How to increase appropriate statin prescribing? Loop in pharmacists with semi-automated referrals

Main take-away:

A new CHIBE study finds that semi-automated orders for pharmacist referral were associated with a 16-percentage point increase in appropriate statin prescribing compared with usual care.

What the study looked at:

In this study published in JAMA Cardiology, a research team led by Dr. Alexander Fanaroff looked at two different approaches to increase statin prescribing to patients at 12 primary care clinics at Penn Medicine’s Lancaster General Hospital. The patients involved in these studies had an indication for a high- or moderate-intensity statin and did not have a current prescription.

In the most successful approach, the study team placed orders for pharmacist referrals in the primary care provider’s electronic health record inbox for co-signing. The orders weren’t tied to the timing of a patient’s in-person clinic visit; instead, the orders were batched so that the primary care provider could sign off on all the orders for their eligible patients at the same time.

There were 975 orders placed to be co-signed, and 719 were co-signed so that the patient was referred to a pharmacist. More than 430 patients had a 1:1 conversation with a pharmacist, 153 patients could not take a statin due to contraindications, and 129 patients could not be reached, so 198 patients (around 20%) started a statin at an appropriate dose.

“When weighted by practice size, a statin was prescribed to 31.6% of patients assigned to intervention arm practices and 15.2% of those assigned to usual care practices,” the study authors wrote. 

What else they looked at:

The research team also tested an interruptive electronic health record alert that appeared during a patient’s visit to a primary care provider and facilitated a referral to a pharmacist, but these alerts were not associated with a significant increase in statin prescriptions. The pharmacist referral was the pre-selected default option, and the clinician only needed to click “accept.”

This approach was associated with a 3.9 percentage point increase in statin prescribing.

Potential reasons why the electronic health record alert didn’t translate to higher statin prescribing:

The study authors pointed out that the interruptive alert added to instead of reduced a clinician’s to-do list. “An EHR alert notifies a primary care provider of a patient’s indication for statin therapy but does not help with the discussion and shared decision-making necessary to start a medication. Interruptive EHR alerts also contribute to alert fatigue and clinician burnout, and clinicians have been conditioned to cancel alerts rather than engage with their content,” they wrote.

Why this study matters:

Statins can lower the risk of heart attacks, stroke and hardening of the arteries, but most Americans who could benefit from a statin are not appropriately treated with a statin. “Clinicians’ limited time and lack of systematic efforts to address preventative care likely contribute to gaps in statin prescribing,” the authors added. This study offers a way to increase appropriate statin prescribing while reducing clinician workload.

Barriers to address:

“Though this strategy was highly effective, statins were still not started in nearly 70% of patients for whom an order was placed, and further research should examine ways to effectively reach these patients,” the study authors wrote. “Key barriers include lack of primary care provider comfort with pharmacist co-management, inability to reach patents in a climate of increasing unsolicited email and text messages, statin misinformation, and perceived side effects.”

What’s next:

Penn Medicine is rolling out this successful strategy across the health system now, and other health systems could potentially benefit from using this approach of asynchronous semi-automated referrals for pharmacist involvement to increase statin prescribing.  

Authors:

Alexander C. Fanaroff, MD, MHS; Qian Huang, MPH; Kayla Clark, MPH; Laurie A. Norton, MBE; Wendell E. Kellum, MD; Dwight Eichelberger, MD; John C. Wood, MD; Zachary Bricker, MSN, RN; Andrea G. Dooley Wood, PharmD; Greta Kemmer, PharmD; Jennifer I. Smith, PharmD; Srinath Adusumalli, MD, MSHP, MBMI; Mary E. Putt, PhD, ScD; Kevin G. Volpp, MD, PhD