title: Translating cholesterol guidelines into primary care practice: a multimodal cluster randomized trial.
abstract: PURPOSE We wanted to determine whether an intervention based on patient activation and a physician decision support tool was more effective than usual care for improving adherence to National Cholesterol Education Program guidelines. METHODS A 1-year cluster randomized controlled trial was performed using 30 primary care practices (4,105 patients) in southeastern New England. The main outcome was the percentage of patients screened for hyperlipidemia and treated to their low-density lipoprotein (LDL) and non-high-density lipoprotein (HDL) cholesterol goals. RESULTS After 1 year of intervention, both randomized practice groups improved screening (89% screened), and 74% of patients in both groups were at their LDL and non-HDL cholesterol goals (P <.001). Using intent-to-treat analysis, we found no statistically significant differences between practice groups in screening or percentage of patients who achieved LDL and non-HDL cholesterol goals. Post hoc analysis showed practices who made high use of the patient activation kiosk were more likely to have patients screened (odds ratio [OR] = 2.54; 95% confidence interval [CI], 1.97-3.27) compared with those who made infrequent or no use. Additionally, physicians who made high use of decision support tools were more likely to have their patients at their LDL cholesterol goals (OR = 1.27; 95% CI, 1.07-1.50) and non-HDL goals (OR = 1.23; 95% CI, 1.04-1.46) than low-use or no-use physicians. CONCLUSION This study showed null results with the intent-to-treat analysis regarding the benefits of a patient activation and a decision support tool in improving cholesterol management in primary care practices. Post hoc analysis showed a potential benefit in practices that used the e-health tools more frequently in screening and management of dyslipidemia. Further research on how to incorporate and increase adoption of user-friendly, patient-centered e-health tools to improve screening and management of chronic diseases and their risk factors is warranted.
authors.affiliation: Department of Family Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA. Charles_Eaton@mhri.org
authors.forename: Charles B
authors.initials: CB
authors.lastname: Eaton
authors.forename: Donna R
authors.initials: DR
authors.lastname: Parker
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Borkan
authors.forename: Jerome
authors.initials: J
authors.lastname: McMurray
authors.forename: Mary B
authors.initials: MB
authors.lastname: Roberts
authors.forename: Bing
authors.initials: B
authors.lastname: Lu
authors.forename: Roberta
authors.initials: R
authors.lastname: Goldman
authors.forename: David K
authors.initials: DK
authors.lastname: Ahern
mesh_terms: D000328:Adult; D000924:Anticholesteremic Agents / Q000627:therapeutic use; D008076:Cholesterol, HDL / Q000097:blood; D008078:Cholesterol, LDL / Q000097:blood; D016288:Computer Terminals; D003194:Computer-Assisted Instruction; D020000:Decision Support Systems, Clinical / Q000706:statistics & numerical data; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D006949:Hyperlipidemias / Q000097:blood / Q000175:diagnosis* / Q000188:drug therapy; D057194:Intention to Treat Analysis; D008297:Male; D008403:Mass Screening / Q000706:statistics & numerical data*; D008875:Middle Aged; D009511:New England; D010043:Outcome and Process Assessment, Health Care; D010353:Patient Education as Topic; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D011320:Primary Health Care / Q000706:statistics & numerical data*
chemical_list: D000924:Anticholesteremic Agents; D008076:Cholesterol, HDL; D008078:Cholesterol, LDL
references.citation: J Gen Intern Med. 1998 Nov;13(11):740-5
references.pmid: 9824519
references.citation: Atheroscler Suppl. 2009 Jun 10;10(1):3-21
references.pmid: 19497553
references.citation: Med Care. 1999 Jan;37(1):5-14
