Clinical Reminders and Beta-Blocker Use Following Echocardiography - Clinical Reminders and Beta-Blocker Use Following Echocardiography
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).
Patients Screened: 7,724
Patients Enrolled: 1,271
Mean Follow Up: 9 months
Mean Patient Age: Mean age, 69 years
Undergoing echocardiography at 1 of 3 echocardiography laboratories in the VA Palo Alto Health Care System with an LVEF <45%
Aortic stenosis with a mean aortic valve gradient of ≥20 mm Hg or mitral stenosis with a mean gradient of ≥5 mm Hg
Prescription for an oral beta-blocker between 1 and 9 months after randomization
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)
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)."
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).
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.
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.
Keywords: Medication Adherence, Myocardial Ischemia, Carbazoles, Heart Failure, Stroke Volume, Propanolamines, Metoprolol, Hospitalization, Diabetes Mellitus, Echocardiography
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