Lead/Presenter: Nishant Shah, COIN - Providence
All Authors: Shah NR (Brown University School of Public Health), Eisman AS (Brown University Alpert Medical School), Morrison AR (Brown University Alpert Medical School) Rudolph JL (Brown University School of Public Health) Sarkar IN (Brown Center for Biomedical Informatics) Wu WC (Brown University School of Public Health)
Referral for cardiac testing is an important opportunity for primary care providers and cardiologists to work collaboratively in optimizing Veterans' cardiovascular care. At the Providence VA, we implemented a structured e-consult in conjunction with all exercise treadmill tests, nuclear stress tests, stress echocardiograms and cardiac CT angiograms to enhance provider dialogue related to test selection and prescription of guideline-directed cardiovascular medications.
Between 4/1/2018-6/30/2018, primary care providers completed e-consults for 100 Veterans aged 40-79 years referred for outpatient cardiac testing at the Providence VA. E-consult responses included guideline-informed feedback on test order appropriateness and opportunities cholesterol lowering through statin initiation/intensification. These 100 Veterans comprised the â€˜intervention' cohort. A similar group of 72 Veterans who underwent cardiac testing under the traditional ordering process between 4/1/2017-6/30/2017 comprised the â€˜pre-intervention' cohort.
In both the pre-intervention and intervention cohorts, included Veterans were predominantly white males; the median age was 66 years and the median 10-year atherosclerotic cardiovascular disease (ASCVD) risk was 17% (intermediate-high risk). In the intervention cohort, the median order-to-test performance time was 20 days, compared to 27 days in the pre-intervention cohort. Furthermore, cardiac tests performed under â€˜rarely appropriate' clinical scenarios represented 4% of studies in the pre-intervention cohort but only 1% in the intervention cohort. Statin underutilization was identified in in 47% of e-consults but corresponding recommendations regarding initiation/uptitration were only implemented 13% of the time within 3 months, and predominantly in the setting of concomitant abnormal testing.
Our pilot intervention demonstrates that e-consults in conjunction with cardiac testing enhances communication between primary care providers and cardiologists, decreases Veteran wait times, helps eliminate performance of rarely appropriate testing, and provides a novel platform to identify and mitigate treatment gaps in Veterans' cardiovascular care.
Our CPRS-embedded e-consult process is easily portable to other VA medical centers and the platform can be expanded to include a wide variety of cardiovascular risk reduction medications/therapies. As such, it may prove to be a valuable tool in improving Veterans' cardiovascular health.