Encouraging Pharmacist Referrals for Evidence-Based Statin Initiation: Two Cluster Randomized Clinical Trials.

Abstract

Importance: Despite statins' benefit in preventing major adverse cardiovascular events, most patients with an indication for statin therapy are not appropriately treated. Clinicians' limited time and lack of systematic efforts to address preventive care likely contribute to gaps in statin prescribing.

Objective: To determine the effect on statin prescribing of 2 interventions to refer appropriate patients to a pharmacist for lipid management.

Design, setting, and participants: These 2 pragmatic cluster randomized clinical trials were conducted among 12 total primary care practices in a community health system. Trial 1 was a delayed-intervention design of a visit-based intervention with randomization at the clinician level in a single clinic, and trial 2 was a parallel-arm trial of an asynchronous intervention with randomization at the clinic level in 11 clinics. Patients who were assigned to a primary care clinician at a participating practice, had an indication for a high-intensity or moderate-intensity statin, and were either not prescribed a statin or prescribed an inappropriately low statin dose were eligible for inclusion.

Intervention: Trial 1 tested an interruptive electronic health record alert that appeared during eligible patients' visits and facilitated referral to a pharmacist, while trial 2 tested an order for pharmacist referral placed by the study team for cosignature by the primary care clinician without regard to the timing of a clinic visit.

Main outcome and measure: The primary outcome was the proportion of patients prescribed a statin.

Results: Overall, 1412 patients were enrolled in trial 1 and 1950 in trial 2. Across both trials, mean (SD) patient age was 65.6 (9.9) years, and 1485 patients (44.2%) were female. Mean (SD) baseline 10-year risk of major cardiovascular events was 17.9% (9.4). In trial 1, the interruptive alert was not associated with a significant increase in statin prescriptions compared with usual care (15.6% vs 11.6%; unadjusted absolute difference, 3.9 percentage points; 95% CI, -0.4 to 8.3). In trial 2, semiautomated pharmacist referrals were associated with an increase in statin prescriptions by 16 percentage points compared with usual care (31.6% vs 15.2%; unadjusted absolute difference, 16.4 percentage points; 95% CI, 12.7-20.1).

Conclusions and relevance: In these 2 cluster randomized clinical trials, visit-based interruptive alerts were not associated with a significant increase in statin prescribing compared with usual care, whereas a strategy of asynchronous semiautomated referral for pharmacist comanagement was associated with a substantial increase. This strategy of asynchronous semiautomated referrals for pharmacist involvement in lipid management could be a scalable and effective approach to increasing statin prescribing for patients at high risk.

Trial registration: ClinicalTrials.gov Identifier: NCT05537064.