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EHR Nudges for Statin Prescribing: Not There Yet

Electronic health record-based clinical decision support (EHR CDS) alerts didn’t increase statin prescribing in a three-arm cluster-randomized trial.

Statin prescribing at guideline-recommended doses increased from 41.2% to 44.5% among cardiologists randomized to 6 months of pop-up alerts requiring action, but that was no better than the slight bump seen among controls receiving no intervention (from 41.8% to 42.6%, P=0.08 between groups).

However, for the subgroup of patients with clinical atherosclerotic cardiovascular disease (ASCVD), the active choice intervention did lead to significantly improved statin prescribing at the optimal dose (from 39.8% to 44.6%, P=0.008), reported Mitesh Patel, MD, MBA, of the University of Pennsylvania in Philadelphia, and colleagues.

Whether there is really a benefit for this subgroup of patients warrants further study, Patel’s group wrote in a manuscript published online in JAMA Cardiology.

The active choice intervention consisted of an unchanging pop-up alert in the EHR that required cardiologists to respond by accepting or declining guideline-directed statin therapy for patients deemed not at goal according to 2013 American Heart Association/American College of Cardiology or 2015 National Lipid Association guidelines.

A passive version of the intervention, in which doctors had to manually navigate within the EHR to access the same CDS alert, did not significantly improve statin prescribing at guideline-directed doses over controls, either (from 39.6% at baseline to 40.6%, P=0.86).

Neither the active nor passive intervention improved statin prescribing overall.

Participating cardiologists complained that the CDS notifications tested did not specify the indications that triggered the alert. The message was also confusing for some who thought the alert was saying the patient was not taking a statin at all, rather than that the dose could be increased, Patel and colleagues reported.

“Future interventions could increase general communications before and after the intervention is implemented, as well as within the alert, so that cardiologists are aware that some alerts are focused on increasing the dose of a statin that the patient is already taking,” they suggested.

Notably, 72.7% of cardiologists assigned to the passive choice intervention reported not even remembering seeing the alert over the 6 months of the study.

“Done well, CDS can greatly enhance personalization, efficiency, and effectiveness of care delivery,” according to Thomas Maddox, MD, MSc, of Healthcare Innovation Lab of BJC HealthCare/Washington University School of Medicine in St. Louis.

“However, CDS has yet to realize its potential. Indeed, clinicians have ignored up to 93% of CDS alerts and are frustrated by excessive rates of false-positive reminders. As a result, only two-thirds of CDS are associated with any measurable change in care, and those that do primarily affect process, rather than outcome, measures,” he wrote in his accompanying editorial.

“CDS interventions require codesign and iterative testing with their intended users. Speaking to clinicians’ needs to understand the clinical rationale behind any recommendations and tailoring them to individual patient characteristics are key. Appreciating the context in which clinicians work and incorporating CDS to accommodate those realities is essential,” he emphasized.

User-centered design principles undoubtedly require large