How successful was the use of a community of practice for the implementation of evidence-based practices for heart failure within the United States Department of Veterans Affairs: Insights from a formative evaluation.

BACKGROUND: Communities of Practice (CoPs) are a promising approach to facilitate the implementation of evidence-based practices (EBPs) to improve care for chronic conditions like heart failure (HF). CoPs involve a complex process of acquiring and converting both explicit and tacit knowledge into clinical activities. This study describes the conceptualization, creation, capacity-building and dissemination of a CoP sustained over 9 years, and evaluates its value and impact on EBP. METHODS: In July 2006, a CoP called the Heart Failure Provider Network (HF Network) was established within the United States Department of Veterans Affairs (VA) with the overarching goal of improving the quality of care for HF patients. We assessed (formative) the HF Network in terms of its various activities (inputs) and proximal impacts (mediators) at the individual level, and its distal impacts (outcomes) at the site level including implementation of new/improved EBPs at the systemwide level. RESULTS: The HF Network membership grew steadily over the 9 years. The CoP has involved a total of 1341 multidisciplinary and multilevel members at all 144 VA Health Care Systems (sites). Most members were practising clinicians (n = 891, 66.4%), followed by administrators (n = 342, 25.5%), researchers (n = 70, 5.2%) and others (n = 38, 2.8%). Participation was assessed to be "active" for 70.6% versus "passive" for 29.4% of members. The distribution of active members (clinicians 64.7%, administrators 21.6%) was similar to the distribution of overall membership. CONCLUSIONS: Survey respondents perceived the HF Network as useful in terms of its varied activities and resources relevant for patient care. Strong evidence shows that these members, particularly those who considered themselves influential in improving quality of care, noted multiple benefits of membership, which included confirmation of their own clinical practices, evidence-based changes to their practice and help in understanding facilitators and barriers in setting up or running HF clinics and other programmes. Such CoPs have strong impacts on the quality of care being delivered for both mandated and non-mandated initiatives.

Interventions to Increase Leukocyte Testing during Treatment with Dimethyl Fumarate.

Dimethyl fumarate (DMF), a treatment for multiple sclerosis, may cause leukopenia and infection. Accordingly, periodic white blood cell (WBC) monitoring is recommended. We sought to evaluate the US Department of Veteran Affairs' safety program which provides facilities with a list of patients prescribed DMF therapy without a documented white blood cell count (WBC). We identified 118 sites with patients treated with DMF from 1 January 2016 through 30 September 2016. Each site was asked if any of seven interventions were used to improve WBC monitoring (academic detailing, provider education without academic detailing, electronic clinical reminders, request for provider action plan, draft orders for WBC monitoring, patient mailings, and patient calls). The survey response rate was 78%. For the 92 responding sites (78%) included sites (1115 patients) the mean rate of WBC monitoring was 54%. In multivariate analysis, academic detailing increased the rate by 17% (95% CI 4 to 30%, p = 0.011) and provider education increased the rate by 9% (95% CI 0.6 to 18%, p = 0.037). The WBC monitoring rate increased by 3.8% for each additional intervention used (95% CI 1.2-6.4%, p = 0.005). Interventions focused on the physician, including academic detailing, were associated with improved WBC monitoring for patients at risk for leukopenia from DMF treatment.

Patient ratings of Veterans Affairs and affiliated hospitals.

OBJECTIVES: Hospital Compare, a website maintained by CMS, allows comparisons of outcomes and processes of care but not of patient satisfaction for hospitals within the Veteran Affairs (VA) Healthcare System. Therefore, we sought to compare online hospital ratings between VA hospitals and their local affiliated hospitals. STUDY DESIGN: Observational analysis. METHODS: We identified 39 VA hospitals and a non-VA affiliated hospital with at least 2 online Yelp ratings. We determined the difference in the mean rating (VA-affiliate rating) with weighting by the number of ratings for each hospital. We used multivariate regression to compare mean Yelp ratings between VA and non-VA affiliate hospitals, adjusting for hospital characteristics (bed size, teaching status, and accreditation). RESULTS: The mean patient rating for VA hospitals (± standard deviation) was higher (3.64 ± 1.0) than the rating for affiliated hospitals (3.09 ± 0.8; P = .0036). There was no significant correlation in rating between a VA hospital and its affiliate (r = 0.07; P = .59). After adjustment for hospital characteristics, the adjusted rating difference (VA-affiliate hospitals) was 0.65 (95% confidence interval, 0.18-1.12). CONCLUSIONS: VA hospitals had higher patient ratings than their non-VA affiliated hospitals, a finding not explained by bed size or teaching status.

