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Randomized Controlled Trial
. 2023 Jan 1;8(1):23-30.
doi: 10.1001/jamacardio.2022.4373.

Effect of Nudges to Clinicians, Patients, or Both to Increase Statin Prescribing: A Cluster Randomized Clinical Trial

Srinath Adusumalli  1 , Genevieve P Kanter  1 , Dylan S Small  2 , David A Asch  1   2 , Kevin G Volpp  1   2   3 , Sae-Hwan Park  1 , Yevgeniy Gitelman  1 , David Do  1 , Damien Leri  1 , Corinne Rhodes  1 , Christine VanZandbergen  1 , John T Howell  1 , Mika Epps  1 , Ann M Cavella  1 , Michael Wenger  1 , Tory O Harrington  1 , Kayla Clark  1 , Julie E Westover  4 , Christopher K Snider  1 , Mitesh S Patel  5
Affiliations
Randomized Controlled Trial

Effect of Nudges to Clinicians, Patients, or Both to Increase Statin Prescribing: A Cluster Randomized Clinical Trial

Srinath Adusumalli et al. JAMA Cardiol. .

Abstract

Importance: Statins reduce the risk of major adverse cardiovascular events, but less than one-half of individuals in America who meet guideline criteria for a statin are actively prescribed this medication.

Objective: To evaluate whether nudges to clinicians, patients, or both increase initiation of statin prescribing during primary care visits.

Design, setting, and participants: This cluster randomized clinical trial evaluated statin prescribing of 158 clinicians from 28 primary care practices including 4131 patients. The design included a 12-month preintervention period and a 6-month intervention period between October 19, 2019, and April 18, 2021.

Interventions: The usual care group received no interventions. The clinician nudge combined an active choice prompt in the electronic health record during the patient visit and monthly feedback on prescribing patterns compared with peers. The patient nudge was an interactive text message delivered 4 days before the visit. The combined nudge included the clinician and patient nudges.

Main outcomes and measures: The primary outcome was initiation of a statin prescription during the visit.

Results: The sample comprised 4131 patients with a mean (SD) age of 65.5 (10.5) years; 2120 (51.3%) were male; 1210 (29.3%) were Black, 106 (2.6%) were Hispanic, 2732 (66.1%) were White, and 83 (2.0%) were of other race or ethnicity, and 933 (22.6%) had atherosclerotic cardiovascular disease. In unadjusted analyses during the preintervention period, statins were prescribed to 5.6% of patients (105 of 1876) in the usual care group, 4.8% (97 of 2022) in the patient nudge group, 6.0% (104 of 1723) in the clinician nudge group, and 4.7% (82 of 1752) in the combined group. During the intervention, statins were prescribed to 7.3% of patients (75 of 1032) in the usual care group, 8.5% (100 of 1181) in the patient nudge group, 13.0% (128 of 981) in the clinician nudge arm, and 15.5% (145 of 937) in the combined group. In the main adjusted analyses relative to usual care, the clinician nudge significantly increased statin prescribing alone (5.5 percentage points; 95% CI, 3.4 to 7.8 percentage points; P = .01) and when combined with the patient nudge (7.2 percentage points; 95% CI, 5.1 to 9.1 percentage points; P = .001). The patient nudge alone did not change statin prescribing relative to usual care (0.9 percentage points; 95% CI, -0.8 to 2.5 percentage points; P = .32).

Conclusions and relevance: Nudges to clinicians with and without a patient nudge significantly increased initiation of a statin prescription during primary care visits. The patient nudge alone was not effective.

Trial registration: ClinicalTrials.gov Identifier: NCT04307472.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Adusumalli reported having been employed by CVS Health outside the submitted work. Dr Asch is a partner and part owner of VAL Health and reported receiving personal fees from VAL Health, North American Center for Continuing Medical Education, Virginia Medical Center, Johns Hopkins University, MITRE Corporation, The University of Chicago, the US Airforce and Spaceforce, Deloitte, and Boehringer Ingelheim outside the submitted work. Dr Volpp reported receiving grants from the National Institute on Aging during the conduct of the study and being part owner of VAL Health and receiving grants from Humana, Hawaii Medical Services Association, and WW International outside the submitted work. Dr Patel reported being owner of and receiving personal fees from Catalyst Health LLC and serving on an advisory board and receiving personal fees from Humana outside the submitted work. No other disclosures were reported.

Figures

Figure.
Figure.. Flow Diagram of Practice Intervention Assignment
All groups received an email notification about the study. The usual care group received no other interventions. The combined group received both the patient nudge and the clinician nudge interventions.
See this image and copyright information in PMC

Comment in

References

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