- Email: [email protected]
ACE inhibitor reminders attached to echocardiography reports of patients with reduced left ventricular ejection fraction
The American Journal of Medicine (2005) 118, 1034-1037
BRIEF OBSERVATION
ACE inhibitor reminders attached to echocardiography reports of patients with reduced left ventricular ejection fraction Paul A. Heidenreich, MD, MS,a Matthew Chacko, MD,a Mary K. Goldstein, MD, MS,a J. Edwin Atwood, MDb a
VA Palo Alto Health Care System, and the Department of Medicine, Stanford University, Stanford, Calif, and Walter Reed Army Medical Center, Washington DC.
b
Although treatment with angiotensin-converting enzyme (ACE) inhibitors is known to improve outcome for patients with left ventricular dysfunction,1,2 their use in the community has been suboptimal.3 Even when ACE inhibitors are prescribed, the dose used is usually below what has been shown to be effective in randomized clinical trials.4 The goal of this study was to determine if the addition of a reminder to the echocardiography report for patients with a reduced ejection fraction could increase the use of moderate or greater doses of ACE inhibitors or alternative appropriate treatment (eg, angiotensin receptor blockers).
Methods Patients Patients undergoing echocardiography at 1 of 3 echocardiography laboratories in the Veterans Administration Palo Alto Health Care System were eligible if they had an ejection fraction ⬍40%, as determined by the attending echocardiographer. Patients were not eligible if they had a mean aortic valve gradient of 20 mm Hg or greater, mitral stenosis with a mean gradient of 5 mm Hg or greater, or any left Views expressed are those of the authors and not necessarily those of the Department of Veterans Affairs or other affiliated organizations. Requests for reprints should be addressed to Paul A. Heidenreich, MD, 111C Cardiology, Palo Alto VA Health Care System, 3801 Miranda Avenue, Palo Alto, CA 94304. E-mail address: [email protected].
0002-9343/$ -see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.amjmed.2004.12.028
ventricular outflow tract obstruction. Patients were randomized regardless of whether or not they were already treated with ACE inhibitors at recommended doses, because this information on prescribing data would not be readily available to an echocardiographer in practice.
Study protocol Patient selection and randomization were computerized and performed in conjunction with the generation of the echocardiography report using an electronic database. Patients who met study criteria were randomized using a computerized random number generator either to have a reminder attached to their report or not to have a reminder. Allocation was concealed from all echocardiographers until the reminder appeared in the report. Patients who had more than 1 echocardiogram either received a reminder for all studies or did not receive a reminder for any study based on the initial randomization. Patients were excluded from analysis if they were already on a moderate or greater dose of an ACE inhibitor or an appropriate alternative at the time of randomization, died within 2 months of the echocardiogram, left the Veterans Administration health care system, or had an allergy or adverse reaction to ACE inhibitors. The study was approved (including waiver of consent) by the Administrative Panel on Human Subjects at Stanford University. We identified 600 consecutive and eligible patients during an 18-month period. All patients were randomized (allocation concealed) to have either a clinical reminder at-
Heidenreich et al
Clinical reminders to improve ACE inhibitor use
1035
Figure 1 Flow of study participants. Patients were not analyzed for the primary outcome if they were already treated with the moderate or greater doses of ACE inhibitors or appropriate equivalent (primary outcome) at the time of randomization, died within 2 months of randomization, left the health care system, or had an adverse reaction to ACE inhibitors. ACEi ⫽ angiotensin-converting enzyme inhibitor.
tached to their echocardiography report (n ⫽ 292) or no reminder (n ⫽ 308) (Figure 1).
Intervention Echocardiography reports randomized to the reminder included the following statement: “Note: Patients with ejection fraction ⱕ40% have a survival benefit with ACE inhibitors (goal dose lisinopril or fosinopril 30-40 mg/day).” The drug examples were chosen because these are the longacting ACE inhibitors available on the Veterans Administration Palo Alto Health Care System formulary. The high goal dose was chosen for the reminder to match goal doses used when randomized trials of ACE inhibitors have demonstrated improved survival benefit.
