Picture of Incidental Calcium To Understand Risk Estimate (PICTURE) Trial (PICTURE)

This is a prospective randomized controlled trial assessing the impact of notifying patients and their clinicians of an incidental finding of coronary artery calcification (CAC) indicating increased cardiovascular risk. Patients will be identified through completed radiology orders for non-gated, non-contrast chest CT in the appropriate clinical context and then will have an EHR screen for inclusion criteria. The presence of CAC will be confirmed by a board-certified physician. Eligible patients will be randomized to CAC notification or usual care using a 1:1 stratified block randomization method based on baseline statin use.

The notification arm will have its CT scans interpreted and reported according to standard clinical practice. Patients randomized to notification will receive a message sent by either the EHR patient portal or postal mail that will inform them of the CAC identified on their recent chest CT. It will provide an overview of CAC, an image of their chest CT, and current guideline recommendation that they discuss this finding with their clinician and consider statin therapy. A patient's primary care physician will be notified simultaneously via a secure EHR message. All communications will be signed by the Principal Investigator. Any treatment decisions will be made by the patient and their clinician.

The usual care arm will have its CT scans interpreted and reported according to standard clinical practice. This may mention the presence of CAC in the official radiology imaging report, per usual practice. The usual care arm will not receive any notification beyond this standard of care. We intend to notify patients in the usual care arm at the end of 6 months if we determine that notification is effective at increasing statin rates.

For patients randomized to notification, the affiliated primary care clinician will receive an electronic health record (EHR) message notifying them of the presence of CAC (with images) and the ACC/AHA guideline recommendation to consider starting statin therapy. Simultaneously, the patient will be notified via a MyHealth message describing the presence of CAC with personalized scan images, its significance, and the recommendation that statin therapy should be considered. For the notification arm, we will check for either statin prescription or a documented discussion in the EHR at 2 months. For those not prescribed a statin and without a documented discussion in Epic at 2 months follow-up, we will send a repeat notification to their home address and to their primary care clinician.

This outcome assesses healthcare resource use (primary care clinical encounters, cardiology referrals, cardiac testing).

Inclusion Criteria: Age 18 and above and <90 Non-gated chest CT with CAC An encounter after January 1, 2020 with a Stanford-affiliated clinician from one of the following clinics: Stanford Internal Medicine (includes University affiliated clinics) Stanford Family Medicine (includes University affiliated clinics) Exclusion Criteria: Metastatic cancer or active cytotoxic chemotherapy Non-English or non-Spanish speaking