Impact of the Hospital to Home Initiative on Readmissions in the VA Health Care System.

BACKGROUND: Hospital to Home (H2H) is a national quality improvement initiative sponsored by the Institute for Healthcare Improvement and the American College of Cardiology, with the goal of reducing readmission for patients hospitalized with heart disease. We sought to determine the impact of H2H within the Veterans Affairs (VA) health care system. METHODS: Using a controlled interrupted time series, we determined the association of VA hospital enrollment in H2H with the primary outcome of 30-day all-cause readmission following a heart failure hospitalization. VA heart failure providers were surveyed to determine quality improvement projects initiated in response to H2H. Secondary outcomes included initiation of recommended H2H projects, follow-up within 7 days, and total hospital days at 30 days and 1 year. RESULTS: Sixty-five of 104 VA hospitals (66%) enrolled in the national H2H initiative. Hospital characteristic associated with H2H enrollment included provision of tertiary care, academic affiliation, and greater use of home monitoring. There was no significant difference in mean 30-day readmission rates (20.0% ± 5.0% for H2H vs 19.3% ± 5.9% for non-H2H hospitals; P = .48) The mean fraction of patients with a cardiology visit within 7 days was slightly higher for H2H hospitals (3.0% ± 2.4% for H2H vs 2.0% ± 1.9% for non-H2H hospitals; P = .05). Patients discharged from H2H hospitals had fewer mean hospitals days during the following year (7.6% ± 2.6% for H2H vs 9.2% ± 3.0 for non-H2H; P = .01) early after launch of H2H, but the effect did not persist. CONCLUSIONS: VA hospitals enrolling in H2H had slightly more early follow-up in cardiology clinic but no difference in 30-day readmission rates compared with hospitals not enrolling in H2H.

Barriers and Facilitators to Scaling Up Outpatient Palliative Care.

BACKGROUND: The Institute of Medicine recommends people with serious advanced illness have access to skilled palliative care. However, the predominant delivery model of nonhospice palliative care is inpatient, consultative care focused on the end of life, with a small specialist palliative care workforce. OBJECTIVE: The study objective was to understand organizational factors that could influence the adoption and scale-up of outpatient palliative care in chronic advanced illness, using the example of heart failure. METHODS: This was a cross-sectional qualitative study. Participants were 17 health care providers and local, regional, and national health system leaders from the Veterans Health Administration (VHA) who were considering whether and how to adopt and sustain outpatient palliative care. Individual interviews using semistructured questions assessed domains of the Consolidated Framework for Implementation Science. RESULTS: Most providers and leaders perceived outpatient palliative care as high priority in the VHA given its patient-centeredness and potential to decrease health care use and costs associated with conditions like heart failure. They also supported a collaborative care team model of outpatient palliative care delivery where a palliative care specialist collaborates with medical nurses and social workers. They reported lack of performance measures/incentives for patient-centered care processes and outcomes as a potential barrier to implementation. Features of outpatient palliative care viewed as important for successful adoption and scale-up included coordination and communication with other providers, ease of integration into existing programs, and evidence of improving quality of care while not substantially increasing overall health care costs. CONCLUSION: Incentives such as performance measures and collaboration with local VHA providers and leaders could improve adoption and scale-up of outpatient palliative care.

Patient and Facility Variation in Costs of VA Heart Failure Patients.

OBJECTIVES: This study sought to determine the variation in annual health care costs among patients with heart failure in the Veterans Affairs (VA) system. BACKGROUND: Heart failure is associated with considerable use of health care resources, but little is known about patterns in patient characteristics related to higher costs. METHODS: We obtained VA utilization and cost records for all patients with a diagnosis of heart failure in fiscal year 2010. We compared total VA costs by patient demographic factors, comorbid conditions, and facility where they were treated in bivariate analyses. We regressed total costs on patient factors alone, VA facility alone, and all factors combined to determine the relative contribution of patient factors and facility to explaining cost differences. RESULTS: There were 117,870 patients with heart failure, and their mean annual VA costs were $30,719 (SD 49,180) with more than one-half of their costs from inpatient care. Patients at younger ages, of Hispanic or black race/ethnicity, diagnosed with comorbid drug use disorders, or who died during the year had the highest costs (all p < 0.01). There was variation in costs by facility as mean adjusted costs ranged from approximately $15,000 to $48,000. In adjusted analyses, patient factors alone explained more of the variation in health care costs (R(2) = 0.116) compared with the facility where the patient was treated (R(2) = 0.018). CONCLUSIONS: A large variation in costs of heart failure patients was observed across facilities, although this was explained largely by patient factors. Improving the efficiency of VA resource utilization may require increased scrutiny of high-cost patients to determine if adequate value is being delivered to those patients.

