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Patient-directed intervention versus clinician reminders alone to improve aspirin use in diabetes: a cluster
Stephen D Persell1, Therese A Denecke-Dattalo, Daniel P Dunham
1Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, USA. spersell@nmff.org
Insights
A patient-directed intervention improved aspirin use in diabetes patients, especially ideal candidates, beyond clinician reminders. Challenges included patient contact and adherence.
Area of Science:
- Preventive medicine
- Cardiovascular health
Background:
- Physician-led strategies have failed to fully address the underutilization of crucial preventive therapies.
- Effective preventive therapies, such as aspirin for cardiovascular risk reduction, remain underused in clinical practice.
Purpose of the Study:
- To evaluate the effectiveness of a patient-directed intervention in increasing aspirin use for primary prevention.
- To compare a combined approach (clinician reminders plus patient outreach) against clinician reminders alone.
Main Methods:
- A cluster-randomized trial involving 19 physicians and 334 eligible patients aged 40+.
- Patients in the intervention group received mailings and nurse calls if aspirin was indicated, alongside computerized clinician reminders.
- The primary outcome measured was self-reported regular aspirin use.
Main Results:
- The overall difference in aspirin use between intervention and reminder-only groups was not statistically significant (46% vs. 39%).
- However, in a subgroup of patients with no baseline aspirin use and no contraindications, the intervention significantly increased aspirin use by 10% (43% vs. 30%, p = .013).
Conclusions:
- A patient-directed intervention can modestly enhance aspirin use in specific patient populations, particularly when added to clinician reminders.
- Barriers to intervention success included patient contact difficulties, perceived or real contraindications, and patient adherence to recommendations.
Background:
Physician-directed approaches have not eliminated the underuse of effective preventive therapies.
Methods:
In a cluster-randomized design, 19 physicians caring for 334 eligible patients at least 40 years of age were randomized. All clinicians received computerized reminders at office visits. Intervention physicians received e-mails asking whether aspirin was indicated for each patient. If so, patients received a mailing and nurse telephone call addressing aspirin. The primary outcome was self-reported regular aspirin use.
Results:
Outcome assessment telephone interviews were completed for 242 (72.5%) patients. At follow-up, aspirin use was reported by 60 (46%) of the 130 intervention patients and 44 (39%) of the 112 reminder-only patients, a nonsignificant 7.2% difference (95% confidence interval: -3.9 to 18 percentage points, p = .20). In the subgroup reporting no aspirin use at baseline and no contraindications, 33 (43%) of the 76 intervention and 22 (30%) of the 74 reminder-only patients used aspirin, a 10% difference accounting for clustering (95% CI: 2.2 to 18 percentage points, p = .013).
Discussion:
A patient-directed intervention modestly increased aspirin use among diabetes patients beyond that achieved using computerized clinician reminders for ideal candidates. Obstacles included difficulty contacting patients, real or perceived contraindications, and failure to follow the nurse's advice.
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