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.
The study has resulted in two publications:
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. Epub 2007 May 21. PMID: 17515459
2: Heidenreich PA, Chacko M, Goldstein MK, Atwood JE. ACE inhibitor reminders attached to echocardiography reports of patients with reduced left ventricular ejection fraction. Am J Med. 2005 Sep;118(9):1034-7.
PUBLICATIONS:
Journal Articles
- Heidenreich PA, Chacko M, Goldstein MK, Atwood JE. ACE inhibitor reminders attached to echocardiography reports of patients with reduced left ventricular ejection fraction. American Journal of Medicine. 2005; 118(9): 1034-7.
