Risk Stratification and Prevention in Chronic Coronary Artery Disease: Use of a Novel Prognostic and Computer-Based Clinical Decision Support System in a Large Primary Managed-Care Group Practice

Abstract

Current therapy for chronic coronary artery disease (CAD) is extremely variable and under-utilizes preventive measures that have demonstrated benefit. Therefore, we sought to determine whether a novel hybrid prognostic and computer-based clinical decision support system (ohms|cad^®; Interactive Heart Management Corporation, Laurence Harbor, New Jersey), that provides the treating physician with real-time, patient-specific recommendations, could improve outcomes, decrease utilization of services, and lower the costs of CAD. This was an observational study in a managed-care group practice with 39,565 members. A subpopulation of 1,628 patients participated in the study after being identified as being at increased risk for CAD. Over the 21 months after introduction of ohms|cad, utilization of cardiovascular services, coronary disease outcomes, and costs were compared with a baseline year by computing the relative risks of discrete CAD-related events. The use of ohms|cad significantly reduced adverse CAD outcomes in the entire population of members. Acute myocardial infarctions were reduced by 30% [relative risk (RR), 0.70; 95% confidence interval (CI), 0.59-0.81] and hospitalizations for angina or suspected infarction by 32% (RR, 0.68; 95% CI, 0.62-0.75). Stress tests decreased by 62% (RR, 0.38; 95% CI, 0.35-0.40), cardiac catheterizations by 20% (RR, 0.80; 95% CI, 0.71-0.89), and coronary angioplasties by 22% (RR, 0.78; 95% CI, 0.62-0.96). The rate of coronary artery bypass grafting was unchanged (RR, 1.06; 95% CI, 0.88-1.26). In addition, there were significant improvements in ambulatory ischemia, most monitored risk factors, and use of aspirin. Net CAD-associated costs in the population were reduced by 17%. Thus, an automated system that provides patient-specific prognostic information and clinical decision support for the treatment of chronic CAD can help increase the use of preventive strategies, and lower the morbidity and cost of chronic CAD.