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Electronic health record-based patient identification and individualized mailed outreach for primary cardiovascular disease prevention: a cluster randomized trial.

ABSTRACT: Many individuals at higher risk for cardiovascular disease (CVD) do not receive recommended treatments. Prior interventions using personalized risk information to promote prevention did not test clinic-wide effectiveness.To perform a 9-month cluster-randomized trial, comparing a strategy of electronic health record-based identification of patients with increased CVD risk and individualized mailed outreach to usual care.Patients of participating physicians with a Framingham Risk Score of at least 5 %, low-density lipoprotein (LDL)-cholesterol level above guideline threshold for drug treatment, and not prescribed a lipid-lowering medication were included in the intention-to-treat analysis.Patients of physicians randomized to the intervention group were mailed individualized CVD risk messages that described benefits of using a statin (and controlling hypertension or quitting smoking when relevant).The primary outcome was occurrence of a LDL-cholesterol level, repeated in routine practice, that was at least 30 mg/dl lower than prior. A secondary outcome was lipid-lowering drug prescribing. Clinicaltrials.gov identifier: NCT01286311.Fourteen physicians with 218 patients were randomized to intervention, and 15 physicians with 217 patients to control. The mean patient age was 60.7 years and 77% were male. There was no difference in the primary outcome (11.0 % vs. 11.1 %, OR 0.99, 95 % CI 0.56-1.74, P?=?0.96), but intervention group patients were twice as likely to receive a prescription for lipid-lowering medication (11.9 %, vs. 6.0 %, OR 2.13, 95 % CI 1.05-4.32, p?=?0.038). In post hoc analysis with extended follow-up to 18 months, the primary outcome occurred more often in the intervention group (22.5 % vs. 16.1 %, OR 1.59, 95 % CI 1.05-2.41, P?=?0.029).In this effectiveness trial, individualized mailed CVD risk messages increased the frequency of new lipid-lowering drug prescriptions, but we observed no difference in proportions lowering LDL-cholesterol after 9 months. With longer follow-up, the intervention's effect on LDL-cholesterol levels was apparent.

SUBMITTER: Persell SD

PROVIDER: S-EPMC3599027 | biostudies-literature | 2013 Apr

REPOSITORIES: biostudies-literature

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Electronic health record-based patient identification and individualized mailed outreach for primary cardiovascular disease prevention: a cluster randomized trial.

Persell Stephen D SD Lloyd-Jones Donald M DM Friesema Elisha M EM Cooper Andrew J AJ Baker David W DW

Journal of general internal medicine 20121111 4

<h4>Background</h4>Many individuals at higher risk for cardiovascular disease (CVD) do not receive recommended treatments. Prior interventions using personalized risk information to promote prevention did not test clinic-wide effectiveness.<h4>Objective and design</h4>To perform a 9-month cluster-randomized trial, comparing a strategy of electronic health record-based identification of patients with increased CVD risk and individualized mailed outreach to usual care.<h4>Participants</h4>Patients ...[more]

