Clinical Reminders to Providers of Patients with Reduced Left Ventricular Ejection Fraction Increase Defibrillator Referral: A Randomized Trial

Background —Many patients who are candidates for 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 1/2007 through 7/2010 in the VA Palo Alto Healthcare System with a left ventricular ejection fraction (LVEF) below 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 LVEF ≤ 35%, 128 patients 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. 46 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 six 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 LVEF, 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][1]. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01217827&atom=%2Fcirchf%2Fearly%2F2013%2F12%2F06%2FCIRCHEARTFAILURE.113.000753.atom