Facilitation of a Multihospital Community of Practice to Increase Enrollment in the Hospital to Home National Quality Improvement Initiative.

BACKGROUND: Hospital to Home (H2H) is a national quality improvement (QI) initiative composed of three recommended hospital interventions to improve the transition of care for hospitalized patients with heart disease. A study was conducted to determine if enrollment of Department of Veterans Affairs (VA) hospitals in H2H and adoption of the recommended interventions would both increase following facilitation of an existing Heart Failure (HF) provider-based community of practice (COP) within the VA health care system. The VA HF COP includes more than 800 VA providers and other VA staff from VA inpatient medical centers. METHODS: In 2010, 122 VA hospitals were randomized to facilitation using the VA HF COP (intervention) or no facilitation (control). COP members from intervention hospitals were invited to periodic teleconferences promoting H2H and received multiple e-mails asking members to report interest and then progress in H2H implementation. RESULTS: Among the 61 hospitals randomized to HF COP facilitation, 33 (54%) enrolled in H2H, compared with 6 (10%) of 61 control hospitals (p<.001) at five months after randomization. Of 38 intervention hospitals responding to the follow-up survey, 13 stated they had initiated 22 QI projects as a result of the H2H campaign. Another 7 hospitals had planned H2H projects. Of 20 control hospitals that responded, 5 had initiated 9 projects as a result of H2H, and no additional hospitals had plans to do so. CONCLUSIONS: Facilitation using the VA HF COP was successful in increasing enrollment in the H2H initiative and providing implementation support for recommended QI projects. Multihospital provider groups are a potentially valuable tool for implementation of national QI campaigns.

Use of implementation theory: a focus on PARIHS.

BACKGROUND: Limited understanding and application of theory in implementation research contributes to variable effectiveness of implementation studies. Better understanding of direct experiences with theory could improve implementation research and the potency of interventions. AIMS: This study was a conceptual exercise aimed at characterizing experiences with and applications of the Promoting Action on Research Implementation in Health Services (PARIHS) framework. METHODS: This was a structured, qualitative study involving document reviews and interviews used to answer the following overarching questions about nine implementation research centers: Why and how was PARIHS used? What strengths and weaknesses were identified for PARIHS? FINDINGS: PARIHS was being used for varied purposes, at varied levels, in varied ways, and to a varying extent within and across centers. Lack of implementation theory use in investigators' early years was common. Variability in the nature of theory use was attributable to characteristics of the centers, individual investigators, and features of PARIHS. Strengths and weaknesses of the PARIHS framework were identified. LINKING EVIDENCE TO ACTION: The study provides information to researchers and theorists about the use of one well-known implementation framework. The information suggests areas for improvements in PARIHS as well as theory use in general, and should assist in the development of theory-based programs of research.

Differential effects of professional leaders on health care teams in chronic disease management groups.

BACKGROUND: Leadership by health care professionals is likely to vary because of differences in the social contexts within which they are situated, socialization processes and societal expectations, education and training, and the way their professions define and operationalize key concepts such as teamwork, collaboration, and partnership. This research examines the effect of the nurse and physician leaders on interdependence and encounter preparedness in chronic disease management practice groups. PURPOSE: The aim of this study was to examine the effect of complementary leadership by nurses and physicians involved in jointly producing a health care service on care team functioning. METHODOLOGY: The design is a retrospective observational study based on survey data. The unit of analysis is heart failure care groups in U.S. Veterans Health Administration medical centers. Survey and administrative data were collected in 2009 from 68 Veterans Health Administration medical centers. Key variables include nurse and physician leadership, interdependence, psychological safety, coordination, and encounter preparedness. Reliability and validity of survey measures were assessed with exploratory factor analysis and Cronbach alphas. Multivariate analyses tested hypotheses. FINDINGS: Professional leadership by nurses and physicians is related to encounter preparedness by different paths. Nurse leadership is associated with greater team interdependence, and interdependence is positively associated with respect. Physician leadership is positively associated with greater psychological safety, respect, and shared goals but is not associated with interdependence. Respect is associated with involvement in learning activities, and shared goals are associated with coordination. Coordination and involvement in learning activities are positively associated with encounter preparedness. PRACTICE IMPLICATIONS: By focusing on increasing interdependence and a constructive climate, nurse and physician leaders have the opportunity to increase care coordination and involvement in learning activities.

