Clinical Reminders and Beta-Blocker Use Following Echocardiography - Clinical Reminders and Beta-Blocker Use Following Echocardiography

Description:

The goal of the trial was to evaluate the effect of a clinical reminder for beta-blocker on the echocardiography reports on prescription frequency among patients with reduced left ventricular ejection fraction (LVEF).

Study Design

Study Design:

Patients Screened: 7,724
Patients Enrolled: 1,271
Mean Follow Up: 9 months
Mean Patient Age: Mean age, 69 years
Female: 2

Patient Populations:

Undergoing echocardiography at 1 of 3 echocardiography laboratories in the VA Palo Alto Health Care System with an LVEF <45%

Exclusions:

Aortic stenosis with a mean aortic valve gradient of ≥20 mm Hg or mitral stenosis with a mean gradient of ≥5 mm Hg

Primary Endpoints:

Prescription for an oral beta-blocker between 1 and 9 months after randomization

Secondary Endpoints:

Prescription for beta-blockers shown to prolong survival in randomized trials of patients with systolic heart failure and available on the formulary (carvedilol and metoprolol succinate)

Drug/Procedures Used:

Patients were randomized to reminder for use of beta-blockers (n = 621) or no reminder (n = 650) on the echocardiography report. The echocardiography report, randomization, and reminder were all generated via an electronic database. The reminder stated: "Note: Patients with reduced left ventricular ejection fraction have a survival benefit with beta-blockers (initial dose: carvedilol 3.125 mg BID or metoprolol succinate 12.5 mg BID)."

Principal Findings:

Mean LVEF at baseline was 33%. Heart failure was present in 61% of patients, ischemic heart disease in 70%, and diabetes in 41%. Slightly more than half of patients were receiving a beta-blocker at study entry (51%); other medications included angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker (65%) and statins (54%).

The primary endpoint of beta-blocker prescription between months 1 and 9 occurred more frequently in the reminder group than the no reminder group (74% vs. 66%, p = 0.002). Prescriptions for a guideline-recommended beta-blocker were also higher in the reminder group compared with the no reminder group (42% vs. 37%, p = 0.048). Primary endpoint results were similar among the cohort of patients not already on a beta-blocker at study entry (n = 619; 56% prescription in the reminder group vs. 44% prescription in the no reminder group), as well as the subgroups of in-patients and outpatients.

Survival free of hospitalization for heart failure was not different between the reminder and no reminder group (hazard ratio 0.99).

Interpretation:

Among patients with reduced LVEF, use of a clinical reminder for beta-blocker use on the echocardiography reports was associated with an increase in beta-blocker prescriptions from 1 to 9 months compared with no reminders.

Beta-blockers have previously been shown to improve clinical outcomes in patients with impaired LV function. However, use of beta-blockers in patients with an indication has been reported as low as 30%. Randomized medication compliance studies are few, but some relatively simple methods have been shown to increase medication compliance, including the present study of using a computer-generated reminder on the echocardiography report. In the recent FAME trial, also undertaken through the Veterans Affairs (VA) health system, use of a pharmacy intervention program that included pre-prepared blister packs of pills was associated with better medication use adherence and improved clinical conditions compared with usual care in patients treated with multiple chronic medications.

References:

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;115:2829-34.

Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Statins, Acute Heart Failure, Echocardiography/Ultrasound

Keywords: Medication Adherence, Myocardial Ischemia, Carbazoles, Heart Failure, Stroke Volume, Propanolamines, Metoprolol, Hospitalization, Diabetes Mellitus, Echocardiography


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