{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,4]],"date-time":"2026-11-04T03:33:26Z","timestamp":1793763206180,"version":"4.6.1"},"reference-count":21,"publisher":"American Medical Association (AMA)","issue":"17","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA"],"published-print":{"date-parts":[[2026,11,3]]},"abstract":"\n Importance<\/jats:title>\n Statin nonadherence is a leading, addressable driver of preventable cardiovascular events. Although health systems routinely use outreach to promote preventive care, most strategies are static and lack evidence from randomized clinical trials.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n To determine whether an adaptive, sequential digital outreach strategy improves short-term statin refill vs usual communication among adults with established atherosclerotic cardiovascular disease (ASCVD) or high ASCVD risk and recent nonadherence within a rapidly implemented, health system\u2013embedded randomized clinical trial.<\/jats:p>\n <\/jats:sec>\n \n Design, Setting, and Participants<\/jats:title>\n Pragmatic, health system\u2013embedded, prospective randomized open blinded end point (PROBE) clinical trial using a 2-stage sequential, multiple assignment, randomized trial (SMART) design. The trial was conducted via Kaiser Permanente Northern California, an integrated health care delivery system serving more than 4.6 million members. Eligible participants were adults 18 years or older with established ASCVD or high ASCVD risk, recent statin nonadherence, and eligibility for all study communication modalities.<\/jats:p>\n <\/jats:sec>\n \n Interventions<\/jats:title>\n Participants were randomized 1:1:1:1 to receive secure portal messaging, SMS\/text messaging, nonsecure email, or usual communication. Initial nonresponders within 14 days underwent prespecified second-stage randomization to repeat the same outreach, switch communication modality, or receive usual communication.<\/jats:p>\n <\/jats:sec>\n \n Main Outcomes and Measures<\/jats:title>\n Rates of 14-day statin refill following each randomization, with 28-day follow-up.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n Among 20\u202f604 participants (mean [SD] age, 54.8 [9.0] years; 40.9% female; 27.8% Asian, 10.9% Black, 33.6% Hispanic; 15.3% with established ASCVD), initial digital outreach increased 14-day statin refill vs usual communication (14.4% vs 12.0%; adjusted risk difference, 2.3 percentage points [95% CI, 1.3-3.4]; adjusted risk ratio, 1.20 [95% CI, 1.10-1.30]). Among initial nonresponders, second-stage outreach further increased refill (13.0% vs 10.4%; adjusted risk difference, 2.5 percentage points [95% CI, 1.3-3.7]; adjusted risk ratio, 1.25 [95% CI, 1.11-1.39]). Switching communication modalities did not improve refill vs repeating the same modality (13.2% vs 12.5%; adjusted risk ratio, 1.06 [95% CI, 0.94-1.17]). Cumulative statin refill through 28 days was higher in those receiving any digital outreach vs usual communication (24.9% vs 21.2%; adjusted hazard ratio, 1.21 [95% CI, 1.13-1.30]). Results were consistent across prespecified subgroups.<\/jats:p>\n <\/jats:sec>\n \n Conclusions and Relevance<\/jats:title>\n Among adults with a statin indication and recent statin nonadherence, adaptive outreach improved short-term refill vs usual communication. A second outreach produced additional gains among initial nonresponders, although switching communication modalities provided no additional benefit. These findings support adaptive, sequential health system outreach strategies to improve cardiovascular prevention when integrated into population health programs.<\/jats:p>\n <\/jats:sec>\n \n Trial Registration<\/jats:title>\n \n ClinicalTrials.gov Identifier:\n NCT07522645<\/jats:ext-link>\n <\/jats:p>\n <\/jats:sec>","DOI":"10.1001\/jama.2026.16372","type":"journal-article","created":{"date-parts":[[2026,8,29]],"date-time":"2026-08-29T16:30:18Z","timestamp":1788021018000},"page":"1518","source":"Crossref","is-referenced-by-count":2,"title":["Digital Outreach to Improve Statin Refills in Patients With Low Statin Adherence"],"prefix":"10.1001","volume":"336","author":[{"given":"Ankeet S.","family":"Bhatt","sequence":"first","affiliation":[{"name":"Division of Research, Kaiser Permanente Northern California, Oakland"},{"name":"Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California"},{"name":"Stanford University School of Medicine, Stanford, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vincent