Real-time EHR-based alerts optimize treatment for heart failure

The use of the electronic health record (EHR) to provide timely, personalized clinical decision support alerts can improve the adoption of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) in the outpatient setting, as shown in the results of the PROMPT-HF trial presented at the American College of Cardiology (ACC) meeting.

When compared with usual care, the EHR-based alerts significantly increased the number of GDMT prescribed by more than 40 percent within 30 days of randomization (26 percent vs 19 percent; adjusted relative risk [RR], 1.41, 95 percent confidence interval [CI], 1.03–1.93; p=0.03). [Ahmad T, et al, ACC 2022]

There were numerical increases in the prescription of each GDMT class in both the alert and usual-care arms: 5.8 percent vs 2.9 percent for beta blockers (p=0.007), 7.7 percent vs 7.0 percent for renin-angiotensin-aldosterone system (RAAS) inhibitors (p=0.22), 7.6 percent vs 5.3 percent for mineralocorticoid receptor antagonists (MRAs; p=0.20), and 9.8 percent vs 7.5 percent for sodium-glucose cotransporter-2 inhibitors (SGLT2is; p=0.41). The number of patients needed to alert to result in an increase in GDMT class was 14.

Moreover, the alert vs the usual-care arm resulted in an increase in the dose of current GDMT or the initiation of a new class of medications (36.2 percent vs 26.2 percent; adjusted RR, 1.39, 95 percent CI, 1.08–1.79; p=0.010). There were no differences noted in 30-day rates of emergency department visits or hospitalization and in safety outcomes.

Lead study author Dr Tariq Ahmad, Yale Heart Failure Program Chief at Yale School of Medicine and Yale New Haven Health, indicated that the results provide an exciting look into the utility of EHR-based alerts to prompt clinicians to get patients on the right therapy for heart failure.

“Appropriate use of medical therapy reduces morbidity and mortality in patients with heart failure. Despite this, the proportion of eligible patients treated with guideline recommended medications remains suboptimal,” Ahmad said. “In this pragmatic randomized controlled trial involving outpatients with HFrEF, a personalized alert triggered via the EHR during office visits led to … rapid and substantial increases in the use of GDMT.”

PROMPT-HF included 1,310 ambulatory HFrEF patients (median age 72 years, 31 percent female, 18 percent Black, median left ventricular ejection fraction [LVEF] 32 percent) who were managed by the 100 clinicians randomized to either an alert or usual care intervention.

The alert notified clinicians of their patient's current LVEF, along with the most recent blood pressure, heart rate, serum potassium and creatinine levels, and estimated glomerular filtration rate—patient-specific clinical data commonly taken into consideration during heart failure medication adjustments.

All four recommended GDMT classes were also displayed, with specifications as to which of them the patients were currently receiving or not receiving. Allergies to recommended drugs or drug categories were specifically noted.

Asked for feedback, 79 percent of clinicians either agreed or strongly agreed that the alerts were effective at enabling improved prescription of GDMT for patients HFrEF. This, according to Ahmad, shows that this low-cost and widely scalable intervention can be part of a multifaceted program that rapidly improves the quality of care in patients with heart failure.

Value-added care

Unlike prior trials that failed to show an impact of informational EHR-based alerts on clinician behaviour, PROMPT-HF provided specific information-based guidance rather than straight information alone, Ahmad pointed out. [BMJ 2021;372:m4786; JACC Heart Fail 2021;9:409-419]

“Furthermore, the alert was developed in concert with practicing clinicians, whose input was used in its design and timing during clinical workflow. We believe that these factors led to most providers finding that it added value to the care of their patients and should be considered in future iterations of EHR alerting in heart failure,” he said. [Proc Natl Acad Sci 2021;118:e2101165118; Eur Heart J 2022;43:1296-1306]

In a related editorial published in the Journal of the American College of Cardiology, a group of experts from McMaster University, Hamilton, Ontario, Canada, acknowledged that the demonstration of the efficient use of an EHR as a platform for trials and Learning Health Systems was one of the merits of PROMPT-HF. [J Am Coll Cardiol 2022;doi:10.1016/j.jacc.2022.03.338]

“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 health care processes and improve outcomes iteratively, while informing recruitment strategies and interventions for future trials,” according to Dr Harriette Van Spall and colleagues.

“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 heart failure care,” they added.