Clinical decision support directed to primary care patients and providers reduces cardiovascular risk: a randomized trial

Abstract

Objective: To test the hypothesis that use of a clinical decision support (CDS) system in a primary care setting can reduce cardiovascular (CV) risk in patients.

Materials and methods: Twenty primary care clinics were randomly assigned to usual care (UC) or CDS. For CDS clinic patients identified algorithmically with high CV risk, rooming staff were prompted by the electronic health record (EHR) to print CDS that identified evidence-based treatment options for lipid, blood pressure, weight, tobacco, or aspirin management and prioritized them based on potential benefit to the patient. The intention-to-treat analysis included 7914 adults who met high CV risk criteria at an index clinic visit and had at least one post-index visit, accounted for clustering, and assessed impact on predicted annual rate of change in 10-year CV risk over a 14-month period.

Results: The CDS was printed at 75% of targeted visits, and providers reported 85% to 98% satisfaction with various aspects of the intervention. Predicted annual rate of change in absolute 10-year CV risk was significantly better in CDS clinics than in UC clinics (-0.59% vs. +1.66%, -2.24%; P < .001), with difference in 10-year CV risk at 12 months post-index favoring the CDS group (UC 24.4%, CDS 22.5%, P < .03).

Discussion: Deploying to both patients and providers within primary care visit workflow and limiting CDS display and print burden to two mouse clicks by rooming staff contributed to high CDS use rates and high provider satisfaction.

Conclusion: This EHR-integrated, web-based outpatient CDS system significantly improved 10-year CV risk trajectory in targeted adults.

Trial registration: ClinicalTrials.gov NCT01420016.

Figure 1.

CONSORT Diagram showing identification of study eligible subjects and exclusions for various reasons in this clinic-randomized trial.

Figure 2.

Provider clinical decision support (CDS) display for a fictitious patient. This is displayed on the EHR screen then printed by the rooming nurse and placed on the exam room door for rapid review by the provider just before the start of the visit. Uncontrolled CV risk factors are prioritized by the potential absolute risk reduction that may be achieved by management of that risk factor. The benefit for BMI is predicated on a 3-unit drop in BMI with a floor BMI of 25.

Figure 3.

Clinical decision support (CDS) display for a fictitious patient. This is printed by the rooming nurse and given to the patient to review while waiting in the exam room for the provider, with this message, “If you want to reduce your chance of a stroke or heart attack, talk to your doctor about the things with the most caution symbols.”

Figure 4.

Schematic diagram illustrating encryption, firewalls, and other measures taken to secure transmission of personally identifiable information between the EMR and the clincial decision support (CDS) web service. Data transfer is governed by business associate agreements.

Figure 5.

Change in CVR.

Figure 6.

Clinical decision support (CDS) use rates at intervention clinic visits of study-eligible patients before the best practice advisory (vanguard) on the left and after the best practice advisory (main study) on the right.