X.","family":"Liu","sequence":"additional","affiliation":[{"name":"Division of Research, Kaiser Permanente Northern California, Oakland"},{"name":"Department of Critical Care Medicine, Kaiser Permanente Northern California, Santa Clara"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Baiyang","family":"Sun","sequence":"additional","affiliation":[{"name":"Division of Research, Kaiser Permanente Northern California, Oakland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mirasol","family":"Apostol-Largeteau","sequence":"additional","affiliation":[{"name":"Division of Research, Kaiser Permanente Northern California, Oakland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ben J.","family":"Marafino","sequence":"additional","affiliation":[{"name":"Division of Research, Kaiser Permanente Northern California, Oakland"},{"name":"Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mariam","family":"Amiri","sequence":"additional","affiliation":[{"name":"Division of Research, Kaiser Permanente Northern California, Oakland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Duc (Lilly)","family":"Tran","sequence":"additional","affiliation":[{"name":"Division of Research, Kaiser Permanente Northern California, Oakland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew P.","family":"Ambrosy","sequence":"additional","affiliation":[{"name":"Division of Research, Kaiser Permanente Northern California, Oakland"},{"name":"Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Howard H.","family":"Dinh","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Kaiser Permanente Northern California, South Sacramento Medical Center, Sacramento"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lucy","family":"Finn","sequence":"additional","affiliation":[{"name":"Kaiser Permanente Northern California, Oakland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Payton","family":"Watt","sequence":"additional","affiliation":[{"name":"Kaiser Permanente Northern California, Oakland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Josephine","family":"Au","sequence":"additional","affiliation":[{"name":"Kaiser Permanente Northern California, Oakland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jaya","family":"Nadella","sequence":"additional","affiliation":[{"name":"Kaiser Permanente Northern California, Oakland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Noreen","family":"Jesani","sequence":"additional","affiliation":[{"name":"Kaiser Permanente Northern California, Oakland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jean C.","family":"Digitale","sequence":"additional","affiliation":[{"name":"Kaiser Permanente Northern California, Oakland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tor","family":"Biering-S\u00f8rensen","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Copenhagen University Hospital \u2013 Herlev and Gentofte, Copenhagen, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brian L.","family":"Claggett","sequence":"additional","affiliation":[{"name":"Division of Cardiovascular Medicine, Brigham and Women\u2019s Hospital, Harvard Medical School, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Scott D.","family":"Solomon","sequence":"additional","affiliation":[{"name":"Division of Cardiovascular Medicine, Brigham and Women\u2019s Hospital, Harvard Medical School, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Muthiah","family":"Vaduganathan","sequence":"additional","affiliation":[{"name":"Division of Cardiovascular Medicine, Brigham and Women\u2019s Hospital, Harvard Medical School, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alan S.","family":"Go","sequence":"additional","affiliation":[{"name":"Division of Research, Kaiser Permanente Northern California, Oakland"},{"name":"Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California"},{"name":"Departments of Epidemiology & Biostatistics and Medicine, University of California, San Francisco"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ivy A.","family":"Ku","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California"},{"name":"The Permanente Medical Group, Kaiser Permanente Northern California, Oakland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gopi","family":"Manthripragada","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California"},{"name":"The Permanente Medical Group, Kaiser Permanente Northern California, Oakland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kevin","family":"Yee","sequence":"additional","affiliation":[{"name":"The