Doc Reminders, Patient Payments to Increase Statins?

Megan Brooks

October 15, 2020

Clinician "nudges" embedded in the electronic health record (EHR) can boost statin prescribing, at least for patients with atherosclerotic cardiovascular disease (ASCVD), a new study suggests.

On the patient side, offering financial incentives to get patients to stick to their statin regimen helped with adherence but didn't translate into improved low-density lipoprotein cholesterol (LDL-C) levels, according to a separate report.

"The EHR is increasingly being used to influence medical decision making. These approaches are very scalable but often are not rigorously tested to help us understand what works and what does not," said Mitesh S. Patel, MD, MBA, with the Penn Medicine Nudge Unit, Perelman School of Medicine at the University of Pennsylvania, in Philadelphia. He is senior author of the clinician study, which was published online October 7 in JAMA Cardiology.

To investigate, Patel and his team randomly embedded one of two types of nudges into patients' EHR.

One was a "passive choice" in which cardiologists had to manually access an alert embedded in the EHR to select options to start or increase statin therapy. The other was an "active choice" pop-up alert that prompted the cardiologist to accept or decline guideline-directed statin therapy.

Each prompt was tailored to flag patients with or at risk for ASCVD and indicated an optimal statin dose based on the patients' information.

Participants included 82 cardiologists from 16 practices in New Jersey and Pennsylvania ― 28 in the active choice group, 27 in the passive choice group, and 27 in a control group. The cardiologists in the control group were informed of the trial but received no other interventions.

The study also included 11,693 patients (mean age, 63.8 years; mean 10-year ASCVD risk score, 15.4; 68% with ASVCD). The baseline rate of optimal statin dosing was balanced across the three groups and ranged from 39% to 41%.

In adjusted analyses, the change in optimal-dose statin prescribing rates 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).

However, in the subgroup of patients with ASCVD, the active choice nudge led to a significant increase in optimal-dose statin prescribing relative to control (adjusted difference in percentage points, 3.8; 95% CI, 1.0 – 6.4; P = .008).

"Among patients with the highest risk, those who already had heart disease, the active choice prompt that forced cardiologists to decide whether to prescribe statins significantly increased statin prescribing. This approach did not work for those without heart disease," Patel told | Medscape Cardiology.

The passive choice intervention that required the cardiologist to open it for use had no impact on any group, he said.

"We conducted a survey of clinicians after the trial and found that some were unsure about why the patient needed to be on a statin, and this may have led them to dismiss it. In future work, we are planning on identifying the indication for treatment ― for these patients, it would be that they are at high risk to develop heart disease," said Patel.

In a linked commentary, Thomas Maddox, MD, Healthcare Innovation Lab, BJC HealthCare/Washington University School of Medicine, St. Louis, Missouri, says this study provides important insights into effective design and evaluation of clinical decision-support (CDS) systems.

CDS interventions require "codesign and iterative testing with their intended users. Speaking to clinicians' needs to understand the clinical rationale behind any recommendations and tailoring them to individual patient characteristics are key," Maddox writes.

Pay Patients to Take Their Meds?

In the other study, published online October 9 in JAMA Network Open, financial incentives improved adherence to statin therapy in some patients, but this did not translate into improved LDL-C levels.

"While financial incentives may motivate some patients, our study suggests that this type of motivation is not enough to help patients create sustainable, healthy habits," Iwan Barankay, PhD, the Wharton School, University of Pennsylvania, told | Medscape Cardiology.

The researchers tested the effect of three sweepstakes-style financial incentives on statin adherence and lipid control in a randomized clinical trial of 805 adults (mean age, 58.5 years). The participants were at elevated risk for ASCVD, their cholesterol levels were suboptimal, and they had imperfect adherence to statin therapy.

Over 6 months, all participants (201 in the control group and 604 in the intervention groups) received daily statin reminders and an electronic pill bottle to gauge adherence.

The financial incentives were a simple daily sweepstakes that gave a financial incentive for daily adherence; a deadline sweepstakes in which the financial incentive was reduced if the participant was adherent only after a reminder; and a sweepstakes plus deposit incentive in which money was deposited or deducted into a virtual account on the basis of adherence.

Adherence to statin therapy was better in people who received financial incentives, but the change in LDL-C level from baseline to 12 months, the primary outcome, did not differ between intervention groups and the control group.

Table. Mean LDL Reduction by Intervention

Intervention Mean LDL-C reduction at 12 months (mg/dL)
Control 33.6
Simple daily sweepstakes 32.4
Deadline sweepstakes 33.2
Sweepstakes + deposit 36.5


"The study shows that financial incentives for statin adherence do not lead to health improvements," Barankay told | Medscape Cardiology.

"Our results instead suggest that future research should explore new ways of supporting patients to overcome personal barriers to medication adherence ― like coaching, social incentives, or tailored education," he said.

The study by Patel et al was supported by the University of Pennsylvania Health System through the Penn Medicine Nudge Unit. Patel has received personal fees and other compensation from Catalyst Health, HealthMine Services, and Holistic Industries and other support from Maddox advises Myia Labs in his role as a cardiologist and the executive director of the Healthcare Innovation Lab at BJC HealthCare/Washington University School of Medicine, for which his employer receives equity compensation in the company. He is also a compensated director for the J. F. Maddox Foundation. The study by Barankay et al was supported by CVS Health and by a grant from the National Institutes of Health. Two authors have disclosed financial relationships with CVS.

JAMA Cardiol. Published online October 7, 2020. Abstract, Commentary

JAMA Netw Open. Published online October 9, 2020. Full text

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