Primary care physicians are more likely to write a prescription for statins for their patients at risk for cardiovascular adverse events in the morning than in the afternoon, new research suggests.

In an observational cohort study, researchers from the Nudge Unit, University of Pennsylvania, Philadelphia, found that patients who had the first appointments of the day were most likely to have statins prescribed for them, and that this likelihood decreased as the day went on.

The study is published online May 11 in JAMA Network Open.

Allison Hare

“Physicians are faced with decision-fatigue, where they are seeing 20 patients in a day and may not have the mental bandwidth or cognitive bandwidth to fully think through every decision for every patient and to make all the appropriate decisions all of the time,” lead author Allison J. Hare, medical student and clinical informatics fellow in the Nudge Unit, told theheart.org | Medscape Cardiology.

The Penn Medicine Nudge Unit attempts to better align clinician decision making with current standards in best practices for the provision of various therapies, Hare explained.

“As we see more and more best-practice guidelines come out, we also see that there is a gap in the intention to treat and actual provision of these therapies,” she said. “There are also increasing expectations for clinicians to provide all of these different evidence-backed therapies. It can be hard to keep up with all these guidelines, especially when you are expected to take care of more and more patients, more and more efficiently.”

Guideline-directed statin therapy has been demonstrated to reduce the risk for major adverse cardiovascular events, yet 50% of statin-eligible patients have not been prescribed one.

“In our prior work at the Nudge Unit, we observed that rates of preventive care, including flu vaccination and cancer screening, declined as the clinic day progressed. We wanted to see if this occurred with statin scripts,” Hare said.

The researchers obtained data from 28 Penn Medicine primary care practices that included 10,757 patients at risk for heart disease for the period from March 2019 to February 2020.

Their mean age was 66.0 years (standard deviation [SD], 10.5 years), 5072 (47.2%) were female, and 7071 (65.7%) were White. Patient characteristics were similar between morning and afternoon appointments.

All patients had clinical atherosclerotic cardiovascular disease, familial hypercholesterolemia, or low-density-lipoprotein cholesterol of at least 190 mg/dL, conditions which qualified them for statins based on the United States Preventive Services Task Force guidelines.

The appointment times for each patient were broken down into hour blocks, ranging from the 8:00 AM hour to the 4:00 PM hour, which bookend open times in most practices.

Overall, statins were prescribed in 36% (n = 3864) of visits.

The data showed a clear decline in statin prescribing as the day went on.

For example, compared with patients who came in at 8:00 AM (the reference group), patients who came in at 9:00 AM were 12% less likely to get a prescription.

Patients coming in for noon appointments were 37% less likely to get a statin prescription, which made them the least likely to get a script.

After the noon visits, there was a slight increase, but the likelihood of a statin prescription remained 27% less likely or worse for the rest of the day.

“In the context of the myriad tasks that clinicians are faced with doing for a single patient, and then also within the context of seeing 20 patients in 15-minute increments, it is easy to see how certain things fall through the cracks,” Hare said.

“It’s impossible for any clinician to remember every single little thing for their patient every single time, so if we can augment the clinician’s ability to make those appropriate decisions with electronic tools, we can narrow that gap a little bit.”

Why the Variability?

“The Nudge Unit uses prompts to ask the physician about prescribing statins. The question is, what is causing the variability in statin prescriptions?” Nieca Goldberg, medical director of the NYU Women’s Heart Program, NYU Grossman School of Medicine, New York City, commented to theheart.org | Medscape Cardiology.

“Is it fatigue, lack of familiarity of guidelines, or is this due to the volume of patients and lack of time to discuss the therapy and make a shared decision with their patient? The answer to these questions was not part of the study,” said Goldberg, who is also an American Heart Association volunteer expert.

“It would be interesting to know the thoughts of the physicians who were studied after they were informed of the results. Also, having a nudge to write the prescription will increase the prescriptions of statins, but will patients take the medication?”

The study was funded in part by a grant from the National Institute on Aging. Hare and Goldberg report no relevant financial relationships.

JAMA Netw Open. 2021;4:e219050. Abstract

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