Outcome The prespecified primary outcome was an active prescription for a moderate or greater daily dose of ACE inhibitor (lisinopril 20 mg, fosinopril 20 mg, captopril 75 mg) or appropriate alternative (losartan 50 mg, irbesartan 150 mg, hydralazine 150 mg when used with isosorbide dinitrate). No other drugs in these classes were prescribed during the study. A moderate dose, rather than the high dose recommendation of the reminder, was chosen as the primary outcome to match the actual
usage of ACE inhibitors during the randomized trials that have demonstrated improved survival and represents the dose currently recommended by clinical guidelines.4 Medication use was determined from review of inpatient or outpatient encounters closest to 6 months (and between 2 and 9 months) following randomization.
Statistics We used t-tests to compare continuous variables and chisquared tests for categorical variables. We used logistic regression models to determine the association of use of moderate or greater doses of ACE inhibitors or equivalent drugs with patient characteristics. Differences in survival between groups were compared using the log-rank test. All analyses were performed using JMP version 5.0 (SAS Institute, Cary, NC). All significance tests were 2-sided. A P value of less than 0.05 was considered statistically significant.
Results Among the 277 included patients (Table 1), an ACE inhibitor (n ⫽ 120), angiotensin receptor blocker (n ⫽ 7) or the combination of hydralazine/isosorbide dinitrate (n ⫽ 2)
1036 Table 1
The American Journal of Medicine, Vol 118, No 9, September 2005 Baseline characteristics of the study sample
Characteristic Number of patients Age (years) Men Hospitalized at time of echocardiography History of heart failure* NYHA class Hypertension Diabetes mellitus Coronary artery disease Past myocardial infarction Medications ACE inhibitor Angiotensin receptor blocker Hydralazine/isosorbide Beta-blocker Digoxin Spironolactone Diuretic Calcium antagonist Echocardiography findings† Systolic blood pressure (mm Hg) Diastolic blood pressure (mm Hg) Ejection fraction (%) Atrial fibrillation or flutter Mitral regurgitation, at least moderate Laboratory values Serum sodium ⬍135 mEq/L Serum creatinine (mg/dL) (n ⫽ 258 intervention, 265 control)
Reminder
No reminder
Number (%), mean ⫾ SD 137 140 68 ⫾ 11 67 ⫾ 12 136 (99) 139 (99) 69 (50) 59/135 (44) 2.0 ⫾ 1.2 67/135 (50) 30/135 (22) 95/135 (70) 55/135 (41)
65 (46) 80/134 (60) 2.1 ⫾ 1.2 80/134 (60) 34/134 (25) 93/134 (69) 67/134 (50)
60/127 (47)
60/132 (45)
3/127 0/127 37/127 44/127 3/127 58/127 23/127
3/132 (2) 2/132 (2) 35/132 (27) 42/132 (32) 10/132 (8) 69/132 (52) 19/132 (14)
(3) (0) (29) (35) (2) (46) (18)
125 ⫾ 19
122 ⫾ 16
73 ⫾ 8 28 ⫾ 7 28/132 (21)
73 ⫾ 11 29 ⫾ 7 22/135 (16)
65/137 (47)
65/136 (48)
21/122 (17)
13/116 (11)
Table 2
Outcomes at 6 months
Outcome
Reminder
No reminder
Moderate or greater ACE use* Systolic blood pressure (mm Hg) Diastolic blood pressure (mm Hg) Creatinine (mg/dL)† Creatinine ⬎3 (mg/dl)†
Number (%), mean ⫾ SD 52/137 (38) 37/140 (26) 126 ⫾ 22 126 ⫾ 23 68 ⫾ 14 68 ⫾ 14 1.8 ⫾ 1.8 1.8 ⫾ 1.9 15/124 (12) 16/134 (12)
ACEi ⫽ Angiotensin converting enzyme inhibitor. *P ⫽ 0.04. All others P ⬎ 0.2 †Creatinine available for 124 patients in the reminder group and 134 in the no reminder group.
moderate or higher doses at 6 months (125/221, 57%) compared with the no reminder group (114/235, 49%; P ⫽ 0.09). Use of any dose of ACE inhibitors during follow-up was no different between the reminder (88%, 121/137) and the no reminder groups (87%, 122/140, P ⫽ 0.77).
