Feedback of Treatment Intensification Data to Reduce Cardiovascular Disease Risk

Despite the availability of highly effective medications for controlling the major cardiovascular disease (CVD) risk factors, many patients continue to be in poor control of systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL), and glycosylated hemoglobin (HbA1c). Evidence indicates that clinician failure to prescribe recommended increases in the intensity of medication regimens is frequently associated 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. This study looked at patients at high risk for CVD who would benefit from treatment intensification. The study team evaluated the intervention’s impact on quality and outcomes of care. This study was a cluster randomized control trial that took place within nine medical facilities at Kaiser Permanente Northern California, in a population of more than 65,000 patients at high risk for CVD.

The main objectives of this study were to:

• Evaluate the effectiveness of measuring and reporting information on the need for treatment intensification in patients at high risk for CVD to improve rates of treatment intensification and to reduce levels of poorly controlled SBP, LDL, and HbA1c.
• Evaluate the impact of the intervention, compared to current population management practice, on total numbers of patient contacts, outpatient visits, and costs of care in relation to improvements in risk factor control.
• Evaluate the effect of the intervention on physician and staff perceptions of the value (effectiveness and efficiency) of the population management program for high risk patients.

While adjusted treatment intensification rates for patients with elevated SBP and LDL levels differed somewhat in favor of the intervention facilities, proportions of patients who had normal risk factor values were similar (or slightly favored the control sites) at the end of the follow-up period. Because the intervention overall had minimal impact on outcomes, a full cost-benefit analyses of the intervention was not undertaken. The qualitative assessment of the intervention showed that facilities would be more willing to use this type of information in population outreach, and that their use would be more effective, if treatment intensification flags were created in a more timely fashion and if patient-level adherence data were also provided.