[Skip to Navigation]
Original Investigation
November 30, 2022

Effect of Nudges to Clinicians, Patients, or Both to Increase Statin Prescribing: A Cluster Randomized Clinical Trial

Author Affiliations
  • 1Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 2Wharton School, University of Pennsylvania, Philadelphia
  • 3Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
  • 4School of Medicine, University of California, San Diego
  • 5Ascension, St Louis, Missouri
JAMA Cardiol. 2023;8(1):23-30. doi:10.1001/jamacardio.2022.4373
Key Points

Question  Can scalable approaches to nudge clinicians, patients, or both increase initiation of a statin prescription during primary care visits?

Findings  In this cluster randomized clinical trial of 4131 patients from 28 primary care practices, nudges to clinicians using electronic health record active choice prompts and monthly peer comparison feedback significantly increased statin prescribing by 5.5 percentage points relative to usual care. Nudges to patients by text message before the visit did not significantly increase statin prescribing, but the combination of nudges to clinicians and patients significantly increased statin prescribing by 7.2 percentage points relative to usual care.

Meaning  Electronic health record–based nudges can be an effective and scalable approach to change prescribing behavior.


Importance  Statins reduce the risk of major adverse cardiovascular events, but less than one-half of individuals in America who meet guideline criteria for a statin are actively prescribed this medication.

Objective  To evaluate whether nudges to clinicians, patients, or both increase initiation of statin prescribing during primary care visits.

Design, Setting, and Participants  This cluster randomized clinical trial evaluated statin prescribing of 158 clinicians from 28 primary care practices including 4131 patients. The design included a 12-month preintervention period and a 6-month intervention period between October 19, 2019, and April 18, 2021.

Interventions  The usual care group received no interventions. The clinician nudge combined an active choice prompt in the electronic health record during the patient visit and monthly feedback on prescribing patterns compared with peers. The patient nudge was an interactive text message delivered 4 days before the visit. The combined nudge included the clinician and patient nudges.

Main Outcomes and Measures  The primary outcome was initiation of a statin prescription during the visit.

Results  The sample comprised 4131 patients with a mean (SD) age of 65.5 (10.5) years; 2120 (51.3%) were male; 1210 (29.3%) were Black, 106 (2.6%) were Hispanic, 2732 (66.1%) were White, and 83 (2.0%) were of other race or ethnicity, and 933 (22.6%) had atherosclerotic cardiovascular disease. In unadjusted analyses during the preintervention period, statins were prescribed to 5.6% of patients (105 of 1876) in the usual care group, 4.8% (97 of 2022) in the patient nudge group, 6.0% (104 of 1723) in the clinician nudge group, and 4.7% (82 of 1752) in the combined group. During the intervention, statins were prescribed to 7.3% of patients (75 of 1032) in the usual care group, 8.5% (100 of 1181) in the patient nudge group, 13.0% (128 of 981) in the clinician nudge arm, and 15.5% (145 of 937) in the combined group. In the main adjusted analyses relative to usual care, the clinician nudge significantly increased statin prescribing alone (5.5 percentage points; 95% CI, 3.4 to 7.8 percentage points; P = .01) and when combined with the patient nudge (7.2 percentage points; 95% CI, 5.1 to 9.1 percentage points; P = .001). The patient nudge alone did not change statin prescribing relative to usual care (0.9 percentage points; 95% CI, −0.8 to 2.5 percentage points; P = .32).

Conclusions and Relevance  Nudges to clinicians with and without a patient nudge significantly increased initiation of a statin prescription during primary care visits. The patient nudge alone was not effective.

Trial Registration  ClinicalTrials.gov Identifier: NCT04307472

Add or change institution