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EHR Alerts for Management of Acute HF in Hospitalized Patients
Quick Takes
- A personalized best practice alert triggered via the EHR during order entry did not increase the proportion of patients being prescribed GDMT at time of discharge.
- Furthermore, overall GDMT prescriptions remained suboptimal, with only one in nine eligible patients being discharged on a comprehensive four-drug evidence-based regimen.
- Further tweaking of such alerts along with changes to clinician incentives appears to be indicated to overcome barriers to implementation of GDMT during hospitalizations for acute HF.
Study Questions:
What is the impact of a tailored electronic health record (EHR) alert on rates of guideline-directed medical therapy (GDMT) prescriptions at discharge in eligible patients hospitalized for acute heart failure (AHF)?
Methods:
The investigators conducted a pragmatic, multicenter, EHR-based, and randomized clinical trial called PROMPT-AHF (Pragmatic Trial of Messaging to Providers About Treatment of Acute Heart Failure). Patients were automatically enrolled 48 hours after admission if they met prespecified criteria for an AHF hospitalization. Providers of patients in the intervention arm received an alert during order entry with relevant patient characteristics along with individualized GDMT recommendations with links to an order set. The primary outcome was an increase in the number of GDMT prescriptions at discharge. The association between the intervention and outcomes was assessed using a generalized linear model adjusted for hospital, age, sex, left ventricular ejection fraction, Elixhauser Comorbidity Index, provider specialty (cardiology vs. noncardiology), and number of GDMT classes at baseline.
Results:
A total of 1,012 patients were enrolled between May 2021 and November 2022. The median age was 74 years; 26% were female, and 24% were Black. At the time of the alert, 85% of patients were on beta-blockers, 55% on angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, 20% on mineralocorticoid receptor antagonist (MRA), and 17% on sodium-glucose cotransporter 2 inhibitor. The primary outcome occurred in 34% of both the alert and no alert groups (adjusted risk ratio, [aRR], 0.95 [0.81, 1.12]; p = 0.99). Patients randomized to the alert arm were more likely to have an increase in MRA (aRR, 1.54 [1.10, 2.16]; p = 0.01). At the time of discharge, 11.2% of patients were on all four pillars of GDMT.
Conclusions:
The authors report that a real-time, targeted, and tailored EHR-based alert system for AHF did not lead to a higher number of overall GDMT prescriptions at discharge.
Perspective:
This study found that a personalized best practice alert triggered via the EHR during order entry did not increase the proportion of patients being prescribed GDMT at time of discharge. Furthermore, while there was evidence of an increase in MRA prescriptions in the alert arm, overall GDMT prescriptions remained suboptimal, with only one in nine eligible patients being discharged on a comprehensive four-drug evidence-based regimen. These results suggest that EHR-based interventions that are known to be effective in the outpatient setting may be significantly less impactful during a hospital admission. Further tweaking of such alerts along with changes to clinician incentives appears to be indicated to overcome barriers to implementation of GDMT during hospitalizations for AHF.
Clinical Topics: Prevention
Keywords: Acute Heart Failure, Electronic Health Records, Inpatients, Prescription Drugs, Secondary Prevention
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