Clinical reminders to providers of patients with reduced left ventricular ejection fraction increase defibrillator
Anurag Gupta1, Parisa Gholami, Mintu P Turakhia
1Medical Service, VA Palo Alto Health Care System, Palo Alto, CA.
Insights
A simple provider reminder significantly increased referrals for implantable cardioverter defibrillators (ICDs) in eligible patients. This intervention improved both referral rates and documented discussions for ICD implantation.
Area of Science:
- Cardiology
- Medical Informatics
- Healthcare Quality Improvement
Background:
- Many patients eligible for implantable cardioverter defibrillators (ICDs) are not referred for implantation.
- Provider referral rates for ICDs can be suboptimal.
- Identifying and addressing barriers to ICD referral is crucial for patient care.
Purpose of the Study:
- To evaluate if a simple provider reminder can increase referrals for implantable cardioverter defibrillators (ICDs).
- To assess the impact of an electronic medical record-based intervention on ICD referral rates.
- To determine if provider reminders improve documented discussions about ICD candidacy.
Main Methods:
- Consecutive patients with left ventricular ejection fraction ≤35% were identified.
- Patients were randomized to either a provider reminder or no intervention.
- Referral for ICD implantation and documented discussion of candidacy were primary and secondary outcomes.
Main Results:
- A provider reminder intervention increased ICD referral rates from 2% to 24% (P=0.004).
- The intervention also improved documented discussions regarding ICD candidacy, rising from 44% to 67% (P=0.05).
- The study involved 89 patients randomized after exclusions.
Conclusions:
- A simple electronic medical record-based reminder to providers effectively increased ICD referral rates.
- Provider-directed interventions can improve the utilization of life-saving therapies like ICDs.
- This highlights a scalable method for enhancing patient access to appropriate cardiac device therapy.
Background:
Many patients who are candidates for implantable cardioverter defibrillators (ICDs) are not referred for potential implantation. We sought to determine if a simple provider reminder would increase referrals.
Methods And Results:
We identified consecutive patients from January 2007 through July 2010 in the VA Palo Alto Health Care System with a left ventricular ejection fraction<35% on echocardiography. Patients were excluded using available administrative data only (no chart review) if they were known to have an ICD, if they were ≥80 years old, or if they did not have a current primary care or cardiology provider within the system. We randomized patients to no intervention or a clinical note to the provider in the medical record. The outcomes were referral for consideration of defibrillator implantation (primary) and documented discussion (secondary). Of 330 patients with left ventricular ejection fraction≤35%, 128 were known to have an ICD, 85 were no longer followed in the healthcare system, and 28 were ≥80 years old, leaving 89 patients to be randomized. Forty-six patients were randomized to intervention and 43 to control. Eleven of 46 (24%) intervention patients were referred for consideration of ICD implantation during the following 6 months versus 1 of 43 (2%) control patients (P=0.004). Overall, 31 of 46 (67%) intervention patients versus 19 of 43 (44%) control patients had documentation discussing potential candidacy for defibrillators (P=0.05).
Conclusions:
In patients with low left ventricular ejection fraction, a simple electronic medical record-based intervention directed to their providers improved the rates of referral for ICD implantation.
Clinical Trial Registration:
URL: http://www.clinicaltrials.gov. Unique identifier: NCT01217827.
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