EHR alerts may help boost guideline-directed therapy for heart failure

An industry-funded cluster-randomized trial found that clinician alerts were associated with an over 40% increase in prescription of four recommended drug classes in patients with heart failure with reduced ejection fraction.

EHR-based alerts for outpatients with heart failure with reduced ejection fraction (HFrEF) led to significantly higher rates of guideline-directed medical therapy (GDMT) at 30 days compared with usual care, an industry-funded study found.

PROMPT-HF (PRagmatic Trial Of Messaging to Providers about outpatient Treatment of Heart Failure) was a cluster-randomized comparative effectiveness trial that examined whether an EHR alert providing personalized recommendations for outpatients with heart failure would increase GDMT use. One hundred clinicians caring for patients with HFrEF were randomized to an alert cohort or a usual care cohort. In the former, an EHR-embedded best practice alert appeared when the clinician opened the order entry module, with information on the patient's current left ventricular ejection fraction and other clinical markers considered for adjustment of heart failure medication, and one of four medication classes used for usual care was displayed. If the patient was not currently prescribed a recommended medication class, the word “none” was bolded in red.

The study's primary outcome was the proportion of patients with HFrEF who had an increase in the number of prescribed GDMT classes at 30 days after randomization. Secondary outcomes were any increase in dose of currently prescribed GDMT, prescription fills, total health care costs, hospitalizations, ED visits, and death. The researchers also surveyed clinicians before and after the study to measure their opinions on user experience with the alert, along with knowledge and comfort level with HFrEF guidelines, via surveys completed before and after the study. The trial was funded by AstraZeneca, and three of the study authors were AstraZeneca employees. Results were published April 5 by the Journal of the American College of Cardiology.

The primary outcome occurred in 176 of 685 participants in the alert arm versus 117 of 625 in the usual care arm (25.7% vs. 18.7%), with GDMT class prescription increased by more than 40% after alert exposure (adjusted relative risk, 1.41 [95% CI, 1.03 to 1.93]; P=0.03). Numerical increases in prescription of each GDMT class were seen in both study arms: 5.8% versus 2.9% for beta-blockers (P=0.007), 7.7% versus 7.0% for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitor (P=0.22), 7.6% versus 5.3% for aldosterone receptor antagonists (P=0.20), and 9.8% versus 7.5% for sodium-glucose cotransporter-2 inhibitors (P=0.41). The secondary outcome of an increase in dose or addition of a class of GDMT was observed in 36.2% of the alert arm and 26.2% of the no alert arm (adjusted relative risk, 1.39 [95% CI, 1.08 to 1.79]; P=0.01].

Among clinicians who received an alert, 79% agreed or strongly agreed that it was effective at enabling improved prescription of GDMT for patients with HFrEF. Twenty-five percent of those who received alerts accepted the recommendations, 48% indicated that they would address suggested interventions in the future, 14% indicated that the patients did not meet the criteria, and the remainder did not acknowledge the alert. The main reasons given for not accepting recommendations were hypotension, renal failure/decompensation, medication not tolerated, and patient refusal.

This low-cost intervention can be rapidly integrated into clinical care and accelerate adoption of high-value therapies in heart failure, the authors concluded. “Our approach of using an easily customizable alert that is delivered at time of clinical decision-making has benefits beyond prior interventions as it can be applied easily to the EHR and scaled much more easily than a patient-facing intervention or a remote team-based program. Most importantly, it can lead to significant improvements in the prescription of guideline directed medications, with only 10 patients needed to alert in order to see a positive change,” they wrote.

An accompanying editorial said that PROMPT-HF showed efficient use of an EHR as a platform for randomized controlled trials and learning health systems.

“PROMPT-HF illustrates how trials embedded in healthcare systems can leverage digital health technology to identify, recruit, and randomize participants; deliver interventions; collect outcomes; and use the resulting evidence to inform healthcare processes and improve outcomes iteratively, whilst informing recruitment strategies and interventions for future trial,” the editorial stated. “This culture of continuous knowledge generation and implementation, in which interventions are seamlessly embedded in the care process and new knowledge is used to guide future care, may finally prompt improvements in HF care.”