PA Heidenreich, Palo Alto VA; T Alloggiamento, Palo Alto VA; B Fadel, Palo Alto VA; JE Atwood, Palo Alto VA

Objectives: Although the use of angiotensin converting enzyme (ACE) inhibitors has improved for patients with low ejection fraction, providers frequently prescribe doses lower than recommended in clinical guidelines. The objective of this study was to determine whether including reminders in echocardiographic reports increases the use of recommended doses of ACE inhibitors or angiotensin receptor blockers (ARBs, used as a second line agent) for patients with depressed left ventricular function.

Methods: A total of 291 patients with ejection fraction less than 40% on echocardiography were randomized (allocation concealed) to have either a clinical reminder attached to their echocardiography report (N=141) or no reminder (N=150). Patients were evaluated at one of three Veteran's echocardiography laboratories serving a tertiary care hospital, a community hospital, and several community clinics. The clinical reminder noted that patients with low ejection fraction have improved survival when treated with moderate to high doses of ACE inhibitors. Goal doses of two ACE inhibitors were provided. The primary outcome measure was treatment with moderate or greater doses of ACE inhibitors or ARBs for patients without contraindications at six months following randomization

Results: Six month medication use was unavailable for 26 (10%) patients that died and for 42 (14%) patients that left the health care system. Another 7 (2%) patients had contraindications to ACE inhibitor use. For the remaining 216 patients (105 reminder group, 111 control group), the mean age was 67 years with standard deviation (SD) 12 years, 100% were male, 70% had a prior diagnosis of heart failure, 70% had coronary artery disease, 65% had hypertension, and 38% had diabetes. The mean New York Heart Association class was 2.2 (SD 1.0) and the mean serum creatinine was 1.7 mg/dl (SD 1.7). Patients that left the health care system had similar characteristics to those that remained. At randomization, 74% of patients were treated with an ACE inhibitor or ARB, and 35% were treated with moderate or higher doses. At six months, patients randomized to the reminder were more likely to be treated with moderate to high doses of ACE inhibitors or ARBs (61.0%, 64/105), than were patients randomized to no reminder (46.0%, 51/111, p=0.03). There was no difference in treatment with any dose of ACE inhibitor or ARB (90.5% for reminder vs. 93.8% for control, p=0.4). No difference in mortality was noted at 6 months (10.4% reminder, vs. 12.1% control, p=0.7) or 1 year (13.2% reminder, vs. 16.1% control, p=0.5). When expired patients were included as medication non-users, the differences in use of moderate or higher doses of ACE or ARB between the reminder (54.7%, 64/117) and control groups (40.8%, 51/125) persisted (p=0.02).

Conclusions: Our findings indicate that a reminder attached to the echocardiography report can improve the use of recommended doses of ACE inhibitors or ARBs for patients with depressed left ventricular ejection fraction.

Impact: Attaching reminders to diagnostic test reports is easily implemented and can be applied to a large number of diseases. Future research should examine the use of diagnostic reports as a method of improving guideline compliance.