Impact of a multifaceted intervention on cholesterol management in primary care practices: guideline adherence for heart health randomized trial

Abstract

Background: Physician adherence to National Cholesterol Education Program clinical practice guidelines has been poor.

Methods: We recruited 68 primary care family and internal medicine practices; 66 were randomly allocated to a study arm; 5 practices withdrew, resulting in 29 receiving the Third Adult Treatment Panel (ATP III) intervention and 32 receiving an alternative intervention focused on the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7). The ATP III providers received a personal digital assistant providing the Framingham risk scores and ATP III-recommended treatment. All practices received copies of each clinical practice guideline, an introductory lecture, 1 performance feedback report, and 4 visits for intervention-specific academic detailing. Data were abstracted at 61 practices from random samples of medical records of patients treated from June 1, 2001, through May 31, 2003 (baseline), and from May 1, 2004, through April 30, 2006 (follow-up). The proportion screened with subsequent appropriate decision making (primary outcome) was calculated. Generalized estimating equations were used to compare results by arm, accounting for clustering of patients within practices.

Results: We examined 5057 baseline and 3821 follow-up medical records. The screening rate for lipid levels increased from 43.6% to 49.0% (ATP III practices) and from 40.1% to 50.8% (control practices) (net difference, -5.3% [P = .22]). Appropriate management of lipid levels decreased slightly (73.4% to 72.3%) in ATP III practices and more markedly (79.7% to 68.9%) in control practices. The net change in appropriate management favored the intervention (+9.7%; 95% confidence interval [CI], 2.8%-16.6% [P < .01]). Appropriate drug prescription within 4 months decreased in both arms (38.8% to 24.8% in ATP III practices and 45.3% to 24.1% in control practices; net change, +7.2% [P = .37]) Overtreatment declined from 6.6% to 3.9% in ATP III and rose from 4.2% to 6.4% in control practices (net change, -4.9% [P = .01]).

Conclusions: A multifactor intervention including personal digital assistant-based decision support may improve primary care physician adherence to the ATP III guidelines. Trial Registration clinicaltrials.gov Identifier: NCT00224848.

Figure 1

Computerized decision support tool screen views from the Guideline Adherence for Heart Health Trial. ATP III indicates Third Adult Treatment Panel; CHD, coronary heart disease; dz, disease; Fm Hx, family history; HDL, high-density lipoprotein cholesterol level; HTN, hypertension; LDL, low-density lipoprotein cholesterol level; Rx, prescription; TC, total cholesterol level; and TG, triglyceride level.

Figure 2

Consort diagram for the Guideline Adherence for Heart Health (GLAD HEART) Trial. ATP III indicates Third Adult Treatment Panel; JNC-7, Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.