Variation in use of left ventriculography in the Veterans Affairs Health Care System.

BACKGROUND: Contrast left ventriculography is a method of measuring left ventricular function usually performed at the discretion of the invasive cardiologist during cardiac catheterization. We sought to determine variation in the use of left ventriculography in the Veterans Affairs (VA) Health Care System. METHODS AND RESULTS: We identified adult patients who underwent cardiac catheterization including coronary angiography between 2000 and 2009 in the VA Health Care System. We determined patient and hospital predictors of the use of left ventriculography as well as the variation in use across VA facilities. Results were validated using data from the VA's Clinical Assessment, Reporting, and Tracking (CART) program. Of 457 170 cardiac catheterization procedures among 336 853 patients, left ventriculography was performed on 263 695 (58%) patients. Use of left ventriculography decreased over time (64% in 2000 to 50% in 2009) and varied markedly across facilities (<1->95% of cardiac catheterizations). Patient factors explained little of the large variation in use between facilities. When the cohort was restricted to those with an echocardiogram in the prior 30 days and no intervening event, left ventriculography was still performed in 50% of cases. CONCLUSIONS: There is large variation in the use of left ventriculography across VA facilities that is not explained by patient characteristics.

Improvement of guideline ß-blocker prescribing in heart failure: a cluster-randomized pragmatic trial of a pharmacy intervention.

BACKGROUND: Treatment with specific beta-blockers and doses recommended by guidelines is often not achieved in practice. We evaluated an intervention directed to the pharmacy to improve prescribing. METHODS AND RESULTS: We conducted a pragmatic cluster-randomized trial, where facilities (n = 12) with patients (n = 220) were the clusters. Eligible patients had a beta-blocker prescription that was not guideline concordant. Level 1 intervention included information to a pharmacist on facility guideline concordance. Level 2 also provided a list of patients not meeting guideline goals. Intervention and follow-up periods were each 6 months. Achievement of full concordance with recommendations was low (4%-5%) in both groups, primarily due to lack of tolerability. However, compared with level 1, the level 2 intervention was associated with 1.9-fold greater odds of improvement in prescribing (95% confidence interval [CI] 1.1-3.2). Level 2 patients also had greater odds of a higher dose (1.9, 95% CI 1.1-3.3). The intervention was aided by the patient lists provided, the electronic medical record system, and staff support. CONCLUSIONS: In actual practice, full achievement of guideline goals was low. However, a simple intervention targeting pharmacy moved patients toward guideline goals. As health care systems incorporate electronic medical records, this intervention should have broader feasibility.

A critical synthesis of literature on the promoting action on research implementation in health services (PARIHS) framework.

BACKGROUND: The Promoting Action on Research Implementation in Health Services framework, or PARIHS, is a conceptual framework that posits key, interacting elements that influence successful implementation of evidence-based practices. It has been widely cited and used as the basis for empirical work; however, there has not yet been a literature review to examine how the framework has been used in implementation projects and research. The purpose of the present article was to critically review and synthesize the literature on PARIHS to understand how it has been used and operationalized, and to highlight its strengths and limitations. METHODS: We conducted a qualitative, critical synthesis of peer-reviewed PARIHS literature published through March 2009. We synthesized findings through a three-step process using semi-structured data abstraction tools and group consensus. RESULTS: Twenty-four articles met our inclusion criteria: six core concept articles from original PARIHS authors, and eighteen empirical articles ranging from case reports to quantitative studies. Empirical articles generally used PARIHS as an organizing framework for analyses. No studies used PARIHS prospectively to design implementation strategies, and there was generally a lack of detail about how variables were measured or mapped, or how conclusions were derived. Several studies used findings to comment on the framework in ways that could help refine or validate it. The primary issue identified with the framework was a need for greater conceptual clarity regarding the definition of sub-elements and the nature of dynamic relationships. Strengths identified included its flexibility, intuitive appeal, explicit acknowledgement of the outcome of 'successful implementation,' and a more expansive view of what can and should constitute 'evidence.' CONCLUSIONS: While we found studies reporting empirical support for PARIHS, the single greatest need for this and other implementation models is rigorous, prospective use of the framework to guide implementation projects. There is also need to better explain derived findings and how interventions or measures are mapped to specific PARIHS elements; greater conceptual discrimination among sub-elements may be necessary first. In general, it may be time for the implementation science community to develop consensus guidelines for reporting the use and usefulness of theoretical frameworks within implementation studies.

