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IIR 01-108 – HSR&D Study

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IIR 01-108
Clinical Reminders in Test Reports to Improve Guideline Compliance
Paul A. Heidenreich MD MS
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: October 2003 - September 2006

BACKGROUND/RATIONALE:
Although beta-blockers are known to prolong survival for patients with reduced left ventricular ejection fraction, their use in the community and the VA is suboptimal.

OBJECTIVE(S):
To determine if a reminder attached to the echocardiography report would increase the use of beta-blockers among patients with depressed left ventricular function.

METHODS:
We are randomizing consecutive patients undergoing echocardiography at one of three VA echocardiography laboratories with reduced left ventricular ejection fraction (<40%) and no echocardiographic contraindication to beta-blockers (e.g. aortic stenosis) to a reminder for use of beta-blockers or to no reminder. The reminder gives starting doses for two commonly used beta-blockers (carvedilol and metoprolol). Patients are excluded from the analysis if they leave the health care system or die within three months of randomization. The primary outcome is a prescription for a beta-blocker between three and nine months following echocardiography

FINDINGS/RESULTS:
The mean age of the 1271 included patients was 69 years, 60% had a history of heart failure, and 51% were receiving treatment with beta-blockers at the time of echocardiography. More patients randomized to the reminder had a subsequent beta-blocker prescription (74%, 458/621), compared to those randomized to no reminder (66%, 428/650, p=0.002). Reminders were most effective for patients without a prior history of heart failure (beta-blocker use 75% reminder vs. 61% no reminder, p=0.001), and without prior use of beta-blockers (subsequent beta-blocker use: 56% reminder vs. 44% no reminder, p=0.003).

IMPACT:
The reminder for the beta-blocker has been implemented in the Palo Alto Health Care System. The CHF QUERI has chosen to promote this reminder and will be evaluting different methods of its implementation in a randomized trial to begin in fiscal year 2008.

PUBLICATIONS:

Journal Articles

  1. Heidenreich PA, Chacko M, Goldstein MK, Atwood JE. ACE inhibitor reminders attached to echocardiography reports of patients with reduced left ventricular ejection fraction. The American journal of medicine. 2005 Sep 1; 118(9):1034-7.
Journal Other

  1. Heidenreich PA, Gholami P, Sahay A, Massie B, Goldstein MK. Clinical reminders attached to echocardiography reports of patients with reduced left ventricular ejection fraction increase use of beta-blockers: a randomized trial. Circulation. 2007 Jun 5; 115(22):2829-34.


DRA: Health Systems
DRE: Diagnosis, Treatment - Observational, Prevention
Keywords: Behavior (provider), Cardiovasc’r disease, Clinical practice guidelines
MeSH Terms: none