Doctors prescribe fewer statins in the afternoon


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 at Nudge Unit, University of Pennsylvania, Philadelphia, found that patients who had the first appointments of the day were more likely to receive statins for them and that this probability decreased as the day passed.

The study is like this published online May 11 a JAMA network open.

Allison Hare

“Doctors face decision fatigue, where they see 20 patients a day and they may not have the mental bandwidth or cognitive bandwidth to fully think through each patient’s decisions and make all of them. the right decisions all the time. ” said lead author Allison J. Hare, a medical student and clinical computing member of the Nudge Unit | Cardiology Medscape.

Hare explains that the Penn Medicine Nudge Unit seeks to better align physician decision-making with current standards in best practices for the provision of various therapies.

“As we see more and more good practice guidelines appear, we also see that there is a gap in the intent to treat and the actual supply of these therapies,” he said. “There are also growing expectations for doctors to provide all of these different therapies supported by evidence. It can be difficult to keep up with all of these guidelines, especially when you are expected to care for more and more patients, every time.” more efficiently. “

Guideline-directed statin therapy has been shown to reduce the risk of major adverse cardiovascular events, although 50% of statin-eligible patients have not been prescribed any.

“In our previous work on the Nudge Unit, we observed that there were rates of preventive care, including grip vaccination and cancer screening decreased as the day of the clinic progressed. We wanted to see if that happened 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 during the period from March 2019 to February 2020.

His 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 clinic atherosclerotic cardiovascular disease, familial hypercholesterolemia, or low-density lipoprotein cholesterol of at least 190 mg / dL, conditions that qualified them for statins based on U.S. Preventive Services Task Force guidelines.

Appointment schedules for each patient were broken down into time blocks, ranging from 8 p.m. AM time at 4:00 PM hour, which allow you to open the books in most practices.

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

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

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

Patients attending the lunch appointments were 37% less likely to receive a statin prescription, making them the least likely to get a script.

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

“In the context of the myriad of tasks that doctors have to do for a single patient, and also in the context of seeing 20 patients in 15-minute increments, it’s easy to see how certain things fall through the cracks,” Hare dit.

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

Why variability?

“The Nudge Unit uses directions to ask the doctor about the prescription of statins. The question is: what causes the variability of statin prescriptions?” Nieca Goldberg, medical director of the NYU Women’s Heart Program, NYU Grossman School of Medicine, New York, commented on | Cardiology Medscape.

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

“It would be interesting to know the thoughts of the doctors who were studied after they were informed of the results. Also, having an impulse to write the prescription will increase the prescription 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 do not report relevant financial relationships.

JAMA Netw Open. 2021; 4: e219050. Summary

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