Background Numerous implementation strategies to improve utilization of statins in patients with hypercholesterolemia have been utilized, with varying degrees of success. The aim of this systematic review is to determine the state of evidence of implementation strategies on the uptake of statins. Methods and results This systematic review identified and categorized implementation strategies, according to the Expert Recommendations for Implementing Change (ERIC) compilation, used in studies to improve statin use. We searched Ovid MEDLINE, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov from inception to October 2018. All included studies were reported in English and had at least one strategy to promote statin uptake that could be categorized using the ERIC compilation. Data extraction was completed independently, in duplicate, and disagreements were resolved by consensus. We extracted LDL-C (concentration and target achievement), statin prescribing, and statin adherence (percentage and target achievement). A total of 258 strategies were used across 86 trials. The median number of strategies used was 3 (SD 2.2, range 1–13). Implementation strategy descriptions often did not include key defining characteristics: temporality was reported in 59%, dose in 52%, affected outcome in 9%, and justification in 6%. Thirty-one trials reported at least 1 of the 3 outcomes of interest: significantly reduced LDL-C (standardized mean difference [SMD] − 0.17, 95% CI − 0.27 to − 0.07, p = 0.0006; odds ratio [OR] 1.33, 95% CI 1.13 to 1.58, p = 0.0008), increased rates of statin prescribing (OR 2.21, 95% CI 1.60 to 3.06, p < 0.0001), and improved statin adherence (SMD 0.13, 95% CI 0.06 to 0.19; p = 0.0002; OR 1.30, 95% CI 1.04 to 1.63, p = 0.023). The number of implementation strategies used per study positively influenced the efficacy outcomes. Conclusion Although studies demonstrated improved statin prescribing, statin adherence, and reduced LDL-C, no single strategy or group of strategies consistently improved outcomes. Trial registration PROSPERO CRD42018114952.

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Online medical reference websites are utilized by health care providers to enhance their education and decision making. However, these resources may not adequately reveal pharmaceutical-author interactions and their potential conflicts of interest (CoIs). This investigation: 1) evaluated the correspondence of two well-utilized CoI databases: the Centers for Medicare and Medicaid Services Open Payments (CMSOP) and ProPublica Dollars for Docs (PDD) and 2) quantified CoIs among authors of a publically available point of care clinical support website. Two data sources were used: the hundred most common drugs and the top fifty causes of death. These topics were entered into a freely available database. The authors (N = 139) were then input into CMSOP and PDD and compensation and number of payment were determined for 2013-2015. The subset of highly compensated authors that also reported quote: Nothing to disclose, unquote, were further examined. There was a high degree of similarity between CMSOP and PDD for compensation (R2 > 0.998) and payment number (R2 > 0.992). The amount received was 1.4% higher in CMSOP ($4,059,194) than in PDD ($4,002,891). The articles where the authors had received the greatest compensation were in neurology (Parkinsons Disease = $1,810,032), oncology (Acute Lymphoblastic Leukemia = $616,727), and endocrinology (Type I Diabetes = $377,388). Two authors reporting Nothing to disclose received appreciable and potentially relevant compensation. CMSOP and PDD produced almost identical results. CoIs were common among authors but self-reporting may be an inadequate reporting mechanism. Recommendations are offered for improving the CoI transparency of pharmaceutical-author interactions in point-of-care electronic resources.

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BACKGROUND: Financial conflicts of interest among physicians have the potential to negatively impact patient care. Physicians contribute content to two popular, evidence-based websites, UpToDate and DynaMed; while other physicians use these websites to influence their clinical decision making. Each website maintains a conflict-of-interest policy, and contributors are required to self-report a disclosure status. This research investigated the occurrence for potential conflicts of interest among the self-reported statuses of UpToDate and DynaMed content contributors. METHODS: An initial list of contributors for each website was compiled using the Centers for Disease Control and Preventions 2017 Leading Causes of Death. The top 50 causes were used to determine a relevant article with clinical implications from each database. All named authors and editors of those articles comprised our list of investigated contributors. Contributor disclosure status was then compared with public records of financial remuneration as reported in the Open Payments database maintained by the Centers for Medicare and Medicaid Services and ProPublicas Dollar for Docs website from 2013 to 2018. Descriptive analysis and Fishers exact tests were performed on the data. RESULTS: Of 76 UpToDate contributors, 57.9% reported nothing to disclose but had a record of receiving a financial payment on Open Payments, which was found to be statistically significant (p = 0.0002). Of DynaMeds 42 contributors who reported nothing to disclose, 83.3% had an entry on Open Payments. However, this was not statistically significant. The sum total of industry payments between 2013-2018 made to UpToDate contributors was $68.1 million. The top ten UpToDate contributors who received the most financial remuneration earned approximately $56.1 million (82.4% of all UpToDate renumeration), were all male, and only one had a nothing-to-disclose status. The sum total of compensation reported for the discordant UpToDate contributors between 2013-2018 was approximately $4.81 million (or 7.07% of the total monies reported to UpToDate contributors.) In that same time frame, DynaMed contributors received a sum total of $9.58 million from industry, while the top ten DynaMed contributors earned $8.88 million (or 92.8%) of that. The top ten DynaMed contributors were 80% male and 20% female, and six individuals reported nothing to disclose, yet had an Open Payments entry. The sum total of money reported for all discordant DynaMed contributors between 2013-2018 was approximately $2.79 million (or 29.2% of the total monies reported to DynaMed contributors). CONCLUSIONS: While this research does not ascertain that a conflict of interest or anything untoward, it does provide evidence that there was a significant difference between having an Open Payment entry among those who did versus those who did not disclose a conflict of interest. Websites such as UpToDate and DynaMed should consider implementing a more stringent conflict of interest policy and employ an unbiased team to verify self-reported disclosure statuses among its content contributors. Similarly, physicians who use such informational websites to inform their clinical decision making should look beyond a contributors self-reported disclosure status and verify relevant financial remuneration from the healthcare industry via Open Payments or Dollars for Docs.