Secondary outcomes Overall mortality was 17% (43/251) at 1 year. Reminders had no measurable effect on survival (hazard ratio [HR] ⫽ 0.98 for mortality with a reminder; 95% confidence interval [CI]: 0.78 to 1.23). There was no discernable effect of reminders on renal function or on systolic or diastolic blood pressure at 6 months following echocardiography (Table 2).
Predictors of ACE inhibitor use
1.5 ⫾ 1.4
1.8 ⫾ 2.0
NYHA ⫽ New York Heart Association. *P ⫽ 0.009, for all other comparisons P ⬎ 0.05. Baseline historical data were available from the medical record (prior to the echocardiogram) in 135 of patients randomized to reminder and 134 of patients randomized to no reminder. †In some patients, the rhythm or degree of mitral regurgitation could not be determined.
were used at less than moderate doses in 50% (129/259) at baseline.
Primary outcome: ACE inhibitor use during follow-up Of patients who were randomized to the reminder group, 38% (52/137) were prescribed moderate or greater doses of ACE inhibitors or equivalent appropriate medications by 6 months compared with 26% (37/140, P ⫽ 0.04) of patients randomized to no reminder. When patients who already were on target doses at baseline were included, a trend remained between the provision of reminders and the use of
In a multivariate logistic model adjusting for demographics (age, sex, race) and clinical variables (ejection fraction, history of heart failure, diabetes, hypertension, coronary artery disease, renal insufficiency, follow up with cardiology), randomization to a reminder (odds ratio [OR] ⫽ 1.70; 95% CI: 1.02 to 2.86) and a baseline creatinine below 1.5 mg/dL (OR ⫽ 2.22; 95% CI: 1.23 to 4.16) were the only variables associated with increased use of moderate or greater doses of ACE inhibitors or equivalent appropriate medication at 6 months after randomization (P ⬍0.05).
Discussion Several interventions have been proposed to improve the quality of care for heart failure patients.5 Attaching a reminder to a diagnostic test report is an attractive strategy, because it is a simple, low-cost intervention. The only requirement for implementation is that the interpreting physician or laboratory be aware of the relevant treatment guideline. In our study, a computer algorithm determined if the patient was a candidate for the reminder based on the findings of an echocardiography. However, a computerized reporting system is not required. Reminders can be added
Heidenreich et al
Clinical reminders to improve ACE inhibitor use
using any reporting format (eg, typed or dictated), with the minimal cost of adding an extra sentence to the report. In a prior, nonrandomized evaluation of reminders attached to echocardiography reports,6 compliance with the American Heart Association’s guidelines for endocarditis prophylaxis7 was greater among patients with a reminder (73%) than in a control group without a reminder (65%, P ⫽ 0.01). The authors concluded that echocardiographers should include reminder statements in their reports. Despite the difference in recommended treatments, (antibiotics vs ACE inhibitors), the absolute benefit of the reminder in this prior study (8% increase) was comparable to the effect of reminders in our study (12% increase). This magnitude of increase compares favorably with other studies of strategies to improve adherence to recommended management. Why do reminders appear to have only a modest effect on the use of recommended therapies? One potential explanation is that clinicians are often reluctant to initiate therapy that may have important side effects. This hypothesis is supported by the results of a randomized trial of computerized reminders directed to resident physicians in the Veterans Administration health care system.8 Physicians randomized to reminders had statistically significantly greater improvements in compliance with several prevention standards, but recommended treatment with anticoagulation for patients with atrial fibrillation was actually lower in the reminder group (75%) than in the control group (82%, P ⫽ 0.10). However, a computerized reminder8 may not be as effective as a reminder that is included in a report signed by a staff cardiologist who may be viewed as a local expert. The strengths of our study include the randomized design and the ease of implementing the intervention. One limitation is the uncertain generalizability given the unique features of the study’s setting. The Palo Alto Veterans Administration health care system contains a mix of academic and nonacademic community-based clinics, where all providers have every patient’s medical record available electronically at all times. Reminders may be less effective in other health systems that do not routinely allow review of the echocardiography report during the patient encounter; however, it is a standard of care that physicians who order an echocardiogram should have the results available to them when they see patients in follow-up. An additional limitation is that our
1037
subjects were predominately men. If physicians respond to reminders differently based on the sex of their patient, our results can be applied only to men. In summary, our trial found that a clinical reminder attached to the echocardiography report significantly increases the prescribed dose of ACE inhibitors or appropriate alternatives to match those used in clinical trials and currently recommended in guidelines from the American Heart Association and American College of Cardiology,4 but the absolute increment of compliance was modest. Additional studies should examine the effectiveness of reminders attached to other diagnostic test reports and address why reminders, even when effective, still do not result in optimal compliance with guideline-proved therapy.
