Using Technology to Advance Care in Hyperlipidemia, Cardiovascular Disease, with Nihar Desai, MD

Nihar Desai, MD
Credit: HCPLive

Often maligned as a burden on bandwidth, the value of using integrated alerts and reminders of optimal practices into electronic health records (EHRs) has become the subject of interest for many in cardiology, including Nihar Desai, MD, who presented on the PROMPT-Lipid trial at the Family Heart Foundation’s 2024 Family Heart Global Summit.

Presented by Desai, an associate professor of Medicine and vice chief of the Section of Cardiovascular Medicine at Yale University School of Medicine, the trial examined the use of EHR-based alerts for improving clinician adherence to guidelines for intensification of lipid-lowering therapy in high-risk atherosclerotic cardiovascular disease (ASCVD) patients.

A cluster-randomized trial conducted within Yale New Haven Health, the trial cluster-randomized clinicians to receive an alert with individualized lipid-lowering therapy recommendations or no alert among patients with very high ASCVD risk and an LDL-C at or greater than 70 mg/dL. The trial’s primary outcome was the 90-day lipid-lowering intensification.

Results of the trial, which included 2500 patients and 96 clinicians, indicate lipid-lowering therapy intensification occurred among 14.1% of the alert group and 10.4% of the no-alert group (Odds Ratio [OR], 1.42; 95% Confidence Interval [CI], 0.96 to 2.10; P = .08), with numerically greater rates of intensifying statins, ezetimibe, and PCSK9 inhibitor use in the alert group. Among those who did not miss the alert, investigators highlighted a more than 2-fold increase in lipid-lowering therapy intensification (OR, 2.33; 95% CI, 1.48 to 3.66; P <.001). Investigators pointed out statistically significant differences were achieved for rates of statin intensification (10.9% vs 6.2%; P = .008), ezetimibe addition (8.9% vs 4.0%; P=0.01), and PCSK9 inhibitors addition (2.0% vs 0.4%; P = .01) among this subgroup of clinicians.

The PROMPT-Lipid trial is 1 of many in recent years conducted with the aim of informing implementation strategies. Although not pertaining to the use or intensification of lipid-lowering therapies, the landmark NUDGE-FLU trial provided evidence of the value of targeted digital prompts in improving patient adherence to vaccination recommendations among a cohort of more than 900,000 individuals.

In the trial, which was presented at the American College of Cardiology 2023 Scientific Sessions, tailored messages to older adults elucidating the cardiovascular benefit of seasonal flu vaccinations were associated with greater vaccine uptake relative to usual care (81.00% vs 80.12%; difference, 0.89 percentage points [99.55% CI, 0.29 to 1.48]; P <.0001).

During the 2024 Family Heart Global Summit, the editorial team of HCPLive Cardiology sat down with Desai to discuss the PROMPT-Lipid study, the most pressing gaps in scientific guidelines and clinical implementation, and the next phases of research in this arena. That conversation is the subject of the following Q&A.

HCPLive Cardiology: Can you highlight the key findings from the PROMPT-Lipid trial?

Desai: So, in the PROMPT-Lipid study, what we found was that when you used or implemented a real-time individualized, targeted, tailored alert within the electronic health record system that providers receiving those alerts were significantly more likely to prescribe evidence-based lipid-lowering therapies for their patients with atherosclerotic cardiovascular disease.

HCPLive Cardiology: What were the most surprising or impactful outcomes related to secondary prevention of ASCVD?

Desai: I think the main thing that we were looking at here, that we were trying to address is: despite years and years of clinical trials, despite all the guideline recommendations that have come out encouraging us to achieve lower and lower LDLs for our patients with atherosclerotic cardiovascular disease, there seems to be this pretty stark gap between what we know we should do and what we actually do.

So, we were poised to try and say, “How can we make progress on that front? How do we actually help enable providers in the midst of busy clinical sessions to do the right thing for the patients that they serve?” And so, we were delighted that a decision support tool or a decision alert was actually able to do that and to make things better for the patients that we serve.

HCPLive: In your presentation, you highlighted how, despite strong evidence and clear guidelines, many patients are not achieving recommended LDL levels. What do you believe are the primary reasons for this gap between scientific guidelines and clinical implementation?

Desai: It's a great question. I think the gap between evidence and practice has many drivers and contributors. Certainly, the cost of therapies and access to care are major factors. Additionally, patients' understanding of the importance of LDL in their overall and cardiovascular health plays a role. Then, of course, there's clinical inertia — it's too easy for busy providers to defer making changes, thinking, 'We'll address it next time,' when they see the patient in six months. The problem with this approach is that many patients will experience recurrent cardiovascular events, hospitalizations, heart attacks, or need bypass surgery or stents in that interim. So, while it's easy to postpone action, clinical inertia is a significant barrier to progress in this area.

HCPLive How can clinicians apply the insights from this trial to improve patient outcomes today, particularly for those at high risk of recurrent ASCVD events?

Desai: There are a couple of important lessons here. First, we should take every opportunity to address LDL and educate our patients about its importance for their overall and cardiovascular health. Additionally, I encourage those interested in using electronic health records to work within their health systems to implement decision support tools and alerts, which can have a much broader impact. While each of us, as individual providers, has an important role to play, we also need to advocate for our patients and communities by thinking about how to best configure our health systems. The electronic health record is a key part of making changes on a larger scale.

HCPLive: Can you talk about the next phase of work/research?

Desai: What we're most excited about now is that we've seen, within our health system, how a targeted, real-time decision support tool can improve lipid-lowering therapy for patients with atherosclerotic cardiovascular disease. The next step is to scale this to other health systems and like-minded institutions with similar goals and a commitment to improving patient care. We're excited to enter this second phase, building a consortium of health systems that want to collaborate, share data, and conduct rigorous implementation science to make things better for the patients we all serve.

Editor’s Note: This transcript was edited for grammar and clarity using artificial intelligence tools.

References:

1. Desai, N. A Pragmatic EMR-Based Approach to Improving Lipid Control: the PROMPT-Lipid Trial. Session presented the annual Family Heart Global Summit in Dallas, Texas, on September 23, 2024.
2. Shah NN, Ghazi L, Yamamoto Y, et al. Pragmatic Trial of Messaging to Providers About Treatment of Hyperlipidemia (PROMPT-LIPID): A Randomized Clinical Trial. Circ Cardiovasc Qual Outcomes. 2024;17(5):e010335. doi:10.1161/CIRCOUTCOMES.123.010335
3. Johansen ND, Vaduganathan M, Bhatt AS, et al. Electronic nudges to increase influenza vaccination uptake in Denmark: a nationwide, pragmatic, registry-based, randomised implementation trial. Lancet. 2023;401(10382):1103-1114. doi:10.1016/S0140-6736(23)00349-5