EHR alerts boosted prescription of guideline-recommended heart failure therapies
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WASHINGTON — A personalized alert triggered via the electronic health record during office visits resulted in more frequent prescription of guideline-directed medical therapies for patients with HF with reduced ejection fraction.
The EHR alerts also increased the rate of uptitration of currently prescribed HFrEF therapies, when the alert indicated that doing so may be beneficial, according to results of the PROMPT-HF trial, which were presented at the American College of Cardiology Scientific Session.
‘Easily scalable strategy’
“We know that guideline-directed medical therapy improves clinical outcomes in heart failure with reduced ejection fraction, but it remains pervasively underprescribed,” said Tariq Ahmad, MD, MPH, associate professor of medicine, medical director of advanced heart failure and cardiovascular medicine, and chief of the heart failure program at Yale School of Medicine. “Efforts to optimize guideline-directed medical therapy are abundant and resource intensive, but limited evidence supports their use. Electronic health records may be used to target and individualize guideline-directed medical therapy recommendations. This approach is easily scalable and a low-cost way to accelerate high-value care.”
The PROMT-HF trial included 100 providers and more than 1,300 patients with HFrEF (median age, 72 years; 31% women; median left ventricular ejection fraction, 32%) in the Yale-New Haven Health System, and utilized its integrated EHR data (Epic Systems). Researchers did not enroll patients with HFrEF already on quadruple therapy.
Ahmad said the PROMPT-HF cohort was similar in demographics, LVEF and prescribed medical therapies at baseline to that of the larger CHAMP-HF trial.
Providers were randomly assigned to receive an EHR alert or usual care with no alert. The personalized alerts were triggered for eligible patients at the time a clinician opened the order entry module in the patient’s EHR, which provided them with individualized guideline-recommended medical therapy recommendations.
Increase in prescriptions
The prescription rate of an additional guideline-directed medical therapy class at 30 days, the primary outcome of PROMPT, was greater among providers who received an EHR alert compared with no alert (RR = 1.41; 95% CI, 1.03-1.93; P = .03). This finding translated to a number needed to alert of 14 to improve guideline-directed medical therapy for one patient with HFrEF.
The alert also resulted in increased rates of the composite secondary outcome of adding another guideline-directed medical therapy class at 30 days and uptitrating current HFrEF therapy compared with no alert (RR = 1.39; 95% CI, 1.08-1.79; P = .01). This finding translated to a number needed to alert of 10 to improve guideline-directed medical therapy for one patient with HFrEF.
There were no interactions by patient age, sex, race, insurance status, LVEF or baseline therapy on the effects of the alert on changes in guideline-directed medical therapy.
Providers were also surveyed on guideline knowledge and user experience.
“We had the physicians fill out a survey of 20 questions that were extracted from the guidelines to see what their knowledge of guideline was before and after the study,” Ahmad said. “We also asked them questions about whether they found the alert helpful or not. This was the only alert in the outpatient setting. On the inpatient side, there were a lot of alerts. The issue of alert fatigue is important there, but 79% of clinicians said they felt that the alerts were helpful.”
The study was simultaneously published in the Journal of the American College of Cardiology.
“A personalized alert triggered via the electronic health record during offices visits led to a significantly higher number of patients with heart failure with reduced ejection fractions on appropriate guideline-directed medical therapy,” Ahmad said. “We feel that this low-cost tool can be rapidly embedded into EHR integrated health care systems and lead to widespread improvements in the care of heart failure patients.”
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Perspective
Back to TopW.H. Wilson Tang, MD
The PROMPT-HF study is a fascinating pragmatic study that looked at an alert for guideline-directed medical therapy in a health system, both in cardiologists and noncardiologists in the outpatient setting. It seems that it did help, although there are interesting findings. The majority of help seems to have focused on beta-blockers and not necessarily as much in the ones that are low in prescription rate, like the newer drugs. During the discussion, there was an interesting discussion of whether they were patient-related vs. clinician-related effects. In fact, the editorial [published in JACC] even suggests that the majority of clinicians seem to find it helpful, although their actions don’t actually match with it. In fact, a lot of people did not do anything. Obviously, some important assessment is needed to figure out why clinicians act on what they do or do not act on what they do.
There’s still a lot to do, but this is a good illustration of how a learning health system can potentially improve care, because these are definitely guideline-directed medical therapies that have shown improvement in clinical outcomes, and effective use of it is important.
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Ghazi L, et al. Joint American College of Cardiology/New England Journal of Medicine Late-Breaking Clinical Trials. Presented at: American College of Cardiology Scientific Session; April 2-4, 2022; Washington, D.C. (hybrid meeting).
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