Targeted Reminders Studied to Improve Guideline-Based Prescription Practices for High-Intensity Statins

March 5, 2023—The American College of Cardiology (ACC) announced that a study demonstrated that patients with cardiovascular disease (eg, heart disease, stroke, or peripheral arterial disease) were significantly more likely to be prescribed guideline-recommended high-intensity statin therapy if their clinicians were sent an automated reminder with information about their cardiovascular disease history, previous statin use, and history of statin associated side effects. The reminders were generated using machine learning algorithms alongside guideline recommendations.

Although medical guidelines recommend high-intensity statins for nearly all patients with established cardiovascular disease, previous studies have shown that rates of guideline compliance are low, noted the ACC press release.

The findings were presented by Salim Virani, MD, at ACC.23/WCC, the ACC’s annual scientific session together with the World Congress of Cardiology held March 4-6, 2023, in New Orleans, Louisiana. Simultaneously, the study, “Cluster Randomized Trial of a Personalized Clinical Decision Support Intervention to Improve Statin Prescribing in Patients With Atherosclerotic Cardiovascular Disease (PCDS Statin),” was published by Dr. Virani, et al online in Circulation.

Dr. Virani is Staff Cardiologist at the Michael E. DeBakey VA Medical Center in Houston, Texas; Vice Provost for Research and Professor at the Aga Khan University in Karachi, Pakistan; and staff at The Texas Heart Institute/Baylor College of Medicine in Houston. The study was funded by the United States Department of Veterans Affairs Health Services Research & Development.

“We found that if you’re able to send reminders that have information that is personally relevant to the patient, it works,” commented Dr. Virani in the ACC 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.”

According to the ACC press release, the reminder system was developed by the investigators using machine learning algorithms to parse clinician notes for evidence of statin-associated side effects (a factor often cited as contributing to low guideline compliance) and generate summaries of patients’ cardiovascular disease history, history of statin use, and any reported side effects.

Then, the investigators 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.

As summarized in the ACC press release, the investigators tested the reminder system by randomly assigning 14 clinics (with a total of 117 clinicians treating 18,427 patients) to implement reminders for a 15-month period and 13 clinics (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.

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

The study is among the largest to date to use machine learning-generated reminders to influence clinicians’ prescribing practices. It was composed of more than 36,000 patients with more than 18,000 in each arm, as noted in the ACC press release.

The investigators found that in the intervention arm, 4,928 reminders were sent in total on 4,532 unique patients. This was approximately half of the cohort that was eligible for reminders because of 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.

Dr. Virani stated in the ACC press release, “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. Our results show that for every 10 reminders sent, health care systems can expect one patient with cardiovascular disease to be initiated or titrated to high-intensity statin therapy.”

Patients featured in synchronous reminders were found to be slightly more likely to be prescribed high-intensity statin therapy, as were patients who had not previously reported a statin-associated side effect.

However, the study showed a 9% increase in high-intensity statin use even in patients with statin associated side effects, among the subset of patients in the intervention arm for whom a reminder was sent to the treating clinician.

“This is important as these patients are the toughest to treat given their prior history of statin associated side effects,” noted Dr. Virani. In addition, statin adherence (as measured by data on prescription refills) was 2.8% higher among patients in the intervention group. The total proportion of patients prescribed any statins (not only high-intensity statin therapy) declined slightly in both groups, but this attrition was lower among patients in the intervention group.

Despite the benefits seen from the alerts, Dr. Virani said that approximately 30% of the clinicians in the study opted out of the trial, underscoring the continuing challenge of creating alerts that can attract clinicians’ attention without overwhelming them. He said that the study was conducted at a time when workflows were changing rapidly because of iterative waves of COVID-19, which may have affected the results.

The investigators plan to further analyze the data to understand why some clinicians opted out of the reminders. In addition, clinicians were not able to click directly from the reminder to initiate a prescription, which may have limited its use as a clinical decision support tool, advised the ACC press release.