Mitesh S. Patel, MD, MBA
Chief Clinical Transformation Officer
When initiating statins, it is critically important for clinicians to ensure that patients understand the associated benefits and risks, explains Mitesh S. Patel, MD, adding that statins have been shown to significantly reduce the risk for major adverse cardiovascular events, including coronary events and stroke. “Studies have shown that statins can reduce mortality and readmissions by up to 30%,” says Dr. Patel. “However, only about 50% of adults in the United States who could benefit from a statin are prescribed one. These data highlight the critical need for new and innovative approaches to increase statin-prescribing rates.”
A way to potentially improve uptake of statins is to use nudges, which are subtle changes to the way information is framed or choices are offered that can have an outsized impact on behavior. Nudges can provide prompts to remind clinicians about a patient’s statin eligibility and require them to accept or decline a prescription order. This automated approach could foster clinician–patient discussions about statins during primary care visits.
Scalable Approaches to Increase Statin Prescribing
Prior research has suggested that nudge interventions directed to clinicians appear to be promising, but a larger trial testing nudges to patients, clinicians, or both has been lacking. To address this research gap, Dr. Patel and colleagues conducted a study, published in JAMA Cardiology, that evaluated whether nudges to clinicians, patients, or both increased the initiation of statin prescribing during clinician visits. “The goal of our study was to test scalable approaches through the EHR and evaluate which approaches increased statin prescribing,” Dr. Patel says.
The cluster randomized clinical trial evaluated statin prescribing in 158 clinicians from 28 practices and included 4,131 patients. The analysis consisted of a 12-month pre-intervention period and a 6-month intervention period. For the study, the clinician nudge combined an active choice prompt in the EHR during patient visits and monthly feedback on prescribing patterns compared with peers. The patient nudge was an interactive text message that was delivered 4 days before a visit. The combined nudge included the clinician and patient nudges, whereas the usual care group received no intervention. The sample included patients with a mean age of 65.5, and 51.3% were male. Most patients (66.1%) were White, and 22.6% of the study population had atherosclerotic cardiovascular disease.
Statin Prescribing Tripled
Results from unadjusted analyses during the pre-intervention period showed that statins were prescribed to 6.0% of patients in the clinician nudge group, 4.8% of patients in the patient nudge group, 4.7% of patients in the combined group, and 5.6% of patients in the usual care group. During the intervention period, statins prescription rates increased to 13.0% for the clinician nudge arm, 8.5% for the patient nudge group, 15.5% for the combined group, and 7.3% for the usual care group.
After adjusting analyses relative to usual care, the clinician nudge significantly increased statin prescribing alone, as well as when combined with the patient nudge. “Nudges to both clinicians and patients tripled statin prescribing and represented a 7.2 percentage point increase when compared with usual care,” says Dr. Patel (Figure). “Nudges to clinicians alone were also effective, but nudges to patients alone were not.” Of note, only one-third of patients agreed to receive the nudge via text message, dampening its overall effect.
Consider Implementing Nudges in EHRs to Increase Statin Uptake
“The most important takeaway from our study is that statins are often prescribed through a shared decision-making process between patients and clinicians,” Dr. Patel says. “Our study found that nudging both parties was the most impactful approach to increase statin prescribing rates. Healthcare systems and medical practices should consider implementing the interventions used in our study, particularly the clinician nudge that can be programmed through the EHR.”