Permanente Medical Group, Kaiser Permanente Northern California, Oakland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kristine","family":"Lee","sequence":"additional","affiliation":[{"name":"The Permanente Medical Group, Kaiser Permanente Northern California, Oakland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mehreen","family":"Khan","sequence":"additional","affiliation":[{"name":"The Permanente Medical Group, Kaiser Permanente Northern California, Oakland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"ADHERE-ASCVD Investigators","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David","family":"Ouyang","sequence":"additional","affiliation":[{"name":"for the ADHERE-ASCVD Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erin","family":"Wong","sequence":"additional","affiliation":[{"name":"for the ADHERE-ASCVD Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julisa","family":"Carter","sequence":"additional","affiliation":[{"name":"for the ADHERE-ASCVD Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gurjot","family":"Kaur","sequence":"additional","affiliation":[{"name":"for the ADHERE-ASCVD Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marilena","family":"Newberry","sequence":"additional","affiliation":[{"name":"for the ADHERE-ASCVD Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Irina","family":"Komardenkova","sequence":"additional","affiliation":[{"name":"for the ADHERE-ASCVD Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lindsey","family":"Burbage","sequence":"additional","affiliation":[{"name":"for the ADHERE-ASCVD Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","reference":[{"issue":"2","key":"joi260093r1","doi-asserted-by":"publisher","first-page":"184","DOI":"10.1016\/j.jacc.2015.05.030","article-title":"Utilization of and adherence to guideline-recommended lipid-lowering therapy after acute coronary syndrome: opportunities for improvement.","volume":"66","author":"Hirsh","year":"2015","journal-title":"J Am Coll Cardiol"},{"issue":"8","key":"joi260093r2","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2020.11051","article-title":"Evaluation of aspirin and statin therapy use and adherence in patients with premature atherosclerotic cardiovascular disease.","volume":"3","author":"Mahtta","year":"2020","journal-title":"JAMA Netw Open"},{"issue":"18","key":"joi260093r3","doi-asserted-by":"publisher","first-page":"1802","DOI":"10.1016\/j.jacc.2022.02.048","article-title":"High-intensity statin use among patients with atherosclerosis in the US.","volume":"79","author":"Nelson","year":"2022","journal-title":"J Am Coll Cardiol"},{"issue":"7","key":"joi260093r4","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2020.8236","article-title":"Estimation of atherosclerotic cardiovascular disease risk among patients in the Veterans Affairs health care system.","volume":"3","author":"Vassy","year":"2020","journal-title":"JAMA Netw Open"},{"issue":"35","key":"joi260093r5","doi-asserted-by":"publisher","first-page":"983","DOI":"10.15585\/mmwr.mm6735a4","article-title":"Vital signs: prevalence of key cardiovascular disease risk factors for Million Hearts 2022\u2014United States, 2011-2016.","volume":"67","author":"Wall","year":"2018","journal-title":"MMWR Morb Mortal Wkly Rep"},{"issue":"5","key":"joi260093r6","doi-asserted-by":"publisher","first-page":"512","DOI":"10.18553\/jmcp.2025.31.5.512","article-title":"The influence of medication adherence on Medicare Star Ratings: a decade-long analysis of health plan performance.","volume":"31","author":"Borrelli","year":"2025","journal-title":"J Manag Care Spec Pharm"},{"issue":"10","key":"joi260093r7","doi-asserted-by":"publisher","first-page":"1455","DOI":"10.1002\/sim.2022","article-title":"An experimental design for the development of adaptive treatment strategies.","volume":"24","author":"Murphy","year":"2005","journal-title":"Stat Med"},{"issue":"3","key":"joi260093r8","doi-asserted-by":"publisher","first-page":"37","DOI":"10.7812\/TPP\/12-031","article-title":"Sociodemographic characteristics of members of a large, integrated health care system: comparison with US Census Bureau data.","volume":"16","author":"Koebnick","year":"2012","journal-title":"Perm J"},{"issue":"4","key":"joi260093r9","doi-asserted-by":"publisher","first-page":"15","DOI":"10.7812\/TPP\/15-225","article-title":"The Kaiser Permanente Northern California Adult Member Health Survey.","volume":"20","author":"Gordon","year":"2016","journal-title":"Perm