References 1. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and chronic heart failure. The SOLVD Investigators. N Engl J Med. 1991;325:293-302. 2. Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. The SOLVD Investigators. N Engl J Med. 1992;327:685-691. 3. Stafford RS, Radley DC. The underutilization of cardiac medications of proven benefit, 1990 to 2002. J Am Coll Cardiol. 2003;41:56 – 61. 4. Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary a report of the American College Of Cardiology/American Heart Association Task Force On Practice Guidelines (Committee To Revise The 1995 Guidelines For The Evaluation And Management Of Heart Failure): developed in collaboration with the International Society For Heart And Lung Transplantation; endorsed by the Heart Failure Society Of America. Circulation. 2001;104:2996 –3007. 5. Krumholz HM, Wang Y, Parent EM, Mockalis J, Petrillo M, Radford MJ. Quality of care for elderly patients hospitalized with heart failure. Arch Intern Med 1997;157:2242–2247. 6. Sanders GP, Yeon SB, Grunes J, Seto TB, Manning WJ. Impact of a specific echocardiographic report comment regarding endocarditis prophylaxis on compliance with American Heart Association recommendations. Circulation 2002;106:300 –303. 7. Durack DT, Lukes AS, Bright DK: New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Am J Med. 1994;96:200 –209. 8. Demakis JG, Beauchamp C, Cull WL, et al. Improving residents’ compliance with standards of ambulatory care: results from the VA Cooperative Study on Computerized Reminders. JAMA. 2000;284:1411–1416.
BRIEF OBSERVATION
ACE inhibitor reminders attached to echocardiography reports of patients with reduced left ventricular ejection fraction Paul A. Heidenreich, MD, MS,a Matthew Chacko, MD,a Mary K. Goldstein, MD, MS,a J. Edwin Atwood, MDb a
VA Palo Alto Health Care System, and the Department of Medicine, Stanford University, Stanford, Calif, and Walter Reed Army Medical Center, Washington DC.
b
Although treatment with angiotensin-converting enzyme (ACE) inhibitors is known to improve outcome for patients with left ventricular dysfunction,1,2 their use in the community has been suboptimal.3 Even when ACE inhibitors are prescribed, the dose used is usually below what has been shown to be effective in randomized clinical trials.4 The goal of this study was to determine if the addition of a reminder to the echocardiography report for patients with a reduced ejection fraction could increase the use of moderate or greater doses of ACE inhibitors or alternative appropriate treatment (eg, angiotensin receptor blockers).
Methods Patients Patients undergoing echocardiography at 1 of 3 echocardiography laboratories in the Veterans Administration Palo Alto Health Care System were eligible if they had an ejection fraction ⬍40%, as determined by the attending echocardiographer. Patients were not eligible if they had a mean aortic valve gradient of 20 mm Hg or greater, mitral stenosis with a mean gradient of 5 mm Hg or greater, or any left Views expressed are those of the authors and not necessarily those of the Department of Veterans Affairs or other affiliated organizations. Requests for reprints should be addressed to Paul A. Heidenreich, MD, 111C Cardiology, Palo Alto VA Health Care System, 3801 Miranda Avenue, Palo Alto, CA 94304. E-mail address: [email protected].
0002-9343/$ -see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.amjmed.2004.12.028
ventricular outflow tract obstruction. Patients were randomized regardless of whether or not they were already treated with ACE inhibitors at recommended doses, because this information on prescribing data would not be readily available to an echocardiographer in practice.
