Patient and physician predictors of hyperlipidemia screening and statin prescription.

OBJECTIVES: Appropriate lipid management has been demonstrated to reduce cardiovascular events, but rates of hyperlipidemia screening and statin therapy are suboptimal. We aimed to evaluate patient and physician predictors of guideline-concordant hyperlipidemia screening and statin prescription. STUDY DESIGN: Retrospective study of patients with primary care provider (PCP) visits from 2014 to 2016 at the University of Pennsylvania Health System. METHODS: Data on patients, screening orders, and prescriptions were obtained from the electronic health record. Multivariate logistic regression models were fit to binary outcomes of lipid screening and statin prescription. RESULTS: Among 97,189 eligible patients, 79.9% had an order for hyperlipidemia screening. In adjusted models, significant patient predictors of greater odds of having screening ordered included a history of diabetes (odds ratio [OR], 1.19; 95% CI, 1.10-1.29; P <.001) or hypertension (OR, 1.16; 95% CI, 1.10-1.23; P <.001). Significant provider predictors of lower odds of having screening ordered were being a resident PCP (OR, 0.63; 95% CI, 0.43-0.93; P = .021) or being trained in family medicine (OR, 0.37; 95% CI, 0.30-0.47; P <.001). Among 40,845 eligible patients, 56.1% were prescribed a statin. In adjusted models, significant patient predictors of greater odds of being prescribed a statin were if they had a history of diabetes (OR, 2.70; 95% CI, 2.32-3.13; P <.001) or clinical cardiovascular disease (OR, 2.26; 95% CI, 1.85-2.76; P <.001). Significant provider predictors of lower odds of being prescribed a statin were being a physician assistant (OR, 0.65; 95% CI, 0.52-0.81; P <.001) or female (OR, 0.82; 95% CI, 0.70-0.96; P = .01). CONCLUSIONS: Both patient and provider factors significantly predicted guideline-concordant care for hyperlipidemia screening and statin therapy.

Effect of an Automated Patient Dashboard Using Active Choice and Peer Comparison Performance Feedback to Physicians on Statin Prescribing: The PRESCRIBE Cluster Randomized Clinical Trial.

Importance: Statins are not prescribed to approximately 50% of patients who could benefit from them. Objective: To evaluate the effectiveness of an automated patient dashboard using active choice framing with and without peer comparison feedback on performance to nudge primary care physicians (PCPs) to increase guideline-concordant statin prescribing. Design, Setting, and Participants: This 3-arm cluster randomized clinical trial was conducted from February 21, 2017, to April 21, 2017, at 32 practice sites in Pennsylvania and New Jersey. Participants included 96 PCPs and 4774 patients not previously receiving statin therapy. Data were analyzed from April 25, 2017, to June 16, 2017. Interventions: Primary care physicians in the 2 intervention arms were emailed a link to an automated online dashboard listing their patients who met national guidelines for statin therapy but had not been prescribed this medication. The dashboard included relevant patient information, and for each patient, PCPs were asked to make an active choice to prescribe atorvastatin, 20 mg, once daily, atorvastatin at another dose, or another statin or not prescribe a statin and select a reason. The dashboard was available for 2 months. In 1 intervention arm, the email to PCPs also included feedback on their statin prescribing rate compared with their peers. Primary care physicians in the usual care group received no interventions. Main Outcomes and Measures: Statin prescription rates. Results: Patients had a mean (SD) age of 62.4 (8.3) years and a mean (SD) 10-year atherosclerotic cardiovascular disease risk score of 13.6 (8.2); 2625 (55.0%) were male, 3040 (63.7%) were white, and 1318 (27.6%) were black. In the active choice arm, 16 of 32 PCPs (50.0%) accessed the patient dashboard, but only 2 of 32 (6.3%) signed statin prescription orders. In the active choice with peer comparison arm, 12 of 32 PCPs (37.5%) accessed the patient dashboard and 8 of 32 (25.0%) signed statin prescription orders. Statins were prescribed in 40 of 1566 patients (2.6%) in the usual care arm, 116 of 1743 (6.7%) in the active choice arm, and 117 of 1465 (8.0%) in the active choice with peer comparison arm. In the main adjusted model, compared with usual care, there was a significant increase in statin prescribing in the active choice with peer comparison arm (adjusted difference in percentage points, 5.8; 95% CI, 0.9-13.5; P = .008), but not in the active choice arm (adjusted difference in percentage points, 4.1; 95% CI, -0.8 to 13.1; P = .11). Conclusions and Relevance: An automated patient dashboard using both active choice framing and peer comparison feedback led to a modest but significant increase in guideline-concordant statin prescribing rates. Trial Registration: ClinicalTrials.gov Identifier: NCT03021759.

If You Book It, Will They Come? Attendance at Postdischarge Follow-Up Visits Scheduled by Inpatient Providers.

BACKGROUND: Postdischarge follow-up visits (PDFVs) are widely recommended to improve inpatient-outpatient transitions of care. OBJECTIVE: To measure PDFV attendance rates. DESIGN: Observational cohort study. SETTING: Medical units at an academic quaternary-care hospital and its affiliated outpatient clinics. PATIENTS: Adult patients hospitalized between April 2014 and March 2015 for whom at least 1 PDFV with our health system was scheduled. Exclusion criteria included nonprovider visits, visits cancelled before discharge, nonaccepted health insurance, and visits scheduled for deceased patients. MEASUREMENTS: The study outcome was the incidence of PDFVs resulting in no-shows or same-day cancellations (NS/SDCs). RESULTS: Of all hospitalizations, 6136 (52%) with 9258 PDFVs were analyzed. Twenty-five percent of PDFVs were NS/SDCs, 23% were cancelled before the visit, and 52% were attended as scheduled. In multivariable regression models, NS/SDC risk factors included black race (odds ratio [OR] 1.94, 95% confidence interval [CI], 1.63-2.32), longer lengths of stay (hospitalizations ≥15 days: OR 1.51, 95% CI, 1.22- 1.88), and discharge to facility (OR 2.10, 95% CI, 1.70-2.60). Conversely, NS/SDC visits were less likely with advancing age (age ≥65 years: OR 0.39, 95% CI, 0.31-0.49) and driving distance (highest quartile: OR 0.65, 95% CI, 0.52-0.81). Primary care visits had higher NS/SDC rates (OR 2.62, 95% CI, 2.03-3.38) than oncologic visits. The time interval between discharge and PDFV was not associated with NS/SDC rates. CONCLUSIONS: PDFVs were scheduled for more than half of hospitalizations, but 25% resulted in NS/SDCs. New strategies are needed to improve PDFV attendance.