Impact of a Noninterruptive Echocardiogram Report-Embedded Nudge on Rates of Referral to Cardiac Specialty Care and Aortic Valve Replacement in Patients with Severe Aortic Stenosis: A Multicenter Intervention

BACKGROUND: Undertreatment of severe aortic stenosis (AS) including absence and delays in referral to cardiac specialty care remains common, particularly when patients are followed by noncardiac specialty providers. Electronic health record (EHR)-based nudges improve adherence to treatment but have not been widely evaluated in valvular heart disease. METHODS: In this multicenter study across 3 diverse US health systems, an automated, noninterruptive EHR-embedded nudge was implemented within the echocardiography report of patients with a first diagnosis (index echo) of severe AS. The study primarily targeted patients whose index echo was ordered by noncardiac specialty providers. The primary end point was referral to a cardiac specialist within 90 days. Secondary endpoints were a composite of completed cardiac specialty visit or aortic valve replacement (AVR) within 90 days, and AVR within 6 months. Analyses compared pre- and post-nudge cohorts using propensity score matching and multivariable logistic regression models. A difference-in-difference analysis was conducted to evaluate whether the nudge's effect differed by referring provider specialty (cardiac vs noncardiac). RESULTS: A total of 5,009 patients (mean age, 78 ± 11 years; 57% men, 88% White, 69% symptomatic) were identified. After propensity score matching (total n = 3,840; prenudge: 2,560 patients; postnudge: 1,280 patients), referral to cardiac specialty care increased from 94% prenudge to 97% postnudge (P < .001), and the composite outcome improved from 89% to 93% postnudge (P = .003). Among noncardiac specialty providers, all 3 outcomes of referral (89% to 96%, P < .001), composite outcome (83% to 88%, P = .017), and AVR within 6 months were higher postnudge (33% to 39%, P = .016). In the multivariable logistic regression model of the full cohort, the nudge was independently associated with higher odds of referral (adjusted odds ratio = 1.62; 95% CI, 1.15-2.30; P = .006) and composite outcome (adjusted odds ratio = 1.40; 95% CI, 1.10-1.79; P = .007), with a significant interaction indicating that the effect was most pronounced among noncardiac specialty providers (P < .001). CONCLUSION: A noninterruptive, scalable, EHR-embedded nudge within echocardiography reports improved referral to cardiac specialty care and treatment in patients with newly diagnosed severe AS, particularly among noncardiac specialty providers. These findings support the role of noninterruptive, automated nudges in standardizing guidelines-based care in severe AS.