Study protocol Patient selection and randomization were computerized and performed in conjunction with the generation of the echocardiography report using an electronic database. Patients who met study criteria were randomized using a computerized random number generator either to have a reminder attached to their report or not to have a reminder. Allocation was concealed from all echocardiographers until the reminder appeared in the report. Patients who had more than 1 echocardiogram either received a reminder for all studies or did not receive a reminder for any study based on the initial randomization. Patients were excluded from analysis if they were already on a moderate or greater dose of an ACE inhibitor or an appropriate alternative at the time of randomization, died within 2 months of the echocardiogram, left the Veterans Administration health care system, or had an allergy or adverse reaction to ACE inhibitors. The study was approved (including waiver of consent) by the Administrative Panel on Human Subjects at Stanford University. We identified 600 consecutive and eligible patients during an 18-month period. All patients were randomized (allocation concealed) to have either a clinical reminder at-
Heidenreich et al
Clinical reminders to improve ACE inhibitor use
1035
Figure 1 Flow of study participants. Patients were not analyzed for the primary outcome if they were already treated with the moderate or greater doses of ACE inhibitors or appropriate equivalent (primary outcome) at the time of randomization, died within 2 months of randomization, left the health care system, or had an adverse reaction to ACE inhibitors. ACEi ⫽ angiotensin-converting enzyme inhibitor.
tached to their echocardiography report (n ⫽ 292) or no reminder (n ⫽ 308) (Figure 1).
Intervention Echocardiography reports randomized to the reminder included the following statement: “Note: Patients with ejection fraction ⱕ40% have a survival benefit with ACE inhibitors (goal dose lisinopril or fosinopril 30-40 mg/day).” The drug examples were chosen because these are the longacting ACE inhibitors available on the Veterans Administration Palo Alto Health Care System formulary. The high goal dose was chosen for the reminder to match goal doses used when randomized trials of ACE inhibitors have demonstrated improved survival benefit.
Outcome The prespecified primary outcome was an active prescription for a moderate or greater daily dose of ACE inhibitor (lisinopril 20 mg, fosinopril 20 mg, captopril 75 mg) or appropriate alternative (losartan 50 mg, irbesartan 150 mg, hydralazine 150 mg when used with isosorbide dinitrate). No other drugs in these classes were prescribed during the study. A moderate dose, rather than the high dose recommendation of the reminder, was chosen as the primary outcome to match the actual
usage of ACE inhibitors during the randomized trials that have demonstrated improved survival and represents the dose currently recommended by clinical guidelines.4 Medication use was determined from review of inpatient or outpatient encounters closest to 6 months (and between 2 and 9 months) following randomization.
Statistics We used t-tests to compare continuous variables and chisquared tests for categorical variables. We used logistic regression models to determine the association of use of moderate or greater doses of ACE inhibitors or equivalent drugs with patient characteristics. Differences in survival between groups were compared using the log-rank test. All analyses were performed using JMP version 5.0 (SAS Institute, Cary, NC). All significance tests were 2-sided. A P value of less than 0.05 was considered statistically significant.
