Improving treatment intensification to reduce cardiovascular disease risk: a cluster randomized trial

Joe V Selby, Julie A Schmittdiel, Bruce Fireman, Marc Jaffe, Laura J Ransom, Wendy Dyer, Connie S Uratsu, Mary E Reed, Eve A Kerr, John Hsu, Joe V Selby, Julie A Schmittdiel, Bruce Fireman, Marc Jaffe, Laura J Ransom, Wendy Dyer, Connie S Uratsu, Mary E Reed, Eve A Kerr, John Hsu

Abstract

Background: Blood pressure, lipid, and glycemic control are essential for reducing cardiovascular disease (CVD) risk. Many health care systems have successfully shifted aspects of chronic disease management, including population-based outreach programs designed to address CVD risk factor control, to non-physicians. The purpose of this study is to evaluate provision of new information to non-physician outreach teams on need for treatment intensification in patients with increased CVD risk.

Methods: Cluster randomized trial (July 1-December 31, 2008) in Kaiser Permanente Northern California registry of members with diabetes mellitus, prior CVD diagnoses and/or chronic kidney disease who were high-priority for treatment intensification: blood pressure ≥ 140 mmHg systolic, LDL-cholesterol ≥ 130 mg/dl, or hemoglobin A1c ≥ 9%; adherent to current medications; no recent treatment intensification). Randomization units were medical center-based outreach teams (4 intervention; 4 control). For intervention teams, priority flags for intensification were added monthly to the registry database with recommended next pharmacotherapeutic steps for each eligible patient. Control teams used the same database without this information. Outcomes included 3-month rates of treatment intensification and risk factor levels during follow-up.

Results: Baseline risk factor control rates were high (82-90%). In eligible patients, the intervention was associated with significantly greater 3-month intensification rates for blood pressure (34.1 vs. 30.6%) and LDL-cholesterol (28.0 vs 22.7%), but not A1c. No effects on risk factors were observed at 3 months or 12 months follow-up. Intervention teams initiated outreach for only 45-47% of high-priority patients, but also for 27-30% of lower-priority patients. Teams reported difficulties adapting prior outreach strategies to incorporate the new information.

Conclusions: Information enhancement did not improve risk factor control compared to existing outreach strategies at control centers. Familiarity with prior, relatively successful strategies likely reduced uptake of the innovation and its potential for success at intervention centers.

Trial registration: ClinicalTrials.gov Identifier NCT00517686.

Figures

Figure 1
Figure 1
Flow sheet for cluster randomized trial showing total numbers of PHASE patients at participating medical centers, exclusions by reason, and final numbers of patients eligible at some time during the six-month intervention in each of six risk factor-based priority levels.

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