were created based on natural language processing extraction of data [3] and performing qualitative interviews to understand statin-associated side effects and clinician needs. Reminders entailed details about ASCVD diagnosis, prior statin use, history of statin-associated side effects, and guideline resources on management.

Reminders were sent for 4,532 patients. Individualized reminders led to a significant increase in high-intensity statin use over the 15 month time-period (odds ratio: 1.06; 95% CI 1.01-1.11; absolute change +10.1% vs. 0.18%). While the overall effect size was not immense, it was noted to be higher in the 53% patients who were not on high-intensity statins at baseline in the intervention arm; in this group, the number of reminders needed to be sent for one patient to be started on a high-intensity statin was 10.

While utilizing automated electronic medical system alerts is a promising strategy to implement medical therapies at a healthcare systems level, careful attention is needed to prevent clinician fatigue and determine how to best incorporate alerts into existing workflows. In this study, algorithms ensured that clinicians did not receive more than 3 reminders in order to prevent alert fatigue. Still, 31.6% clinicians opted out of reminders.

This study, presented at the 2023 American College of Cardiology meeting, illustrates a feasible strategy to improve the implementation of statins. Further work is needed to ascertain whether adherence to statins is maintained over a longer follow-up time. In addition, it is important to consider whether the use of other guideline-directed medical therapies was affected when high-intensity statin use increased.

References:

1. Nelson AJ, Haynes K, Shambhu S et al. High-Intensity Statin Use Among Patients With Atherosclerosis in the U.S. J Am Coll Cardiol. 2022;79(18):1802-13.
2. Virani SS, Ramsey D, Westerman D et al. Cluster Randomized Trial Of A Personalized Clinical Decision Support Intervention To Improve Statin Prescribing In Patients With Atherosclerotic Cardiovascular Disease (PCDS Statin). Circulation. 2023.
3. Gobbel GT, Matheny ME, Reeves RR et al. Leveraging structured and unstructured electronic health record data to detect reasons for suboptimal statin therapy use in patients with atherosclerotic cardiovascular disease. Am J Prev Cardiol. 2022;9:100300.

Dr. Gurleen Kaur is an internal medicine resident at Brigham and Women’s Hospital and served as a CardioNerds Conference Scholar for the American College of Cardiology 2023 Scientific Sessions.