Results Among the 277 included patients (Table 1), an ACE inhibitor (n ⫽ 120), angiotensin receptor blocker (n ⫽ 7) or the combination of hydralazine/isosorbide dinitrate (n ⫽ 2)
1036 Table 1
The American Journal of Medicine, Vol 118, No 9, September 2005 Baseline characteristics of the study sample
Characteristic Number of patients Age (years) Men Hospitalized at time of echocardiography History of heart failure* NYHA class Hypertension Diabetes mellitus Coronary artery disease Past myocardial infarction Medications ACE inhibitor Angiotensin receptor blocker Hydralazine/isosorbide Beta-blocker Digoxin Spironolactone Diuretic Calcium antagonist Echocardiography findings† Systolic blood pressure (mm Hg) Diastolic blood pressure (mm Hg) Ejection fraction (%) Atrial fibrillation or flutter Mitral regurgitation, at least moderate Laboratory values Serum sodium ⬍135 mEq/L Serum creatinine (mg/dL) (n ⫽ 258 intervention, 265 control)
Reminder
No reminder
Number (%), mean ⫾ SD 137 140 68 ⫾ 11 67 ⫾ 12 136 (99) 139 (99) 69 (50) 59/135 (44) 2.0 ⫾ 1.2 67/135 (50) 30/135 (22) 95/135 (70) 55/135 (41)
65 (46) 80/134 (60) 2.1 ⫾ 1.2 80/134 (60) 34/134 (25) 93/134 (69) 67/134 (50)
60/127 (47)
60/132 (45)
3/127 0/127 37/127 44/127 3/127 58/127 23/127
3/132 (2) 2/132 (2) 35/132 (27) 42/132 (32) 10/132 (8) 69/132 (52) 19/132 (14)
(3) (0) (29) (35) (2) (46) (18)
125 ⫾ 19
122 ⫾ 16
73 ⫾ 8 28 ⫾ 7 28/132 (21)
73 ⫾ 11 29 ⫾ 7 22/135 (16)
65/137 (47)
65/136 (48)
21/122 (17)
13/116 (11)
Table 2
Outcomes at 6 months
Outcome
Reminder
No reminder
Moderate or greater ACE use* Systolic blood pressure (mm Hg) Diastolic blood pressure (mm Hg) Creatinine (mg/dL)† Creatinine ⬎3 (mg/dl)†
Number (%), mean ⫾ SD 52/137 (38) 37/140 (26) 126 ⫾ 22 126 ⫾ 23 68 ⫾ 14 68 ⫾ 14 1.8 ⫾ 1.8 1.8 ⫾ 1.9 15/124 (12) 16/134 (12)
ACEi ⫽ Angiotensin converting enzyme inhibitor. *P ⫽ 0.04. All others P ⬎ 0.2 †Creatinine available for 124 patients in the reminder group and 134 in the no reminder group.
moderate or higher doses at 6 months (125/221, 57%) compared with the no reminder group (114/235, 49%; P ⫽ 0.09). Use of any dose of ACE inhibitors during follow-up was no different between the reminder (88%, 121/137) and the no reminder groups (87%, 122/140, P ⫽ 0.77).
Secondary outcomes Overall mortality was 17% (43/251) at 1 year. Reminders had no measurable effect on survival (hazard ratio [HR] ⫽ 0.98 for mortality with a reminder; 95% confidence interval [CI]: 0.78 to 1.23). There was no discernable effect of reminders on renal function or on systolic or diastolic blood pressure at 6 months following echocardiography (Table 2).
Predictors of ACE inhibitor use
1.5 ⫾ 1.4
1.8 ⫾ 2.0
NYHA ⫽ New York Heart Association. *P ⫽ 0.009, for all other comparisons P ⬎ 0.05. Baseline historical data were available from the medical record (prior to the echocardiogram) in 135 of patients randomized to reminder and 134 of patients randomized to no reminder. †In some patients, the rhythm or degree of mitral regurgitation could not be determined.
were used at less than moderate doses in 50% (129/259) at baseline.
Primary outcome: ACE inhibitor use during follow-up Of patients who were randomized to the reminder group, 38% (52/137) were prescribed moderate or greater doses of ACE inhibitors or equivalent appropriate medications by 6 months compared with 26% (37/140, P ⫽ 0.04) of patients randomized to no reminder. When patients who already were on target doses at baseline were included, a trend remained between the provision of reminders and the use of
In a multivariate logistic model adjusting for demographics (age, sex, race) and clinical variables (ejection fraction, history of heart failure, diabetes, hypertension, coronary artery disease, renal insufficiency, follow up with cardiology), randomization to a reminder (odds ratio [OR] ⫽ 1.70; 95% CI: 1.02 to 2.86) and a baseline creatinine below 1.5 mg/dL (OR ⫽ 2.22; 95% CI: 1.23 to 4.16) were the only variables associated with increased use of moderate or greater doses of ACE inhibitors or equivalent appropriate medication at 6 months after randomization (P ⬍0.05).
