PROMPT-HF: Customized Alert in EHR Improved Guideline Adherence For HF Treatment
"Targeted and tailored clinical decision support prompts in the electronic health record (EHR) can accelerate adoption of underutilized therapies for patients with heart failure (HF)," based on findings from the PROMPT-HF trial presented April 3 at ACC.22 and simultaneously published in the Journal of the American College of Cardiology (JACC).
The cluster randomized trial enrolled 100 clinicians in the Yale New Haven Health system who were seeing the greatest number of patients with HF with reduced ejection fraction (HFrEF). Half of the clinicians were assigned to begin receiving customized alerts for the Yale New Haven Epic EHR system, while the other half were not.
The alert was programmed and developed based on consultations with clinicians and behavioral economics experts and occurred when clinicians were inputting follow-up orders after a patient visit. It listed the medications and doses patients had been prescribed along with what they should be taking based on guideline-directed medical therapy (GDMT) for beta blockers, ACE inhibitors/ARBs/angiotensin receptor-neprilysin inhibitors (ARNi), mineralocorticoid receptor antagonist (MRA) medications and SGLT2 inhibitors. Clinicians were able to adjust dosing or prescribe additional medications during the same patient visit.
The study, which met its primary endpoint of an increase in GDMT prescribed at 30 days post randomization, is the first to show significant improvements in the use of GDMT for HF using a low-cost, scalable intervention to prompt clinicians to prescribe recommended medications, researchers said.
Over the course of about seven months, clinicians saw 1,310 patients with HFrEF. At the end of the trial period, 26% of patients whose clinicians received the alerts had an increase in the number of prescribed GDMT, compared with 19% of those patients whose physicians did not receive alerts (p=0.03). Patients in the clinician alert group were also more likely to receive an increase in the dosage for medications they were currently taking.
"The results were quite remarkable," said Tariq Ahmad, MD, chief of the Yale Heart Failure Program at Yale School of Medicine and Yale New Haven Health and the study's lead author. "We were able to dramatically increase the number of guideline-directed medical therapies used in a very rapid fashion."
In an evaluation, 80% of participating clinicians reported finding the alerts to be "very helpful." Although the trial did not assess clinical health outcomes, researchers said that increasing the use of GDMT is highly likely to lead to direct health improvements. Ahmad and colleagues note that further research is needed to compare the improvements in care achieved through electronic record alerts in various patient populations based on socioeconomic, racial and ethnic demographics, types and severity of HF, and other relevant clinical variables.
"There is a huge gap between our knowledge [on HF treatments] and the implementation of this knowledge," Ahmad said. "We felt that one of the reasons why past trials have been negative is that they're not integrated into the usual clinical flow. When a clinician is seeing a patient, that is an opportune time to remind them to put patients on the right medications. I have no question that if you were able to do this on a larger scale, that it would lead to dramatic improvements in patient survival and reductions in hospitalizations."
In a related JACC editorial comment, Harriette G.C. Van Spall, MD, MPH; Gregg C. Fonarow, MD, FACC; and Mamas A. Mamas, DPhil, MA, MBBCh, add that, "PROMPT-HF illustrates how trials embedded in health care 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, whilst informing recruitment strategies and interventions for future trials. 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."
Keywords: ACC Annual Scientific Session, ACC22, Outpatients, Heart Failure
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