Color-Coded Cues and Physician Prompts Boost Evidence-Based Therapy in High-Risk CVD

A quality-improvement strategy that targets both the patient and the physician with prompts, reminders, and face-to-face discussion may help optimize use of evidence-based therapies in patients at high cardiovascular risk, the BRIDGE-CV trial suggests. Not only did physicians prescribe more guideline-recommended medications by participating in the program, but they also dramatically boosted the rate of smoking cessation among their patients.

“From our end, we believe that this strategy is very simple, it's very doable, and we have had very, very good results,” lead author M. Julia Machline-Carrion, MD, PhD (São Paulo, Brazil), said in an interview with TCTMD.

The intervention relies on a specially-trained case manager who facilitates discussions with patients about their risk before being seen by a physician, checks current medication use against guideline recommendations, and points out any inconsistencies to the physician.

Machline-Carrion said the results suggest that this type of intervention may be particularly useful in middle-income countries like Brazil because it does not require expensive information technology and both the case managers and the physicians can be trained to use it in 1 day.

Medication Prescribing Improved, But Risk Modification Unchanged

For the BRIDGE-CV trial, published online April 3, 2019, in JAMA Cardiology, Machline-Carrion and colleagues enrolled 1,619 stable patients with established CV or PAD from 40 clusters of outpatient clinics at hospitals or primary care units throughout Brazil. Approximately 50% had a history of prior MI, and more than 20% had a prior stroke. The clusters were randomized to the intervention or standard care.

A nurse was designated as the case manager for each cluster. These case managers, who were trained in clinical guidelines, conducted 15- to 20-minute patient interviews immediately before and after each patient in the intervention arm saw the physician. During the interviews, the case manager filled out a one-page, color-coded checklist containing sections for evidence-based medications recommended for controlling blood pressure, cholesterol, diabetes, and platelets, and checked it against patient medical records. That information was incorporated into another form that was then given to the physician as a sort of “road map” where any discrepancies between the recommendations and the patient’s medications were highlighted.

Another patient evaluation was conducted by the case manager after the patient had seen the physician. At that time, if any suggested medication actions were not taken during the visit, the case manager prompted the physician to review them again. In the intervention group, both patients and physicians received written materials regarding the importance of smoking cessation and other lifestyle changes that could help modify risk factors.

Compared with usual care, patients in the intervention group were more likely to be given prescriptions for all eligible evidence-based therapies (73.5% vs 58.7%; OR 2.30; 95% CI 1.14-4.65). Prescriptions of statins and antiplatelets were significantly higher in the intervention group compared with placebo, while the difference in ACE inhibitors and angiotensin receptor blockers did not reach statistical significance. High-dose statins in patients without contraindications were prescribed for 10.6% of the intervention group versus 7.0% of the control group, a difference that did not reach statistical significance.

At 12 months, there were no differences between the intervention and usual care groups in the percentage of patients who achieved LDL cholesterol levels < 70 mg/dL. There also were no differences in the percentage of patients who achieved systolic blood pressure levels < 140 mm Hg or < 120 mm Hg, or diastolic BP levels < 90 mm Hg, and no differences in measures of diabetes control.

One area where risk modification was strikingly improved, however, was smoking cessation. At 12 months, 51.9% in the intervention group reported smoking cessation compared with just 18.2% in the usual-care group (P < 0.001).

According to Machline-Carrion, the clusters randomized to the intervention protocol were encouraged to continue using it after the study period ended. The researchers hypothesize that they may not have seen a difference in risk modification because the study period was too short and because the trial was underpowered to detect significant differences in clinical outcomes.

Demonstration of Clinical Improvement Still Needed

The current study is the latest in the BRIDGE family of trials. Previously, this case manager-based intervention style and physician prompts have been used successfully to improve medication adherence in stroke and ACS patients.

In an email, Mark Huffman, MD (Northwestern University Feinberg School of Medicine, Chicago, IL), who was not involved in the research, said this study addresses an important, unmet need in clinical practice all over the world: how to help patients with existing vascular disease get the best treatment to help them live longer and feel better.

Huffman noted that the World Health Organization’s 25 x 25 campaign has set a target to reduce premature mortality from noncommunicable diseases, including CV disease, by 25% by 2025.

“The scope of the problem is even larger in middle-income countries like Brazil than in high-income countries like the US,” he said.

Huffman added that while prescriptions are an important process outcome, “long-term adherence rates and improvements in risk factor control will be needed to improve clinical outcomes. The prescription rates in the comparator group are relatively high in this study compared with representative, community-based samples in the US and other low- and middle-income countries. Whether the intervention would be more effective in settings (both inside and outside of Brazil) where the baseline rates are even lower . . . might be an area of future study.”

To TCTMD, Machline-Carrion said a more diverse strategy may be needed to increase patient adherence to prescriptions and to more aggressively target blood pressure control. 

“This study is not the final answer and it does not answer everything,” she said. “But it’s an important first step using very simple tools, and I believe that in the future we could improve and increase the amount of patients and physicians using these types of tools.”