Feedback of Treatment Intensification Data to Reduce Cardiovascular Disease Risk

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DESCRIPTION (Provided by the Applicant): Background: Despite the availability of highly effective medications for controlling the major cardiovascular disease (CVD) risk factors, many patients, including many at high risk for developing CVD, continue to be in poor control of blood pressure (BP), LDL-cholesterol (LDL-c), and hemoglobin A1c (A1c). Recent evidence indicates that clinician failure to prescribe recommended increases in the intensity of medication regimens is frequently found in association with poor control of these outcomes. "Treatment intensification," the frequency with which clinicians appropriately increase pharmacotherapy in the face of poor control, has been proposed as a new measure of clinical quality. The linkage of process measures such as treatment intensification to clinical benefit is often supported by strong clinical trial evidence. Such measures could also be more useful than reports of risk factor control because the actions needed to improve control are implicit in the measures and because concerns about case-mix differences are largely avoided. However, there is little empirical evidence that reporting and improving these process measures can lead to better outcomes. Project Description: We propose a cluster randomized trial intervention involving eight or more medical facilities of Kaiser Permanente Northern California (KP) and more than 65,000 patients at high risk for CVD. At intervention facilities, patient-level information obtained from KP's electronic health record on the need for treatment intensification (for systolic BP, LDL-c, and A1c) and on recent medication adherence are added to a population management database and fed back through software currently used by staff working with primary care providers. Staff at control facilities continue to use the same population management database and software but only receive information on risk factor levels and selected medications. Specific Aims: SA1: Evaluate the effectiveness of measurement and feedback of treatment intensification information in patients at high risk of CVD for improving rates of treatment intensification and for reducing levels of poorly controlled SBP, LDL-c, and A1c. SA2: Evaluate the impact of the intervention, compared to current practice, on total numbers of patient contacts, outpatient visits, and costs of care in relation to improvements in risk factor control. SA3. Evaluate the effect of this innovation on physician and staff perceptions of the value (effectiveness and efficiency) of the population management program for high risk patients. Relevance: If this translational study demonstrates that feedback of information on treatment intensification leads to higher rates of intensification and improved risk factor control, it will have demonstrated a population level use of health information technology for improving clinical quality, and will also have validated treatment intensification as a metric of clinical quality.