REVEAL-HF: Prognosis information does not impact 1-year outcomes
Click Here to Manage Email Alerts
An embedded electronic health record algorithm that provided HF mortality risk information did not affect clinical decision making about initiation or intensity of treatment or improve outcomes in adults with HF, data show.
“We have been coming up with risk scores for heart failure for the last few decades, but no one has ever studied whether this information improves patient care,” Tariq Ahmad MD, MPH, associate professor at Yale School of Medicine and chief of the Yale Heart Failure Program, told Healio. “We show, for the first time, that this information does not impact patient outcomes. The implications are that we need to produce risk-based recommendations in heart failure if risk scores are to matter. Otherwise, clinicians do not know what to do with this information, as we showed in this study.”
Medical records data to predict risk
For the REVEAL-HF study, Ahmad and colleagues analyzed data from 3,124 adults hospitalized for HF across the Yale New Haven Health System who had N-terminal pro–B natriuretic peptide levels of 500 pg/mL or greater and received IV diuretics within 24 hours of admission. Researchers randomly assigned patients to the alert system (median age, 77 years; 50% women) or to the usual care (median age, 77 years; 51% women). The alert group had their risk for 1-year mortality calculated using an algorithm derived and validated with similar historic patients in the EHR.
The estimate, which included a categorical risk assessment, was presented to clinicians while they were interacting with a patient’s EHR. The primary outcome was a composite of 30-day hospital readmissions and 1-year all-cause mortality.
Within the cohort, 17.9% of patients in the intervention group and 17.6% of patients in the usual care group were admitted to the ICU, and 23% of patients in each group had left ventricular ejection fraction of 40% or less.
The model achieved an area under the curve of 0.74 in the trial population. The primary outcome occurred in 38.9% of patients in the alert group and in 39.3% of patients in the usual-care group (P = .89). There were no between-group differences in the prescription of HF medications at discharge, the placement of an implantable cardioverter defibrillator or referral to palliative care.
“There was no evidence that information about risk affected key treatment decisions in patients with heart failure,” the researchers wrote. “Specifically, we found no evidence of differences in discharge prescription of heart failure medical therapies. Patients with higher predicted risk tended to be less likely to be receiving these therapies, but this was equally balanced between study groups.”
The researchers noted that clinicians may require more prescriptive decision support, adding that the findings “call into question the hypothesis that prognostic information alone prompts changes in clinical decision-making that improves outcomes in patients with heart failure.”
Ahmad said research is needed around tying risk assessments to specific interventions and seeing whether that approach helps patients.
‘Move away from theory and aspiration’
In a related commentary, Andrew Oseran, MD, MBA, a clinical cardiology fellow at Massachusetts General Hospital, and Rishi K. Wadhera, MD, MPP, MPhil, a cardiologist at Beth Israel Deaconess Medical Center and Harvard Medical School, wrote that the REVEAL-HF investigators provide an example of why it is “important to develop, implement and assess quality initiatives in an evidence-based manner.
“Hospitals, health systems and policymakers must prioritize the rigorous evaluation of new initiatives so that they are grounded in evidence and achieve their stated goals, and frontline clinicians should lead in those efforts to ensure that improved patient care always remains the guiding principle,” Oseran and Wadhera wrote. “Given the substantial clinical burden of cardiovascular disease in the U.S., it is imperative that we move away from theory and aspiration toward an empirical approach to quality improvement, in order to meaningfully advance health outcomes.”
Reference:
Oseran AS, et al. JAMA Cardiol. 2022;doi:10.1001/jamacardio.2022.2493.
For more information:
Tariq Ahmad, MD, MPH, can be reached at tariq.ahmad@yale.edu; Twitter: @yalehfdoc.
Collapse
Read more about
Click Here to Manage Email Alerts