Abstract
Background/Aims Prophylactic aspirin use is recommended for reducing the risk of stroke in women and myocardial infarction in men. The United States Preventives Services Task Force (USPSTF) recommends a shared decision-making approach between patients and providers to consider the benefits and harms of daily aspirin use. We conducted an exploratory study using a three-arm randomized controlled approach to compare usual care to two tools that could facilitate shared decision-making.
Methods Subjects at risk for cardiovascular disease (CVD) were randomized at three clinic sites at Geisinger. Intervention patients received either:
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a printed “pre-visit summary” (PVS) that described their specific Framingham CVD risk, benefits of aspirin use, and harms of GI bleed (PVS-only arm); or
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PVS plus an interactive, graphical clinical decision support (CDS) tool embedded in the electronic health record for providers to use during the clinical encounter (PVS+CDS arm).
Control patients were given neither tool, but were followed to monitor secular trends. Patients were surveyed within four weeks of their visit and asked about conversations about aspirin with the clinician and appropriate use. All analyses were intention-to-treat.
Results Conversations about appropriate aspirin use between patient and provider occurred for 52% of PVS+CDS subjects, 39% of PVS-only subjects, and 19% of control subjects. Aspirin was initiated by 31% of PVS+CDS subjects, 24% of PVS-only subjects, and 17% of control subjects. “Daily” aspirin use (defined as at least 3–4 times a week) was reported by 27% of PVS+CDS subjects, 17% of PVS-only subjects, and 8% of control subjects. All differences between the three study arms are statistically significant (P < 0.05). Additional analyses are underway. Less than 10% of providers in the PVS+CDS arm activated the shared decision-making tool. We will conduct interviews with providers to better understand the low activation rates.
Conclusions In an exploratory study, we demonstrated clinically meaningful and significant improvements in discussions of appropriate aspirin use between patients and their providers, which correlated with aspirin initiation and regular use, in a population of adults at risk for cardiovascular disease. Shared decision making via health information technology can activate patients and providers resulting in increased use of appropriate preventive care.
