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Reminders in echocardiography reports increased use of β blockers in reduced left ventricular ejection fraction
  1. S George Carruthers, MD, FRCPC
  1. United Arab Emirates University, Al Ain, United Arab Emirates

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    In patients with reduced left ventricular ejection fraction (LVEF), do clinical reminders attached to echocardiography reports increase use of β blockers?

    Heidenreich PA, Gholami P, Sahay A, et al. Clinical reminders attached to echocardiography reports of patients with reduced left ventricular ejection fraction increase use of b-blockers. A randomized trial. Circulation 2007;115:2829–34.

    Clinical impact ratings GP/FP/Primary care ★★★★★★⋆ IM/Ambulatory care ★★★★★★⋆ Cardiology ★★★★★⋆⋆

    METHODS

    Embedded ImageDesign:

    randomised controlled trial.

    Embedded ImageAllocation:

    concealed.*

    Embedded ImageBlinding:

    {blinded (data collectors)}†.*

    Embedded ImageFollow-up period:

    9 months after echocardiography.

    Embedded ImageSetting:

    3 Veterans Affairs (VA) echocardiography laboratories in the US.

    Embedded ImagePatients:

    1546 patients with LVEF <45%, assessed by attending echocardiographer. Exclusion criteria were aortic stenosis (mean valve gradient ⩾20 mm Hg) or mitral stenosis (mean gradient ⩾5 mm Hg).

    Embedded ImageIntervention:

    the echocardiography report of the reminder group (n = 755) included a written reminder that β blockers (carvedilol, initial dose 3.125 mg twice daily, or metoprolol, initial dose 12.5 mg twice daily) improve survival in patients with reduced LVEF and recommended cardiology follow-up for patients with New York Heart Association class III or IV symptoms. Reminders were not placed in the reports of the control group (n = 791).

    Embedded ImageOutcomes:

    prescription for any β blocker recorded in the VA pharmacy database within 9 months after echocardiography. Secondary outcomes included prescription for a guideline-recommended β blocker (carvedilol or metoprolol).

    Embedded ImagePatient follow-up:

    82% were included in the analysis (mean age 69 y, 98% men, 51% on β blockers at baseline).

    *See glossary

    †Information provided by author.

    MAIN RESULTS

    Prescription rates for any β blockers or guideline-recommended β blockers (carvedilol and metoprolol) were higher in the reminder group than in the no-reminder group (table).

    Reminder v no reminder for prescription of β blockers in echocardiography report of patients with reduced left ventricular ejection fraction*

    CONCLUSION

    In patients with reduced left ventricular ejection fraction undergoing echocardiography, inclusion of a written reminder in the echocardiography report increased the use of β blockers.

    Commentary

    So-called treatment “gaps” related to physician lapses in following evidence-based clinical guidelines are the result of specific physician or system shortcomings.1 Efforts to identify and validate uncomplicated, inexpensive procedures that improve physician adherence are welcome, especially when the disease in question, congestive heart failure (CHF), contributes immensely to morbidity, mortality, and healthcare expense, and treatment (β blockers) is low-cost and readily available. The value of β blockade in heart failure is well established,2 but many eligible patients do not receive this or other scientifically confirmed treatments.3 Fear of aggravating a patient’s precarious cardiac status is a common concern. Certainly β blocker treatment in CHF demands very low initial doses and carefully monitored titration, but when used properly, the risk of adverse events is low.

    The simple reminder on the echocardiography reports of patients qualifying for treatment in the study by Heidenreich et al is readily reproducible. Including specific prescribing details for guideline-recommended β blockers, metoprolol and carvedilol, was useful. Even with the encouraging baseline status of patients (51% using β blockers) and improved utilisation of β blockers, particularly after the reminder, 1 in 4 patients did not receive a proven intervention. Thus, much remains to be done to accomplish the ideal.

    The problem of eliminating treatment gaps will likely require as many solutions as there are apparent causes. Antipathy to “cookbook” medicine is clearly unhelpful. Neither is the threat of litigation for neglecting a proven treatment likely to improve implementation. Rewarding physician behaviour that most benefits most patients is an attractive option.

    References

    View Abstract

    Footnotes

    • Sources of funding: VA Health Services Research Development Office and American Society of Echocardiography.