Divergent trends in survival and readmission following a hospitalization for heart failure in the Veterans Affairs health care system 2002 to 2006.

OBJECTIVES: This study sought to determine recent trends over time in heart failure hospitalization, patient characteristics, treatment, rehospitalization, and mortality within the Veterans Affairs health care system. BACKGROUND: Use of recommended therapies for heart failure has increased in the U.S. However, it is unclear to what extent hospitalization rates and the associated mortality have improved. METHODS: We compared rates of hospitalization for heart failure, 30-day rehospitalization for heart failure, and 30-day mortality following discharge from 2002 to 2006 in the Veterans Affairs Health Care System. Odds ratios for outcome were adjusted for patient diagnoses within the past year, laboratory data, and for clustering of patients within hospitals. RESULTS: We identified 50,125 patients with a first hospitalization for heart failure from 2002 to 2006. Mean age did not change (70 years), but increases were noted for most comorbidities (mean Charlson score increased from 1.72 to 1.89, p < 0.0001). Heart failure admission rates remained constant at about 5 per 1,000 veterans. Mortality at 30 days decreased (7.1% to 5.0%, p < 0.0001), whereas rehospitalization for heart failure at 30 days increased (5.6% to 6.1%, p = 0.11). After adjustment for patient characteristics, the odds ratio for rehospitalization in 2006 (vs. 2002) was 0.54 (95% confidence interval [CI]: 0.47 to 0.61) for mortality, but 1.21 (95% CI: 1.04 to 1.41) for heart failure rehospitalization at 30 days. CONCLUSIONS: Recent mortality and rehospitalization rates in the Veterans Affairs Health Care System have trended in opposite directions. These results have implications for using rehospitalization as a measure of quality of care.

Patient satisfaction after treatment of nonmelanoma skin cancer.

BACKGROUND: Patient satisfaction is an important aspect of patient-centered care but has not been systematically studied after treatment of nonmelanoma skin cancer (NMSC), the most prevalent cancer. OBJECTIVE: To compare patient satisfaction after treatment for NMSC and to determine factors associated with better satisfaction. METHODS: We prospectively measured patient, tumor, and care characteristics in 834 consecutive patients at two centers before and after destruction, excision, and Mohs surgery. We evaluated factors associated with short-term and long-term satisfaction. RESULTS: In all treatment groups, patients were more satisfied with the interpersonal manners of the staff, communication, and financial aspects of their care than with the technical quality, time with the clinician, and accessibility of their care (p<.05). Short-term satisfaction did not differ across treatment groups. In multivariable regression models adjusting for patient, tumor, and care characteristics, higher long-term satisfaction was independently associated with younger age, better pretreatment mental health and skin-related quality of life, and treatment with Mohs surgery (p<.05). CONCLUSIONS: Long-term patient satisfaction after treatment of NMSC is related to pretreatment patient characteristics (mental health, skin-related quality of life) and treatment type (Mohs) but not tumor characteristics. These results can guide informed decision-making for treatment of NMSC.

Effects of vulvodynia on quality of life.

BACKGROUND: The experiences of women with vulvodynia are poorly understood. OBJECTIVE: We sought to determine the effects of vulvodynia on quality of life. METHODS: We conducted a survey of 280 patients in a university-based vulvar disorders clinic. Skin-related quality of life was measured with a vulvar-specific version of Skindex-29. RESULTS: The response rate was 95%; 101 patients (36%) had vulvodynia, and 179 patients (64%) had other vulvar conditions. Women with vulvodynia had significantly worse quality of life than patients with many other dermatologic conditions, and worse functioning than women with other vulvar conditions (mean functioning scores [+/-SD] of patients with psoriasis, other vulvar conditions, and vulvodynia were 23 +/- 27, 34 +/- 24, and 44 +/- 22, respectively, P = .05). A diagnosis of vulvodynia was the strongest independent correlate of poor quality of life (eg, for poor functioning, odds ratio = 1.8, 95% confidence interval 1.0-3.1). LIMITATIONS: Limitations are single academic medical center and comorbid illnesses determined by self-report. CONCLUSION: Vulvodynia has broad and substantial effects on quality of life.