Discussion Several interventions have been proposed to improve the quality of care for heart failure patients.5 Attaching a reminder to a diagnostic test report is an attractive strategy, because it is a simple, low-cost intervention. The only requirement for implementation is that the interpreting physician or laboratory be aware of the relevant treatment guideline. In our study, a computer algorithm determined if the patient was a candidate for the reminder based on the findings of an echocardiography. However, a computerized reporting system is not required. Reminders can be added
Heidenreich et al
Clinical reminders to improve ACE inhibitor use
using any reporting format (eg, typed or dictated), with the minimal cost of adding an extra sentence to the report. In a prior, nonrandomized evaluation of reminders attached to echocardiography reports,6 compliance with the American Heart Association’s guidelines for endocarditis prophylaxis7 was greater among patients with a reminder (73%) than in a control group without a reminder (65%, P ⫽ 0.01). The authors concluded that echocardiographers should include reminder statements in their reports. Despite the difference in recommended treatments, (antibiotics vs ACE inhibitors), the absolute benefit of the reminder in this prior study (8% increase) was comparable to the effect of reminders in our study (12% increase). This magnitude of increase compares favorably with other studies of strategies to improve adherence to recommended management. Why do reminders appear to have only a modest effect on the use of recommended therapies? One potential explanation is that clinicians are often reluctant to initiate therapy that may have important side effects. This hypothesis is supported by the results of a randomized trial of computerized reminders directed to resident physicians in the Veterans Administration health care system.8 Physicians randomized to reminders had statistically significantly greater improvements in compliance with several prevention standards, but recommended treatment with anticoagulation for patients with atrial fibrillation was actually lower in the reminder group (75%) than in the control group (82%, P ⫽ 0.10). However, a computerized reminder8 may not be as effective as a reminder that is included in a report signed by a staff cardiologist who may be viewed as a local expert. The strengths of our study include the randomized design and the ease of implementing the intervention. One limitation is the uncertain generalizability given the unique features of the study’s setting. The Palo Alto Veterans Administration health care system contains a mix of academic and nonacademic community-based clinics, where all providers have every patient’s medical record available electronically at all times. Reminders may be less effective in other health systems that do not routinely allow review of the echocardiography report during the patient encounter; however, it is a standard of care that physicians who order an echocardiogram should have the results available to them when they see patients in follow-up. An additional limitation is that our
1037
subjects were predominately men. If physicians respond to reminders differently based on the sex of their patient, our results can be applied only to men. In summary, our trial found that a clinical reminder attached to the echocardiography report significantly increases the prescribed dose of ACE inhibitors or appropriate alternatives to match those used in clinical trials and currently recommended in guidelines from the American Heart Association and American College of Cardiology,4 but the absolute increment of compliance was modest. Additional studies should examine the effectiveness of reminders attached to other diagnostic test reports and address why reminders, even when effective, still do not result in optimal compliance with guideline-proved therapy.
References 1. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and chronic heart failure. The SOLVD Investigators. N Engl J Med. 1991;325:293-302. 2. Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. The SOLVD Investigators. N Engl J Med. 1992;327:685-691. 3. Stafford RS, Radley DC. The underutilization of cardiac medications of proven benefit, 1990 to 2002. J Am Coll Cardiol. 2003;41:56 – 61. 4. Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary a report of the American College Of Cardiology/American Heart Association Task Force On Practice Guidelines (Committee To Revise The 1995 Guidelines For The Evaluation And Management Of Heart Failure): developed in collaboration with the International Society For Heart And Lung Transplantation; endorsed by the Heart Failure Society Of America. Circulation. 2001;104:2996 –3007. 5. Krumholz HM, Wang Y, Parent EM, Mockalis J, Petrillo M, Radford MJ. Quality of care for elderly patients hospitalized with heart failure. Arch Intern Med 1997;157:2242–2247. 6. Sanders GP, Yeon SB, Grunes J, Seto TB, Manning WJ. Impact of a specific echocardiographic report comment regarding endocarditis prophylaxis on compliance with American Heart Association recommendations. Circulation 2002;106:300 –303. 7. Durack DT, Lukes AS, Bright DK: New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Am J Med. 1994;96:200 –209. 8. Demakis JG, Beauchamp C, Cull WL, et al. Improving residents’ compliance with standards of ambulatory care: results from the VA Cooperative Study on Computerized Reminders. JAMA. 2000;284:1411–1416.