Effectiveness of a Cardiovascular Health Electronic Health Record Application for Cancer Survivors in Community Oncology Practice

Academic Background

The cardiovascular health (CVH) of cancer survivors has become an increasingly important concern. Studies have shown that cancer survivors generally have poorer cardiovascular health, partly due to the potential cardiotoxicity of cancer treatments and shared risk factors between cancer and cardiovascular disease. Cardiovascular disease has become the most common non-cancer cause of death among cancer survivors, and in some common cancer types, deaths from cardiovascular disease even exceed those from cancer recurrence. Therefore, how to effectively assess and manage cardiovascular risk in the long-term follow-up of cancer survivors has become a critical issue in clinical practice.

Although guidelines from organizations such as the National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO) recommend cardiovascular health assessment and counseling for cancer survivors, 40%-60% of oncologists report that they do not routinely discuss cardiovascular risk with patients. This indicates significant gaps in current clinical practices regarding cardiovascular health management. To address this challenge, health information technology (Health IT) tools show great potential in helping physicians better adhere to guidelines and provide cardiovascular health management services.

Research Background and Objectives

This study aimed to evaluate the effectiveness of an electronic health record (EHR)-based tool called the Automated Heart-Health Assessment (AH-HA) in cancer survivors. The tool integrates the American Heart Association (AHA)’s “Life’s Simple 7” cardiovascular health factors to help physicians better discuss cardiovascular health issues during routine follow-up visits for cancer survivors. The study hypothesized that oncologists using the AH-HA tool would discuss cardiovascular health with patients significantly more frequently than those in the usual care (UC) group and would make more referrals to primary care physicians or cardiologists.

Research Team and Publication Information

The study was led by Dr. Kathryn E. Weaver, with team members from institutions such as Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Comprehensive Cancer Center, and Virginia Commonwealth University. The results were published on November 21, 2024, in the Journal of Clinical Oncology, with the DOI: https://doi.org/10.1200/jco.24.00342.

Research Methods

Study Design and Implementation

This study was a hybrid type 1 effectiveness-implementation clinical trial coordinated by the Wake Forest National Cancer Institute Community Oncology Research Program (NCORP) research base. Oncology clinics were randomized to either the AH-HA tool group or the usual care group, and cancer survivors who had received curative cancer treatment at least six months prior and were undergoing routine follow-up were recruited. The AH-HA tool automatically displayed patients’ “Life’s Simple 7” cardiovascular health factors through the EHR, combined with information on cancer treatments with potential cardiotoxicity. The primary endpoint was patient-reported discussions related to non-ideal or missing cardiovascular health factors.

Study Participants and Recruitment

The study recruited 645 cancer survivors, of whom 82% were breast cancer survivors, 8% were endometrial cancer survivors, 5% were colorectal cancer survivors, and the remainder were lymphoma, prostate cancer, or multiple cancer type survivors. Most survivors were female (96%), 84% were non-Hispanic white, 8% were Black, and 3% were Hispanic. The study was conducted from October 1, 2020, to February 28, 2023.

Intervention

The AH-HA tool was based on the AHA’s “Life’s Simple 7” framework and automatically displayed patients’ cardiovascular health data through the EHR, combined with cancer treatment information. During the development of the tool, the research team sought input from oncologists and patients to ensure its usability. Oncologists in the intervention group received two 30-minute online training sessions on how to use the AH-HA tool for cardiovascular health management. Physicians in the usual care group conducted routine follow-ups according to their clinic standards and did not have access to the AH-HA tool.

Data Analysis

The study used a mixed-effects logistic regression model to assess the impact of the AH-HA tool on cardiovascular health discussions, adjusting for the random effects of clinics. The primary outcome was the proportion of patients reporting discussions on at least one non-ideal or missing cardiovascular health factor. Additionally, the study evaluated patient-reported referrals to primary care physicians or cardiologists, as well as discussions and tests recorded in the EHR.

Research Results

Cardiovascular Health Discussions

The results showed that the AH-HA tool significantly increased the frequency of discussions between physicians and patients about cardiovascular health. In the AH-HA group, 97.6% of patients reported discussions on at least one non-ideal or missing cardiovascular health factor, compared to only 54.7% in the usual care group (p < .001). Furthermore, the average number of factors discussed in the AH-HA group was 4.06, significantly higher than the 1.27 in the usual care group (p < .001). The number of discussions recorded in the EHR also showed a similar trend, with significantly more discussions in the AH-HA group than in the usual care group (3.83 vs. 0.77, p = .03).

Referrals and Tests

The proportion of patients in the AH-HA group who reported referrals to primary care physicians was significantly higher than in the usual care group (38.9% vs. 25%, p = .02). However, the proportion of referrals to cardiologists was low in both groups (approximately 6%) and did not differ significantly. Additionally, the number of orders for cholesterol and HbA1c tests was significantly higher in the AH-HA group than in the usual care group (p < .002).

Conclusion

The AH-HA tool demonstrated significant effectiveness in promoting discussions about cardiovascular health and increasing referrals to primary care among cancer survivors. The results suggest that this EHR-embedded tool can significantly increase the frequency of discussions between physicians and patients about cardiovascular health and enhance referrals to primary care physicians. Future research should further explore how to promote the AH-HA tool in different types of oncology clinics and assess its long-term impact on patients’ cardiovascular health.

Research Highlights

1. Significant Effectiveness: The AH-HA tool significantly increased the frequency of discussions between physicians and patients about cardiovascular health, with the discussion rate rising from 54.7% in the usual care group to 97.6% in the AH-HA group.
2. Multi-Factor Discussions: Patients in the AH-HA group reported discussions on more non-ideal or missing cardiovascular health factors, with an average of 4.06 factors discussed, significantly higher than the 1.27 in the usual care group.
3. Increased Primary Care Referrals: The proportion of patients in the AH-HA group who reported referrals to primary care physicians was significantly higher than in the usual care group, indicating the tool’s potential in promoting multidisciplinary collaboration.

Research Significance

This study provides an effective tool for managing the cardiovascular health of cancer survivors. By integrating EHR data, AH-HA helps physicians better identify and manage patients’ cardiovascular risks. The results support the promotion of similar technological tools in oncology clinical practice to optimize cardiovascular health management for cancer survivors and reduce the burden of cardiovascular disease.