Translating Cholesterol Guidelines Into Primary Care Practice: A Multimodal Cluster Randomized Trial

Abstract

PURPOSE We wanted to determine whether an intervention based on patient activation and a physician decision support tool was more effective than usual care for improving adherence to National Cholesterol Education Program guidelines.METHODS A 1-year cluster randomized controlled trial was performed using 30 primary care practices (4,105 patients) in southeastern New England. The main outcome was the percentage of patients screened for hyperlipidemia and treated to their low-density lipoprotein (LDL) and non-high-density lipoprotein (HDL) cholesterol goals.RESULTS After 1 year of intervention, both randomized practice groups improved screening (89% screened), and 74% of patients in both groups were at their LDL and non-HDL cholesterol goals (P <.001). Using intent-to-treat analysis, we found no statistically signifi cant differences between practice groups in screening or percentage of patients who achieved LDL and non-HDL cholesterol goals. Post hoc analysis showed practices who made high use of the patient activation kiosk were more likely to have patients screened (odds ratio [OR] = 2.54; 95% confidence interval [CI], 1.97-3.27) compared with those who made infrequent or no use. Additionally, physicians who made high use of decision support tools were more likely to have their patients at their LDL cholesterol goals (OR = 1.27; 95% CI, 1.07-1.50) and non-HDL goals (OR = 1.23; 95% CI, 1.04-1.46) than low-use or no-use physicians.CONCLUSION This study showed null results with the intent-to-treat analysis regarding the benefi ts of a patient activation and a decision support tool in improving cholesterol management in primary care practices. Post hoc analysis showed a potential benefi t in practices that used the e-health tools more frequently in screening and management of dyslipidemia. Further research on how to incorporate and increase adoption of user-friendly, patient-centered e-health tools to improve screening and management of chronic diseases and their risk factors is warranted.Ann Fam Med 2011;9:528-537. doi:10.1370/afm.1297. INTRODUCTIONC oronary heart disease (CHD) remains the leading cause of death in the United States and in most Western countries.1 Strong evidence linking hyperlipidemia to CHD and the clinical benefi ts of medical therapy in the treatment of hyperlipidemia led to evidence-based consensus guidelines regarding the optimal management of hyperlipidemia for the United States, the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III Cholesterol Management Guidelines. Despite the publication of these guidelines in 2001 529 CHOL ES T EROL GUIDEL INES IN TO PR AC T ICEThis problem of underscreening and undertreatment of dyslipidemia is also true for Canada, Britain, Australia, and other European Union countries. [7][8][9][10][11][12][13][14] Potential barriers to the implementation of cholesterol guidelines into clinical practice appear related to clinician knowledge, attitudes, and behaviors; patient knowledge, attitudes, and behaviors; doctor-patient co...

Patient and public attitudes to and awareness of clinical practice guidelines: a systematic review with thematic and narrative syntheses

“…Five studies reported that participants thought guidelines could be used as a simple tool to provide health information and recommendations which could lead to a better understanding of their health [15,16,21,22,38]. However, surveys conducted by SIGN and NICE found that only 8% of respondents thought guidelines were used to inform the public or dealt with advice for patients [30,34].…”

Clinical Decision Support Systems and Prevention

“…The update search (January 2011 through October 2012) identified 14 articles representing 13 unique studies. 81–94 Of these, seven studies 81–87 met the inclusion criteria; however, one study 86 was judged to be of limited quality and therefore excluded from analysis. From the combined searches, a total of 45 studies 24–34,36–39,41–48,50–56,58,60,61,63,65–68,80–85,87 qualified for analysis in this review.…”

“…Nineteen studies 25,34,36,39,44,46–48,51,53–55,58,60,61,63,82,84,87 were conducted in practices with an academic affiliation, and three studies 25,28,80 took place in Veterans Affairs facilities. Studies focused on screening for CVD risk factors (six studies) 36,42,43,48,66,67 ; hypertension management (seven studies) 25,33,37,39,50,51,63 ; lipid management (six studies) 24,27,33,68,81,84 ; and diabetes management or CVD prevention among a diabetic population (15 studies). 26,29,30,38,41,44,45,47,52,58,60,65,82,85,87 Further, 11 studies 28,31,32,34,46,53–56,61,80 addressed other disease areas in addition to CVD prevention.…”

“…Median duration of intervention was 12 months (IQI=6, 18.5) and the median number of included clinicians was 24 (IQI=13, 68), with a median of 1,190 total patients (IQI=588, 3545) per study. CDSS users were usually physicians (39 studies), 24–26,28,29,31,33,34,36–39,41,43–48,50–56,58,61,63,65–68,81–85,87 followed by nurses (12 studies) 24–26,29,36,41,45,47,50,61,63,84 ; physician assistants (five studies) 24,25,31,36,45 ; and pharmacists (two studies). 51,60 Most interventions used locally developed CDSSs (24 studies), 24,25,27,28,31,37–39,44–48,51,54,55,58,61,63,65,66,83,85,87 and were integrated within EHRs (29 studies).…”

“…24,28–30,32–34,37–39,42,43,46,50–52,54–56,63,66–68,80,82–85,87 Decision support was usually delivered to the clinician synchronously during patient visits (38 studies), 24–28,30,33,34,36–39,41–44,46,48,51–56,58,60,61,65–68,80–85,87 and CDSS recommendations were usually system-initiated when delivered automatically without a clinician request (37 studies). 25–34,36,39,42,44–48,51–54,56,58,60,61,63,65–68,80–85 Most CDSSs were tailored to provide support for chronic disease management (24 studies) 24–29,37–39,41,44,45,51,52,58,63,65,80–85,87 ; pharmacotherapy (17 studies) 30,33,46,47,50,52,55,58,60,63,65,66,81,82,84,85,87 ; preventive care (15 studies) …”