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Screening tool improved appropriate referrals for ICD implant
Gravelin L. Circ Cardiovasc Qual Outcomes. 2011;4:152-156.
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The use of a screening tool increased the likelihood of referral to an electrophysiologist among patients in whom an implantable cardioverter defibrillator would help prevent sudden cardiac death, a new study suggested.
Laura M. Gravelin, MD, and investigators examined screening tools from medical records of patients from two outpatient cardiology offices. The screening tool analyzed in this study questioned general cardiologists as to whether their patients’ ejection fraction was 35% or less, and if so, the physician was then asked whether the patients were referred to an electrophysiologist for an ICD. Appropriate referrals in the screening group were then compared with similar data before screening tool implementation.
Researchers reported that significantly more eligible patients were offered a referral during the screening period vs. pre-implementation at both sites. Specifically, at site one, the referral rate was 80% (eight of 10 eligible patients) vs. 33% (five of 15; P<.02 for trend) in favor of the screening period, whereas at site two, it was 100% (44 of 44 eligible patients) vs. 60% (21 of 35; P<.001 for trend) in favor of screening. Among all patients referred, 41% accepted. No sex-specific differences were reported in this study.
Besides these findings, researchers said barriers to referral include physicians’ understanding and recollecting the importance of ICD therapy for primary prevention, as well as patients’ willingness to undergo evaluation.
“Verification of these findings on a larger scale, as well as studies defining the foundation of these barriers, may further improve use of ICDs in patients for whom their mortality benefit is well described,” they said. – by Brian Ellis
The study by Gravelin et al illustrates the potential for integrating guidelines into daily clinical practice, ideally through use of an electronic medical record, which can alert clinicians to the potential for life-saving treatments such as an ICD. Guidelines are not recipes or mandates for care, but are rather useful "check lists" of factors to be considered. Alerting clinicians to factors such as a low ejection fraction is similar to highlighting abnormal lab values such as a high potassium or low blood sugar.
Whether or not to implant an ICD is a complex decision, however, and one that should be made by an expert clinician who considers more than just the ejection fraction, which is only the beginning of the story. An opportunity exists to glean additional information from the medical record that would complement and improve on a simple ejection fraction measurement to select patients who would benefit from an ICD, to uncover new, real-time, real-world data that could be used to improve the guidelines.
– L. Samuel Wann, MD
Cardiology Today Section Editor
Disclosure: Dr. Wann reported no relevant financial disclosures.
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