references.pmid: 10413387
references.citation: J Am Med Inform Assoc. 2003 Jan-Feb;10(1):16-20
references.pmid: 12509354
references.citation: Ann Fam Med. 2006 May-Jun;4(3):205-12
references.pmid: 16735521
references.citation: N Engl J Med. 2004 Apr 8;350(15):1495-504
references.pmid: 15007110
references.citation: J Gen Intern Med. 2005 Dec;20(12):1091-6
references.pmid: 16423096
references.citation: Am Heart J. 2006 Oct;152(4):785-92
references.pmid: 16996859
references.citation: Circulation. 2004 Jul 13;110(2):227-39
references.pmid: 15249516
references.citation: Arch Intern Med. 2009 Apr 13;169(7):678-86
references.pmid: 19364997
references.citation: Ann Fam Med. 2007 Jan-Feb;5(1):14-20
references.pmid: 17261860
references.citation: JAMA. 2003 Apr 9;289(14):1833-6
references.pmid: 12684363
references.citation: Circulation. 2007 Mar 20;115(11):1363-70
references.pmid: 17353444
references.citation: Eur J Cardiovasc Prev Rehabil. 2010 Jun;17(3):363-72
references.pmid: 20168234
references.citation: Ann Intern Med. 2004 Oct 5;141(7):523-32
references.pmid: 15466769
references.citation: J Med Pract Manage. 2009 Jan-Feb;24(4):224-30
references.pmid: 19288645
references.citation: Arch Intern Med. 2000 Feb 28;160(4):459-67
references.pmid: 10695686
references.citation: Drug Alcohol Rev. 2006 Jan;25(1):49-57
references.pmid: 16492577
references.citation: Ann Fam Med. 2005 Jul-Aug;3 Suppl 2:S20-7
references.pmid: 16049077
references.citation: J Med Internet Res. 2009 Jan 13;11(1):e1
references.pmid: 19141433
references.citation: Diabetes Care. 2003 Mar;26(3):750-7
references.pmid: 12610033
references.citation: Obes Res. 2004 Jun;12(6):1011-8
references.pmid: 15229342
references.citation: Eur Heart J. 2001 Apr;22(7):554-72
references.pmid: 11259143
references.citation: Arch Intern Med. 2009 Oct 26;169(19):1748-55
references.pmid: 19858431
references.citation: JAMA. 2002 Nov 20;288(19):2469-75
references.pmid: 12435261
references.citation: Am J Prev Med. 2011 May;40(5 Suppl 2):S162-72
references.pmid: 21521591
references.citation: Health Educ Res. 1994 Mar;9(1):69-84
references.pmid: 10146734
references.citation: Arch Intern Med. 2007 Nov 26;167(21):2296-303
references.pmid: 18039987
references.citation: Lancet. 2002 Jul 6;360(9326):7-22
references.pmid: 12114036
references.citation: Lancet. 2002 Nov 23;360(9346):1623-30
references.pmid: 12457784
references.citation: J Gen Intern Med. 2003 Oct;18(10):854-63
references.pmid: 14521649
references.citation: Lancet. 2003 Apr 5;361(9364):1149-58
references.pmid: 12686036
references.citation: Prev Cardiol. 2008 Winter;11(1):29-35
references.pmid: 18174789
references.citation: Diabetes Educ. 2007 Jan-Feb;33(1):118-27
references.pmid: 17272798
references.citation: Pharmacoeconomics. 2004;22 Suppl 3:1-12
references.pmid: 15669149
references.citation: J Am Board Fam Med. 2006 Jan-Feb;19(1):46-53
references.pmid: 16492005
references.citation: Am J Prev Med. 2003 Aug;25(2):88-94
references.pmid: 12880874
references.citation: Fam Pract. 2002 Dec;19(6):596-604
references.pmid: 12429661
references.citation: J Gen Intern Med. 2006 Jan;21(1):22-9
references.pmid: 16423119
references.citation: Eur Heart J. 1997 Oct;18(10):1569-82
references.pmid: 9347267
references.citation: JAMA. 2002 Oct 9;288(14):1775-9
references.pmid: 12365965
references.citation: Med J Aust. 2008 Sep 15;189(6):319-22
references.pmid: 18803535
references.citation: Psychol Bull. 2007 Jul;133(4):673-93
references.pmid: 17592961
references.citation: Circulation. 2007 Feb 6;115(5):e69-171
references.pmid: 17194875
references.citation: Am J Prev Med. 2007 May;32(5 Suppl):S75-82
references.pmid: 17466822
references.citation: Ann Behav Med. 1998 Summer;20(3):174-80
references.pmid: 9989324
references.citation: Health Psychol. 1999 Jan;18(1):21-8
references.pmid: 9925042
references.citation: Med Sci Sports Exerc. 2008 Jul;40(7 Suppl):S567-73
references.pmid: 18562974