PMID: 23143672

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Project description:ImportanceApproximately 24 million US individuals receive care at federally qualified health centers, which historically have low rates of colorectal cancer screening. The US Preventive Services Task Force recommends routine colorectal cancer screening for individuals aged 50 to 75 years.ObjectiveTo determine the effectiveness of an electronic health record (EHR)-embedded mailed fecal immunochemical test (FIT) outreach program implemented in health centers as part of standard care.Design, setting, and participantsThis cluster randomized pragmatic clinical trial was conducted in 26 federally qualified health center clinics, representing 8 health centers in Oregon and California, randomized to intervention (n = 13) or usual care (n = 13). All participants were overdue for colorectal cancer screening during the accrual interval (February 4, 2014 to February 3, 2015).InterventionsElectronic health record-embedded tools to identify eligible adults and to facilitate implementation of a stepwise mailed intervention involving (1) an introductory letter, (2) a mailed FIT, and (3) a reminder letter; training, collaborative learning, and facilitation through a practice improvement process.Main outcomes and measuresEffectiveness was measured as clinic-level proportions of adults who completed a FIT, and secondarily, any colorectal cancer screening within 12 months of accrual or by August 3, 2015. Implementation was measured as clinic-level proportions of adults who were mailed an introductory letter and ordered a FIT.ResultsTwenty-six clinics with 41 193 adults (mean [SD] age, 58.5 [6.3] years; 22 994 women) were randomized to receive the direct mail colorectal screening intervention (13 clinics; 21 134 patients) or usual care (13 clinics; 20 059 patients). Compared with usual care clinics, intervention clinics had significantly higher adjusted clinic-level proportion of participants who completed a FIT (13.9% vs 10.4%; difference, 3.4 percentage points; 95% CI, 0.1%-6.8%) and any colorectal cancer screening (18.3% vs 14.5%; difference, 3.8 percentage points; 95% CI, 0.6%-7.0%). We observed large variation across health centers in effectiveness (FIT completion differences range, -7.4 percentage points to 17.6 percentage points) and implementation (proportion who were mailed a FIT range, 6.5% to 68.2%). The number needed to mail to achieve a completed FIT was 4.8 overall, and 4.0 in clinics that mailed a FIT reminder.Conclusions and relevanceAn EHR-embedded mailed FIT outreach intervention significantly improved rates of FIT completion and rates of any colorectal cancer screening. Higher rates of colorectal cancer screening occurred in clinics that successfully implemented the mailed outreach program.Trial registrationClinicalTrials.gov identifier: NCT01742065.

Project description:Importance:Cardiovascular disease is the leading cause of death in the United States. To improve cardiovascular outcomes, primary care must have valid methods of assessing performance on cardiovascular clinical quality measures, including aspirin use (aspirin measure), blood pressure control (BP measure), and smoking cessation counseling and intervention (smoking measure). Objective:To compare observed performance scores measured using 2 imperfect reference standard data sources (medical record abstraction [MRA] and electronic health record [EHR]-generated reports) with misclassification-adjusted performance scores obtained using bayesian latent class analysis. Design, Setting, and Participants:This cross-sectional study used a subset of the 2016 aspirin, BP, and smoking performance data from the Healthy Hearts for Oklahoma Project. Each clinical quality measure was calculated for a subset of a practice's patient population who can benefit from recommended care (ie, the eligible population). A random sample of 380 eligible patients were included for the aspirin measure; 126, for the BP measure; and 115, for the smoking measure. Data were collected from 21 primary care practices belonging to a single large health care system from January 1 to December 31, 2018, and analyzed from February 21 to April 17, 2019. Main Outcomes and Measures:The main outcomes include performance scores for the aspirin, BP, and smoking measures using imperfect MRA and EHRs and estimated through bayesian latent class models. Results:A total of 621 eligible patients were included in the analysis. Based on MRA and EHR data, observed aspirin performance scores were 76.0% (95% bayesian credible interval [BCI], 71.5%-80.1%) and 74.9% (95% BCI, 70.4%-79.1%), respectively; observed BP performance scores, 80.6% (95% BCI, 73.2%-86.9%) and 75.1% (95% BCI, 67.2%-82.1%), respectively; and observed smoking performance scores, 85.7% (95% BCI, 78.6%-91.2%) and 75.4% (95% BCI, 67.0%-82.6%), respectively. Misclassification-adjusted estimates were 74.9% (95% BCI, 70.5%-79.1%) for the aspirin performance score, 75.0% (95% BCI, 66.6%-82.5%) for the BP performance score, and 83.0% (95% BCI, 74.4%-89.8%) for the smoking performance score. Conclusions and Relevance:Ensuring valid performance measurement is critical for value-based payment models and quality improvement activities in primary care. This study found that extracting information for the same individuals using different data sources generated different performance score estimates. Further research is required to identify the sources of these differences.

Dataset Information

Electronic health record-based patient identification and individualized mailed outreach for primary cardiovascular disease prevention: a cluster randomized trial.

Publications

Electronic health record-based patient identification and individualized mailed outreach for primary cardiovascular disease prevention: a cluster randomized trial.

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