Author + information
- S1936878X16309706-0d1eecb4492e23ffd834b0053cc04389Paul A. Heidenreich, MD, MS∗ (, )
- S1936878X16309706-6e4d436bf86f0f6d0111b5445839a854Parisa Gholami, MPH,
- S1936878X16309706-81453dea68f5a4689a1cc49592fb34c4Shoutzu Lin, MS and
- S1936878X16309706-fa91023b23ce5795d323af96abb26aa9Anju Sahay, PhD
- ↵∗Palo Alto VA Health Care System, 3801 Miranda Avenue, GRECC 182B, Palo Alto, California 94304
Patients with a high B-type natriuretic peptide (BNP) level have an increased prevalence of a reduced left ventricular ejection fraction (LVEF) (e.g., <40%) and may benefit from life-prolonging therapies (1). However, BNP testing may occasionally go unnoticed by the patient’s primary care provider (2). Thus, patients with elevated levels may not have follow-up measurement of LVEFs. Those with depressed LVEFs will not be identified and cannot benefit from several life-prolonging therapies (1). The objective of this study was to determine the impact of a clinical reminder to physicians of patients who have a BNP >200 pg/ml, no previous systolic dysfunction, and no follow-up imaging. We randomized consecutive patients (inpatient or outpatient) from January 1, 2011 to February 15, 2012 with a BNP value of at least 200 pg/ml, with no previous diagnosis of systolic dysfunction (LVEF <40%) and no LVEF measurement recorded in the chart after the BNP measurement for at least 6 months. The primary outcome was measurement of LVEF by any imaging at 4 months after randomization obtained through chart review. A waiver of consent was granted by the Stanford Institutional Review Board.
The mean age of the 115 patients was 77 ± 12 years, 99% were men, 6% were black, and the mean BNP was 485 ± 457 pg/ml. In the 2 years before randomization, 65% had a diagnosis of heart failure, 55% had diabetes, 86% had hypertension, and 55% had ischemic heart disease. A previous LVEF value was known in 61% (mean 55 ± 8%). Overall, 39% of patients were hospitalized in the previous 12 months.
Among the patients randomized to the physician reminder, 39% (22 of 57 patients) had an LVEF measurement within 4 months compared with 10% (6 of 58 patients) of those randomized to usual care (p = 0.0005) (Figure 1). In another 15 patients in the reminder group, the physician accepted the order for echocardiography, but it was never performed due to patient cancellation (n = 12) or subsequent physician discontinuation (n = 3).
At 4 months of follow-up, a new diagnosis of moderate or greater depressed systolic dysfunction (LVEF <40%) was made in 6 patients: 5 of 57 (9%) patients in the reminder group compared with 1 of 57 (2%) patients in the usual care group (p = 0.11). This corresponded to a rate of a low LVEF of 23% (5 of 22 patients) among those who underwent imaging during follow-up. The number needed to remind to identify an additional patient with an LVEF <40% was 15. Among the 6 patients newly diagnosed with a low LVEF, 4 (83%) filled a prescription for a recommended beta-blocker, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker within 6 months of randomization.
Our study found that an electronic reminder (combined with a draft order for echocardiography) to providers of patients with a high BNP level and an LVEF that was not known to be low increased appropriate follow-up of LVEF measurement. Although our study was not powered to determine a difference in health outcomes, we did find a trend toward a greater diagnosis of depressed LVEF that was subsequently treated appropriately with life-prolonging medications. We estimated that for every 15 reminders sent to providers, 1 additional patient would be diagnosed with an LVEF <40% and potentially benefit from treatment.
Such a reminder is inexpensive to implement and can be automated with electronic medical records. Our study had potential limitations, including the male preponderance of the veteran population. We chose a BNP threshold of 200 pg/ml to identify candidates for follow-up echocardiography. The United Kingdom’s Chronic Heart Failure Guideline of the National Institute for Health Care Excellence (3) recommends that patients with suspected heart failure and a BNP level between 100 and 400 pg/ml should have echocardiography and specialist assessment within 6 weeks. Thus, health systems may choose to use the more sensitive threshold of 100 pg/ml, although it is unclear if the impact of the reminder would be as strong as the effect observed in this study.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose. The study was supported by grants from the Veteran’s Affairs Health Services Research Development Office Investigator Initiated Research (CHF QUERI-04-326), and the American Society of Echocardiography (Outcomes Grant). None of the funders had a role in design and conduct of the study, data collection, management, analysis, or interpretation, as well as preparation, review, or approval of the manuscript. Dr. Heidenreich had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The views expressed are those of the authors and not necessarily those of the Department of Veterans Affairs or other affiliated organizations.
(Clinicaltrials.gov identifier: Provider Notification for High B-type Natriuretic Peptide Values; NCT01734135.)
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- Heidenreich P.A.,
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- ↵National Institute for Health and Clinical Excellence. Chronic heart failure in adults: management. Available at: http://nice.org.uk/guidance/cg108. Accessed March 15, 2016.