J"},{"issue":"21","key":"joi260093r11","doi-asserted-by":"publisher","first-page":"2155","DOI":"10.1001\/jama.2022.21506","article-title":"Adjustment for baseline characteristics in randomized clinical trials.","volume":"328","author":"Holmberg","year":"2022","journal-title":"JAMA"},{"issue":"4","key":"joi260093r12","doi-asserted-by":"publisher","first-page":"336","DOI":"10.1001\/jama.2022.24324","article-title":"Sequential, multiple assignment, randomized trial designs.","volume":"329","author":"Kidwell","year":"2023","journal-title":"JAMA"},{"issue":"1","key":"joi260093r13","doi-asserted-by":"publisher","first-page":"46","DOI":"10.1001\/jama.2025.6681","article-title":"Add-on treatment with zilebesiran for inadequately controlled hypertension: the KARDIA-2 randomized clinical trial.","volume":"334","author":"Desai","year":"2025","journal-title":"JAMA"},{"issue":"3","key":"joi260093r14","doi-asserted-by":"publisher","first-page":"327","DOI":"10.1264\/jsme2.ME19073","article-title":"Nestedness in arbuscular mycorrhizal fungal communities in a volcanic ecosystem: selection of disturbance-tolerant fungi along an elevation gradient.","volume":"34","author":"Atunnisa","year":"2019","journal-title":"Microbes Environ"},{"issue":"3","key":"joi260093r15","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2023.5174","article-title":"Association of daily step patterns with mortality in US adults.","volume":"6","author":"Inoue","year":"2023","journal-title":"JAMA Netw Open"},{"issue":"5","key":"joi260093r16","doi-asserted-by":"publisher","first-page":"701","DOI":"10.3390\/polym17050701","article-title":"One-pot synthesis of amphiphilic linear and hyperbranched polyelectrolytes and their stimuli-responsive self-assembly in aqueous solutions.","volume":"17","author":"Gerardos","year":"2025","journal-title":"Polymers (Basel)"},{"issue":"6","key":"joi260093r17","doi-asserted-by":"publisher","first-page":"1315","DOI":"10.1016\/j.cgh.2023.12.027","article-title":"Randomized trial of patient outreach approaches to de-implement outdated colonoscopy surveillance intervals.","volume":"22","author":"Lee","year":"2024","journal-title":"Clin Gastroenterol Hepatol"},{"issue":"9","key":"joi260093r18","doi-asserted-by":"publisher","first-page":"1094","DOI":"10.1016\/j.jacc.2025.12.027","article-title":"Cardiovascular statistics in the United States, 2026: JACC Stats.","volume":"87","author":"Wadhera","year":"2026","journal-title":"J Am Coll Cardiol"},{"issue":"10382","key":"joi260093r19","doi-asserted-by":"publisher","first-page":"1103","DOI":"10.1016\/S0140-6736(23)00349-5","article-title":"Electronic nudges to increase influenza vaccination uptake in Denmark: a nationwide, pragmatic, registry-based, randomised implementation trial.","volume":"401","author":"Johansen","year":"2023","journal-title":"Lancet"},{"issue":"22","key":"joi260093r20","doi-asserted-by":"publisher","first-page":"1900","DOI":"10.1001\/jama.2024.21060","article-title":"Electronic nudges to increase influenza vaccination in patients with chronic diseases: a randomized clinical trial.","volume":"332","author":"Johansen","year":"2024","journal-title":"JAMA"},{"issue":"2","key":"joi260093r21","doi-asserted-by":"publisher","first-page":"153","DOI":"10.1001\/jama.2024.4088","article-title":"The integration of clinical trials with the practice of medicine: repairing a house divided.","volume":"332","author":"Angus","year":"2024","journal-title":"JAMA"},{"key":"joi260093r10","unstructured":"Centers for Medicare & Medicaid Services. Medicare 2025 Part C & D Star Ratings technical notes. Updated October 3, 2024. Accessed July 22, 2026. https:\/\/www.cms.gov\/files\/document\/2025-star-ratings-technical-notes.pdf"}],"container-title":["JAMA"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jama\/articlepdf\/2853392\/jama_bhatt_2026_oi_260093_1792777062.97883.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,11,3]],"date-time":"2026-11-03T16:04:32Z","timestamp":1793721872000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jama\/fullarticle\/2853392"}},"subtitle":["The ADHERE-ASCVD Randomized Clinical Trial"],"short-title":[],"issued":{"date-parts":[[2026,11,3]]},"references-count":21,"journal-issue":{"issue":"17","published-print":{"date-parts":[[2026,11,3]]}},"URL":"https:\/\/doi.org\/10.1001\/jama.2026.16372","relation":{},"ISSN":["0098-7484"],"issn-type":[{"value":"0098-7484","type":"print"}],"subject":[],"published":{"date-parts":[[2026,11,3]]}}}