10th International Workshop on Adverse Drug Reactions and Lipodystrophy in HIV 6-8 November 2008, London, UK

EFFICACY OF A COMPUTERISED PHYSICIAN REMINDER SYSTEM TO CONTROL CARDIOVASCULAR RISK FACTORS IN HIV-INFECTED PATIENTS RECEIVING ANTIRETROVIRAL THERAPY (CART): A RANDOMISED CONTROLLED CLUSTER TRIAL NESTED INTO THE SWISS HIV COHORT STUDY (SHCS)

Antiviral Therapy 2008; 13(Suppl. 4):A15 (abstract no. O-21)

HC Bucher^1,2, M Rickenbach³, J Young¹, TR Glass¹, Y Vallet³, E Bernasconi⁴, M Cavassini⁵, C Fux⁶, V Schiffer⁷, P Vernazza⁸, R Weber⁹, M Battegay², and the Swiss HIV Cohort Study
¹Basel Institute for Clinical Epidemiology & Biostatistics, Basel, Switzerland; ²Division of Infectious Diseases & Hospital Hygiene, University Hospital Basel, Basel, Switzerland; ³Swiss HIV Cohort Data Centre CHUV, Lausanne, Switzerland; ⁴Regional Hospital Lugano, Lugano, Switzerland; ⁵Division of Infectious Diseases CHUV, Lausanne, Switzerland; ⁶Division of Infectious Diseases, Insel Spital, Bern, Switzerland; ⁷Division of Infectious Diseases, University Hospital Geneva, Geneva, Switzerland; ⁸Division of Infectious Diseases, Kantonsspital St Gallen, St Gallen, Switzerland; ⁹Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland

BACKGROUND: Exposure to cART might lead to marked metabolic changes and increased risk of coronary heart disease (CHD) events. Computerized clinical decision support systems have been advocated to improve the management of patients at risk for CHD, but there is insufficient evidence whether such systems improve CHD risk factors in HIV-infected and uninfected patients.

METHODS: In total, 165 clinicians at the seven study SHCS centres, associated hospitals and private practices were randomised in June 2006 to the provision of CHD risk profiles plus guidelines for cART-treated patients versus the provision of evidence-based guidelines for CHD risk factor management alone. CHD risk profiles, which included CHD risk factors, Framingham risk score, CHD drug prescriptions and CHD events, were generated on flow charts by the SHCS data centre based on a computerized program and data from biannual assessments at baseline and during the 12 month intervention period. CHD risk profiles were filed in patient charts by study nurses. Clinicians were randomised in strata of centre and patient volume and instructed about the trial by the responsible clinician of the centre (guardian). The primary outcome was the reduction in total cholesterol; secondary outcomes were systolic and diastolic blood pressure and Framingham risk score. Patients eligible for analysis had to be on cART for >90 days, aged 18 or older, not pregnant and with complete CHD risk factor data at baseline. We used linear regression with outcome measured at baseline and concomitant lipid lowering or antihypertensive medication as covariates and, to adjust for missing outcomes, weighted each patient’s outcome by the inverse probability of the patient being included in the analysis.

RESULTS: Of the 5,782 screened patients, 26 women were pregnant, 1,421 patients were not on cART over the full 90 days prior to baseline and 377 patients had at least some missing CHD risk information, leaving an intention-to-treat population of 4,089 patients. Mean differences in patients cared by physicians with routine provision of CHD risk profiles compared with guidelines alone was for total cholesterol -0.03 mmol/l (95% confidence interval -0.12–0.05), for systolic and diastolic blood pressure -0.4 mmHg (-1.7–0.9) and -0.4 mmHg (-1.6–0.7), respectively, and for the Framingham risk score -0.1 (-0.3–0.1). There was no obvious difference between groups in the discontinuation of any protease inhibitors or in the initiation of drugs with more favourable lipid profiles (abacavir or atazanavir). In both groups roughly 15% of patients with Framingham 10 years risk score ≥10% started either blood pressure or lipid-lowering drugs during the trial.

CONCLUSIONS: Systemic, computerized, routine provision of CHD risk profiles in addition to guidelines did not significantly improve risk factors for CHD in patients on cART.

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2008-11-06
O-21

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