Visit Volume and Effectiveness of Electronic Tools to Improve HF Care

Quick Takes

  • Electronic health record alerts increased prescribing of mineralocorticoid antagonists (MRAs) when deployed in a single medical center as part of a randomized controlled trial.
  • The impact of these alerts on MRA prescribing was greatest for high-volume as compared to non–high-volume cardiologists.

Study Questions:

Does physician workload modify the effectiveness of electronic health record (EHR) alerts designed to increase prescribing of mineralocorticoid antagonists (MRAs) for patients with heart failure (HF) and reduced ejection fraction?


This was a prespecified, cross-sectional subgroup analysis of the BETTER CARE-HF trial. The BETTER CARE-HF trial was a cluster-randomized, three-arm pragmatic trial comparing EHR alerts to automated monthly messages to usual care on rates of MRA prescribing. Cluster randomization occurred at the level of the cardiologist, stratified by volume and subspecialty. EHR alerts were displayed for patients randomized to the alert arm who were not on MRA therapy but who were eligible for a prescription and who lacked a contraindication to an MRA. In contrast, automated messages were sent monthly to physicians between clinic visits and included lists of recently seen or upcoming patients eligible for an MRA. Visit volume for this analysis was defined primarily by the overall number of visits/cardiologist over the prior 6-month period and, secondarily, the number of clinic visits per half-day session for each cardiologist. The primary outcome was new MRA prescriptions at the end of the study period. Intervention effect was measured using generalized linear mixed-effect models comparing high visit volume (upper tertile) to non–high visit volume (middle and lower tertile) cardiologists.


Between April 2022 and October 2022, 2,211 patients were randomized in the BETTER CARE-HF trial, of whom 932 (42.2%) saw 58 high visit volume cardiologists. Patients seeing high visit volume cardiologists were less likely to be female, of self-identified Black race, English speaking, or covered by private insurance. Among patients randomized to usual care, 5.5% in the high-volume group compared to 14.8% in the non–high-volume group were newly prescribed an MRA. In the monthly message arm, 10.3% of patients in the high-volume group as compared to 19.6% in the non–high-volume group were prescribed an MRA. Finally, in the alert arm, 31.2% in the high-volume group compared with 28.2% in the non–high-volume group were prescribed an MRA. The impact of alerts as compared with usual care was greatest for patients seen by high-volume cardiologists (relative risk [RR], 5.16; 95% confidence interval [CI], 2.57-10.38) relative to those seen by non–high-volume cardiologists (RR, 1.93; 95% CI, 1.29-2.90; p for interaction = 0.02). Visit volume did not modify the effectiveness of monthly messages as compared with usual care. Findings were similar when visit volume was defined by the average number of visits per half-day of clinic.


In this prespecified subgroup analysis of the BETTER CARE-HF trial, automated EHR alerts improved MRA prescribing for HF patients with the greatest impact on high-volume cardiologists.


Contemporary guideline-directed medical therapy (GDMT) for HF patients substantially reduces disease-associated morbidity and mortality, although few patients are prescribed all four classes of GDMT and even fewer are on GDMT at target doses. Through EHR alerts, the BETTER CARE-HF trial was able to increase rates of MRA prescribing, similar to the PROMPT-HF trial, though in the latter, alerts were designed to increase prescribing of all four classes of GDMT (Ghazi L, et al., J Am Coll Cardiol 2022;79:2203-13). In the current analysis, EHR alerts were most effective for high-volume cardiologists. This suggests that alerts may act by decreasing cognitive load, which may be most significant for high-volume physicians.

Limitations of this trial in general, however, and of this subgroup analysis are of note. First, the study was single center. Second, the trial was designed only to increase MRA prescribing. Thus, whether alerts would differentially impact high- versus non–high-volume cardiologists when targeting all four classes of GDMT is unknown. Third, the impact of alerts on nonphysicians (i.e., advanced practice providers, pharmacists) was not evaluated. Fourth, whether alerts targeting medication up-titration (as opposed to initiation) would perform differently based on cardiologist visit volume was not tested. Finally, it is unknown how alerts interact with volume type when implemented for noncardiologists who may receive multiple alerts for a range of disease states.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Electronic Health Records, Heart Failure, Mineralocorticoid Receptor Antagonists

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