The Enhancing Secondary Prevention in Coronary Artery Disease trial

Background: Proven efficacious therapies are sometimes underused in patients with chronic cardiac conditions, resulting in suboptimal outcomes. We evaluated whether evidence summaries, which were either unsigned or signed by local opinion leaders, improved the quality of secondary prevention care delivered by primary care physicians of patients with coronary artery disease. Methods: We performed a randomized trial, clustered at the level of the primary care physician, with 3 study arms: control, unsigned statements or opinion leader statements. The statements were faxed to primary care physicians of adults with coronary artery disease at the time of elective cardiac catheterization. The primary outcome was improvement in statin management (initiation or dose increase) 6 months after catheterization. Results: We enrolled 480 adults from 252 practices. Although statin use was high at baseline (n = 316 [66%]), most patients were taking a low dose (mean 32% of the guideline-recommended dose), and their low-density lipoprotein (LDL) cholesterol levels were elevated (mean 3.09 mmol/L). Six months after catheterization, statin management had improved in 79 of 157 patients (50%) in the control arm, 85 of 158 (54%) patients in the unsigned statement group (adjusted odds ratio [OR] 1.18, 95% CI 0.71–1.94, p = 0.52) and 99 of 165 (60%) patients in the opinion leader statement group (adjusted OR 1.51, 95% CI 0.94–2.42, p = 0.09). The mean fasting LDL cholesterol levels after 6 months were similar in all 3 study arms: 2.35 (standard deviation [SD] 0.86) mmol/L in the control arm compared with 2.24 (SD 0.73) among those in the opinion leader group (p = 0.48) and 2.19 (SD 0.68) in the unsigned statement group (p = 0.32). Interpretation: Faxed evidence reminders for primary care physicians, even when endorsed by local opinion leaders, were insufficient to optimize the quality of care for adults with coronary artery disease. ClinicalTrials.gov trial register no. NCT00175240.

[1]  F. McAlister,et al.  A randomized trial of the effect of community pharmacist and nurse care on improving blood pressure management in patients with diabetes mellitus: study of cardiovascular risk intervention by pharmacists-hypertension (SCRIP-HTN). , 2008, Archives of internal medicine.

[2]  Sowmya R. Rao,et al.  Electronic health records in ambulatory care--a national survey of physicians. , 2008, The New England journal of medicine.

[3]  J. Rumsfeld,et al.  Implementing electronic clinical reminders for lipid management in patients with ischemic heart disease in the veterans health administration: QUERI Series , 2008, Implementation science : IS.

[4]  F. McAlister,et al.  The efficacy and safety of intensive statin therapy: a meta-analysis of randomized trials , 2008, Canadian Medical Association Journal.

[5]  F. McAlister,et al.  Multifaceted intervention to improve diagnosis and treatment of osteoporosis in patients with recent wrist fracture: a randomized controlled trial , 2008, Canadian Medical Association Journal.

[6]  Miriam C.J.M. Sturkenboom,et al.  Electronic Alerts Versus On-Demand Decision Support to Improve Dyslipidemia Treatment: A Cluster Randomized Controlled Trial , 2008, Circulation.

[7]  K. Shojania,et al.  The tension between needing to improve care and knowing how to do it. , 2007, The New England journal of medicine.

[8]  Simon Capewell,et al.  Explaining the decrease in U.S. deaths from coronary disease, 1980-2000. , 2007, The New England journal of medicine.

[9]  F. McAlister,et al.  Exploring the treatment-risk paradox in coronary disease. , 2007, Archives of internal medicine.

[10]  R. McPherson,et al.  Canadian Cardiovascular Society position statement--recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease. , 2006, The Canadian journal of cardiology.

[11]  Craig Ramsay,et al.  Effect of enhanced feedback and brief educational reminder messages on laboratory test requesting in primary care: a cluster randomised trial , 2006, The Lancet.

[12]  J. Grimshaw,et al.  A randomized trial to assess the impact of opinion leader endorsed evidence summaries on the use of secondary prevention strategies in patients with coronary artery disease : the ESP-CAD trial protocol [ NCT 00175240 ] , 2006 .

[13]  R. Califf,et al.  Long-Term Adherence to Evidence-Based Secondary Prevention Therapies in Coronary Artery Disease , 2006, Circulation.

[14]  Deepak L. Bhatt,et al.  International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis. , 2006, JAMA.

[15]  Sharon E Straus,et al.  Impact of a patient decision aid on care among patients with nonvalvular atrial fibrillation: a cluster randomized trial , 2005, Canadian Medical Association Journal.

[16]  F. McAlister,et al.  A cluster randomized trial to assess the impact of opinion leader endorsed evidence summaries on improving quality of prescribing for patients with chronic cardiovascular disease: rationale and design [ISRCTN26365328] , 2005, BMC cardiovascular disorders.

[17]  S. Derose,et al.  Point-of-Service reminders for prescribing cardiovascular medications. , 2005, The American journal of managed care.

[18]  B. McNeil,et al.  Effects of treatment recommendations and specialist intervention on care provided by primary care physicians to patients with myocardial infarction or heart failure. , 2004, The American journal of medicine.

[19]  C. Furberg,et al.  From knowledge to practice in chronic cardiovascular disease: a long and winding road. , 2004, Journal of the American College of Cardiology.

[20]  J M Grimshaw,et al.  Effectiveness and efficiency of guideline dissemination and implementation strategies , 2004, International Journal of Technology Assessment in Health Care.

[21]  C. McDonald,et al.  Effects of computerized guidelines for managing heart disease in primary care , 2003, Journal of General Internal Medicine.

[22]  David Parkin,et al.  Effect of computerised evidence based guidelines on management of asthma and angina in adults in primary care: cluster randomised controlled trial , 2002, BMJ : British Medical Journal.

[23]  Jeremy M. Grimshaw,et al.  Changing Provider Behavior: An Overview of Systematic Reviews of Interventions , 2001, Medical care.

[24]  J. Grimshaw,et al.  Effect of audit and feedback, and reminder messages on primary-care radiology referrals: a randomised trial , 2001, The Lancet.

[25]  D. Wood,et al.  Clinical reality of coronary prevention guidelines: a comparison of EUROASPIRE I and II in nine countries , 2001, The Lancet.

[26]  W. Ghali,et al.  Overview of the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease. On behalf of the APPROACH investigators. , 2000, The Canadian journal of cardiology.

[27]  W G Henderson,et al.  Improving residents' compliance with standards of ambulatory care: results from the VA Cooperative Study on Computerized Reminders. , 2000, JAMA.

[28]  E A Balas,et al.  Improving preventive care by prompting physicians. , 2000, Archives of internal medicine.

[29]  S. Eldridge,et al.  Effect of postal prompts to patients and general practitioners on the quality of primary care after a coronary event (POST): randomised controlled trial , 1999, BMJ.

[30]  B. Everitt,et al.  Analysis of longitudinal data , 1998, British Journal of Psychiatry.

[31]  T C Chalmers,et al.  Randomized versus historical controls for clinical trials. , 1982, The American journal of medicine.

[32]  G. Barnett,et al.  Randomized controlled trial of an informatics-based intervention to increase statin prescription for secondary prevention of coronary disease , 2007, Journal of General Internal Medicine.

[33]  P. Austin,et al.  Secondary prevention after acute myocardial infarction in four Canadian provinces, 1997-2000. , 2004, The Canadian journal of cardiology.

[34]  Brian S. Mittman,et al.  Changing Provider Behavior , 1992 .