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Original Investigation
October 7, 2020

Effect of Passive Choice and Active Choice Interventions in the Electronic Health Record to Cardiologists on Statin Prescribing: A Cluster Randomized Clinical Trial

Author Affiliations
  • 1Penn Medicine, University of Pennsylvania, Philadelphia
  • 2Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 3Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia
  • 4Wharton School, University of Pennsylvania, Philadelphia
  • 5Crescenz Veterans Affairs Medical Center, Philadelphia
JAMA Cardiol. Published online October 7, 2020. doi:10.1001/jamacardio.2020.4730
Key Points

Question  Do passive choice or active choice decision support interventions in the electronic health record directed to cardiologists improve guideline-directed statin prescribing?

Findings  In this cluster randomized clinical trial of 82 cardiologists from 16 practices including 11 693 patients, neither intervention resulted in a significant change in statin prescribing for the overall sample. Among the subset of patients with an atherosclerotic cardiovascular disease clinical diagnosis, the active choice intervention led to a significant increase in statin prescribing at the optimal dose, but the passive choice intervention did not.

Meaning  Nudges to cardiologists through the electronic health record may be more effective for increasing statin prescribing if they clearly describe their indication, are designed to require action, and are targeted to high-risk patients with existing atherosclerotic cardiovascular disease; these approaches may need to be combined with other interventions to increase their effect.

Abstract

Importance  Statin therapy is underused for many patients who could benefit.

Objective  To evaluate the effect of passive choice and active choice interventions in the electronic health record (EHR) to promote guideline-directed statin therapy.

Design, Setting, and Participants  Three-arm randomized clinical trial with a 6-month preintervention period and 6-month intervention. Randomization conducted at the cardiologist level at 16 cardiology practices in Pennsylvania and New Jersey. The study included 82 cardiologists and 11 693 patients. Data were analyzed between May 8, 2019, and January 9, 2020.

Interventions  In passive choice, cardiologists had to manually access an alert embedded in the EHR to select options to initiate or increase statin therapy. In active choice, an interruptive EHR alert prompted the cardiologist to accept or decline guideline-directed statin therapy. Cardiologists in the control group were informed of the trial but received no other interventions.

Main Outcomes and Measures  Primary outcome was statin therapy at optimal dose based on clinical guidelines. Secondary outcome was statin therapy at any dose.

Results  The sample comprised 11 693 patients with a mean (SD) age of 63.8 (9.1) years; 58% were male (n = 6749 of 11 693), 66% were White (n = 7683 of 11 693), and 24% were Black (n = 2824 of 11 693). The mean (SD) 10-year atherosclerotic cardiovascular disease (ASCVD) risk score was 15.4 (10.0); 68% had an ASVCD clinical diagnosis. Baseline statin prescribing rates at the optimal dose were 40.3% in the control arm, 39.1% in the passive choice arm, and 41.2% in the active choice arm. In adjusted analyses, the change in statin prescribing rates at optimal dose over time was not significantly different from control for passive choice (adjusted difference in percentage points, 0.2; 95% CI, −2.9 to 2.8; P = .86) or active choice (adjusted difference in percentage points, 2.4; 95% CI, −0.6 to 5.0; P = .08). In adjusted analyses of the subset of patients with clinical ASCVD, the active choice intervention resulted in a significant increase in statin prescribing at optimal dose relative to control (adjusted difference in percentage points, 3.8; 95% CI, 1.0-6.4; P = .008). No other subset analyses were significant. There were no significant changes in statin prescribing at any dose for either intervention.

Conclusions and Relevance  The passive choice and active choice interventions did not change statin prescribing. In the subgroup of patients with clinical ASCVD, the active choice intervention led to a small increase in statin prescribing at the optimal dose, which could inform the design or targeting of future interventions.

Trial Registration  ClinicalTrials.gov Identifier: NCT03271931

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