EHR alert had small effect on lipid therapy in highest-risk patients
A trial alert nudged clinicians seeing patients with very high-risk atherosclerotic cardiovascular disease to intensify therapy by prescribing a high-intensity statin, adding ezetimibe, or prescribing a proprotein subtilisin/kexin type 9 inhibitor.
A real-time, targeted, individualized electronic health record (EHR) alert resulted in a numerically higher but not statistically significant increase in patients with atherosclerotic cardiovascular disease receiving lipid lowering therapy intensification compared with usual care, a study found.
The PROMPTLIPID (PRagmatic Trial of Messaging to Providers about Treatment of HyperLIPIDemia) study tested whether EHR alerts improve treatment intensification in patients with very high-risk atherosclerotic cardiovascular disease. It was a pragmatic trial in which cardiovascular and internal medicine clinicians within a single health system were cluster-randomized to receive an EHR alert with individualized lipid-intensifying recommendations or no alert. The primary outcome was intensification, entailing a change to high-intensity statin or addition of ezetimibe or a proprotein subtilisin/kexin type 9 inhibitor (PCSK9i) within 90 days. Secondary outcomes included low-density lipoprotein cholesterol (LDL-C) level, proportion of patients with LDL-C <70 or <55 mg/dL, rate of major adverse cardiovascular events (MACE), ED visits, and six-month mortality. Results were published by Circulation: Cardiovascular Quality and Outcomes on April 18.
The no-alert group included 47 clinicians and 1,370 patients (median age, 71 years; 50.1% female; median LDL-C, 93 mg/dL). The alert group included 49 clinicians and 1,130 patients (median age, 72 years; 47% female; median LDL-C, 91 mg/dL). Overall, the primary outcome was observed in 14.1% of patients in the alert group as compared with 10.4% in the no-alert group. Among patients of clinicians in the intervention group who did not dismiss the alert, there was a more than twofold increase in lipid-therapy intensification (21.2% versus 10.4%, odds ratio, 2.33 [95% CI, 1.48 to 3.66]).
There were no differences in any secondary outcome at six months. However, in both groups, LDL-C levels at 90 and 180 days for those with available follow-up data were significantly lower than baseline.
Despite abundant evidence and guideline recommendations, lipid-lowering therapy remains underused, the study authors wrote, and EHR alerts, along with strategies to reduce clinician dismissal, may help address persistent gaps in LDL-C management.
"When clinicians did not defer the alert, there were significantly greater prescriptions of high-intensity statins, ezetimibe, and PCSK9i than for patients whose clinicians saw no alert," the authors wrote. "However, clinician receptiveness of the alert before and upon seeing the alert varied. To drive more clinicians to open the order set from the alert, future iterations of the alert may require repeated clinician focus groups to better understand motivations to accept the alert, as well as improve the user interface of the alert."