Varsha Keelara Tanguturi, Roukoz Abou-Karam, Fangzhou Cheng, Rong Duan, Ignacio Inglessis, Nathaniel Langer, Evin Yucel, Jonathan Passeri, Judy Hung, Sammy Elmariah
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引用次数: 0
Abstract
Background: Symptomatic severe aortic stenosis (AS) remains undertreated with high resultant mortality despite increased growth and availability of aortic valve replacement (AVR) since the advent of transcatheter therapies. We evaluate the impact of electronic provider notifications (EPN) on rates of AVR at 1-year.
Methods: In a pragmatic cluster randomized clinical trial conducted within multicenter academic health system from March 2022 through November 2023, 285 providers who had ordered a transthoracic echocardiogram (TTE) with findings potentially indicative of severe AS with aortic valve area ≤ 1.0 cm2 were enrolled. Providers were randomly assigned to receive EPN for each of their patients with severe AS on TTE or to usual care. Notifications highlighted the detection of severe AS and included patient-specific clinical guideline recommendations for its management. The primary endpoint was the proportion of patients with severe AS receiving AVR within 1-year of the index TTE.
Results: A total of 144 providers were randomized to intervention and 141 to control, resulting in 496 and 443 patients assigned to each group, respectively. The patient cohort had mean age of 77±11 years, was 47% female, and had mean aortic valve area 0.8±0.1 cm2. Rates of AVR within 1-year were 48.2% with EPN versus 37.2% with usual care (OR 1.62; 95% CI 1.13-2.32; p=0.009) and 60.7% and 46.5%, respectively, amongst symptomatic patients (OR 1.77; 95% CI 1.17-2.65; p=0.006). Notification treatment effect was highest with EPN in patients >80 years of age (OR 2.00; 95% CI 1.17-3.41; p=0.01), in women (OR 2.78; 95% CI 1.69-4.57; p<0.001), and when index TTE was performed within the inpatient setting (OR 2.49, 95% CI 1.44-4.31; p<0.001). Within 1-year, restricted mean survival time was longer with EPN in all (12 days; p=0.04) and symptomatic patients (23 days; p=0.01).
Conclusions: In this first study of EPN in valvular heart disease, EPN increased rates of AVR for severe AS, lessened gender and age disparities in AVR utilization, and improved survival time. EPN may provide a simple, scalable intervention to raise awareness of critical TTE findings and improve the quality of care for severe AS.
背景:有症状的严重主动脉瓣狭窄(AS)由于经导管治疗的出现,尽管生长和主动脉瓣置换术(AVR)的可用性增加,但仍未得到充分治疗,导致死亡率高。我们评估了电子供应商通知(EPN)对1年AVR率的影响。方法:在2022年3月至2023年11月在多中心学术卫生系统中进行的一项实用的集群随机临床试验中,纳入了285名经胸超声心动图(TTE)的提供者,这些提供者的检查结果可能表明主动脉瓣面积≤1.0 cm2的严重AS。服务提供者被随机分配接受EPN为他们的病人严重AS在TTE或常规护理。通知强调了严重AS的检测,并包括针对其管理的患者特异性临床指南建议。主要终点是严重AS患者在TTE指数1年内接受AVR的比例。结果:共有144名提供者被随机分配到干预组,141名提供者被随机分配到对照组,每组分别有496名和443名患者。患者平均年龄77±11岁,女性占47%,平均主动脉瓣面积0.8±0.1 cm2。EPN组1年内AVR为48.2%,常规护理组为37.2% (OR 1.62;95% ci 1.13-2.32;p=0.009),有症状患者中分别为60.7%和46.5% (OR 1.77;95% ci 1.17-2.65;p = 0.006)。在80岁的患者中,EPN的通知治疗效果最高(OR 2.00;95% ci 1.17-3.41;p=0.01),女性(OR 2.78;95% ci 1.69-4.57;结论:在这项关于EPN在瓣膜性心脏病中的首次研究中,EPN增加了严重AS的AVR发生率,减少了AVR使用的性别和年龄差异,并延长了生存时间。EPN可能提供一种简单的、可扩展的干预措施,以提高对关键TTE发现的认识,并改善严重AS的护理质量。
期刊介绍:
Circulation is a platform that publishes a diverse range of content related to cardiovascular health and disease. This includes original research manuscripts, review articles, and other contributions spanning observational studies, clinical trials, epidemiology, health services, outcomes studies, and advancements in basic and translational research. The journal serves as a vital resource for professionals and researchers in the field of cardiovascular health, providing a comprehensive platform for disseminating knowledge and fostering advancements in the understanding and management of cardiovascular issues.