Variation in care for recurrent nonmelanoma skin cancer in a university-based practice and a veterans affairs clinic.

OBJECTIVE: To learn if treatment of recurrent nonmelanoma skin cancer (NMSC) varied in different practice settings. DESIGN: Prospective cohort study of consecutive patients with recurrent NMSC. SETTING: A university-based dermatology practice and the dermatology clinic at the affiliated Veterans Affairs Medical Center (VAMC). Conventional therapies for NMSC were available at both sites. Patients All 191 patients diagnosed as having recurrent NMSC in 1999 and 2000 were included in the study. Data were collected from medical record review and surveys mailed to patients. Main Outcome Measure Performance of Mohs micrographic surgery (Mohs). RESULTS: Patients at the VAMC were older, less educated, poorer, and had more comorbid illnesses, but their tumors were similar to those of patients at the university-based practice. Treatment choices differed at the 2 sites: the proportions of tumors treated in the VAMC and university sites were 60% and 14%, respectively, for excisional surgery; and 24% and 61%, respectively, for Mohs (P < .001). In multivariate analyses adjusting for patient, tumor, and physician features that may have affected treatment choice, tumors treated at the university-based site remained significantly more likely to be treated with Mohs (odds ratio, 8.68 [95% confidence interval, 3.66-20.55]; P < .001). CONCLUSIONS: Substantial variation existed in the treatment of recurrent NMSC in different practice settings. This variation was not explained by measured clinical characteristics of the patients or the tumors.

Predictors of skin-related quality of life after treatment of cutaneous basal cell carcinoma and squamous cell carcinoma.

OBJECTIVE: To identify predictors of skin-related quality of life (QOL) after treatment of nonmelanoma skin cancer (NMSC). DESIGN: Prospective cohort study of consecutive patients with NMSC diagnosed in 1999 and 2000. SETTING: University-affiliated private practice and a Veterans Affairs clinic. PATIENTS: A total of 633 patients who responded to a questionnaire before treatment. MAIN OUTCOME MEASURE: Skin-related QOL, measured with the 16-item version of Skindex-16, a validated measure. Skindex-16 scores vary from 0 (best QOL) to 100 (worst QOL) and are reported in 3 domains: symptoms, emotional effects, and effects on functioning. RESULTS: Controlling for treatment group, the strongest independent predictor of skin-related QOL after treatment of NMSC was pretreatment skin-related QOL. Other patient characteristics that predicted better QOL included less comorbidity and better mental health status. No tumor or care characteristic (including location of tumor, size of tumor, site of therapy, or training level of treating clinician [attending physician, resident, or nurse practitioner]) was found to predict better skin-related QOL after treatment of NMSC. CONCLUSIONS: Patients with better pretreatment skin-related QOL, less comorbidity, and better mental health status had better skin-related QOL after treatment of NMSC. These findings may be useful for pretreatment assessment and counseling.

Clinical reminders attached to echocardiography reports of patients with reduced left ventricular ejection fraction increase use of beta-blockers: a randomized trial.

BACKGROUND: Although beta-blockers are known to prolong survival for patients with reduced left ventricular ejection fraction, they are often underused. We hypothesized that a reminder attached to the echocardiography report would increase the use of beta-blockers for patients with reduced left ventricular ejection fraction. METHODS AND RESULTS: We randomized 1546 consecutive patients with a left ventricular ejection fraction <45% found on echocardiography at 1 of 3 laboratories to a reminder for use of beta-blockers or no reminder. Patients were excluded from analysis if they died within 30 days of randomization (n=89), did not receive medications through the Veterans Affairs system after 30 days (n=180), or underwent echocardiography at >1 laboratory (n=6). The primary outcome was a prescription for an oral beta-blocker between 1 and 9 months after randomization. The mean age of the 1271 included patients was 69 years; 60% had a history of heart failure, and 51% were receiving treatment with beta-blockers at the time of echocardiography. More patients randomized to the reminder had a subsequent beta-blocker prescription (74%, 458 of 621) compared with those randomized to no reminder (66%, 428 of 650; P=0.002). The effect of the reminder was not significantly different for subgroups based on patient location (inpatient versus outpatient) or prior use of beta-blockers. CONCLUSIONS: A reminder attached to the echocardiography report increased the use of beta-blockers in patients with depressed left ventricular systolic function.