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August 28, 2019

Effectiveness of Interventions Aimed at Increasing Statin-Prescribing Rates in Primary Cardiovascular Disease Prevention: A Systematic Review of Randomized Clinical Trials

Author Affiliations
  • 1Faculty of Medical Science, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
  • 2ICES, Toronto, Ontario, Canada
  • 3School of Public Health, University of Michigan, Ann Arbor
  • 4Schulich Heart Centre, Sunnybrook Health Services Centre, Toronto, Ontario, Canada
  • 5University of Toronto, Toronto, Ontario, Canada
  • 6Western University of Health Sciences, Pomona, California
  • 7St. Michael’s Hospital, Toronto, Ontario, Canada
  • 8Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada
  • 9Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
  • 10Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
  • 11Patient Partnership, Community Heart Outcomes Improvement and Cholesterol Education Study (CHOICES) Trial at ICES, Toronto, Ontario, Canada
  • 12Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
  • 13Women’s College Hospital, Toronto, Ontario, Canada
JAMA Cardiol. 2019;4(11):1160-1169. doi:10.1001/jamacardio.2019.3066
Key Points

Question  What type of interventions are most effective at increasing statin-prescribing rates among patients for whom primary cardiovascular disease prevention is indicated?

Findings  This systematic review found that patient-education initiatives were effective in more than half of the trials that attempted them, and interventions that combined audit and feedback with electronic decision-support tools were also effective. Generic physician-education initiatives were generally ineffective.

Meaning  Patient-focused interventions are more effective than generic physician-focused educational interventions at increasing statin-prescribing rates among patients suited for primary prevention, and both kinds of interventions are most effective when providing personalized cardiovascular risk information, dynamic decision-support tools, or audit and feedback reports.


Importance  Statins are a cornerstone medication in cardiovascular disease prevention, but their use in clinical practice remains suboptimal, with less than half of people who are indicated for statins actually taking the medication.

Objective  To perform a systematic review and synthesis of the literature on patient-oriented and physician-oriented interventions aimed at increasing statin-prescribing rates in adults without a history of cardiovascular disease.

Evidence Review  PubMed, Embase, and the Cochrane Library were searched for randomized clinical trials published between January 2000 and May 2019. Data abstraction was performed using the Cochrane Public Health Review Group’s data collection template, and a narrative synthesis of study results was conducted. The risk of bias in each study was qualitatively assessed, and a funnel plot was created to further evaluate the risk of publication bias.

Findings  Among 7948 citations and 128 full-text articles reviewed, 20 studies (of 109 807 patients) were included in the review. Eight trials reported a statistically significant increases in statin-prescribing rates. Among the effective trials, absolute effect sizes ranged from 4.2% (95% CI, 2.2%-6.4%) to 23% (95% CI, 7.3%-38.9%) and odds ratios from 1.29 (95% CI, 1.01-1.66) to 11.8 (95% CI, 8.8-15.9). Patient-education initiatives were the most commonly effective intervention, with 4 of 7 trials indicating increases in statin-prescribing rates. Two trials combined electronic decision-support tools with audit-and-feedback systems, both of which were effective overall. Physician-education programs without dynamic input regarding patient risk or updated treatment recommendations were generally found to be less effective.

Conclusions and Relevance  While heterogeneous in their interventions and outcomes, a number of interventions have demonstrated increases in statin-prescribing rates, with patient-education initiatives demonstrating more promising results than those focused on physician education alone. As opposed to more education about generic recommendations, tailored patient-focused and physician-focused interventions were more effective when they provided personalized cardiovascular risk information, dynamic decision-support tools, or audit-and-feedback reports in a multicomponent program. There are a number of modestly successful approaches to implement increases in rates of statin prescribing, a proven yet underused cardiovascular disease prevention class of therapy.

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