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.
Keywords: death, sudden, cardiac; defibrillators; guideline adherence; randomized controlled trial; reminder systems.