Randomized controlled trial of an informatics-based intervention to increase statin prescription for secondary prevention of coronary disease

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This research studied whether or not the use of a computer-assisted physician-directed intervention could improve treatment of hyperlipidemia. It evaluated if changes in hyperlipidemia prescriptions, time to prescription change, and changes in LDL levels could be improved by using an e-mail summary reminder using available and relevant information for making a sound medical decision. A summary e-mail was sent to physicians with patients in their panel who had hyperlipidemia based on lab values. It contained possible medication choices, anticipated postintervention NCEP-goal achievement, predicted postintervention LDL result, and provided patient insurance formulary preference and copay information. It also had a one-click response set consisting of 3 mutually exclusive actions. These consisted of: • Change in medications: This hyperlink generated a specific statin prescription and updated the patient's EHR. The prescription, an explanatory letter, a "Statins Frequently Asked Questions" sheet, and a tailored hyperlipidemia patient information page were automatically printed to be signed by the physician and mailed to the patient • Repeat of lab test: This link automatically generated a patient letter requesting a repeat fasting lipid profile as well as a completed laboratory requisition and hyperlipidemia patient information page • Decline to provide further treatment: When providers declined to change medical management, a questionnaire captured the physician's clinical rationale for not changing care in that particular patient. All of the information was automatically entered into the EHR. The study was a randomized controlled trial with two hundred thirty-five patients under the care of 14 primary care physicians in an academically affiliated practice with an electronic health record. Each patient with CAD or risk equivalent above National Cholesterol Education Program-recommended low-density lipoprotein (LDL) treatment goal for greater than 6 months was randomized, stratified by physician and baseline LDL. Physicians received a single e-mail per intervention patient. E-mails were visit independent, provided decision support, and facilitated "one-click" order writing. The results showed that a greater proportion of intervention patients had prescription changes at 1 month (15.3% vs 2%, P=.001) and 1 year (24.6% vs 17.1%, P=.14). The median interval to first medication adjustment occurred earlier among intervention patients (0 vs 7.1 months, P=.005). Among patients with baseline LDLs >130 mg/dL, the first postintervention LDLs were substantially lower in the intervention group (119.0 vs 138.0 mg/dL, P=.04). Physician processing time was under 60 seconds per e-mail. The researchers concluded that a visit-independent disease management tool resulted in significant improvement in secondary prevention of hyperlipidemia at 1-month postintervention and showed a trend toward improvement at 1 year. Comment: While it may seem counterintuitive that e-mail independent of the patient visit would be a good means of communicating a clinical reminder, this intervention worked well. A significant part of the success of this new strategy is the inclusion of a concise means of assessing the patient’s status, ordering the new medication, documentation of the prescription, and addressing patient follow-up all in one e-mail. This research points to creating many-faceted solutions that assist the practitioner to use electronic data efficiently. We need more synthesizing uses of technology like this in order to optimize the benefits of electronic data in clinical applications. JG