EHR Alerts Improve Guideline-Directed Heart Failure Treatment Strategies

Tariq Ahmad, MD, MPH

A notification system design to identify patients with heart failure with reduced ejection fraction (HFrEF) resulted in significantly greater rates of guideline-directed medical therapy among clinicians, according to a new study.

Data from the PROMPT-HF trial, presented in late-breaking sessions at the American College of Cardiology (ACC) 2022 Scientific Sessions in Washington, DC, this weekend, showed that a simple, low-cost alert in electronic health records (EHRs) resulted in an approximate 38% increased use of guideline-directed care for patients with HFrEF being treated in an ambulatory setting.

The data, presented by study author Tariq Ahmad, MD, MPH, chief of heart failure at Yale School of Medicine, highlight a feasible and novel method to improve evidence-based care in eligible patients with heart failure—at a time when experts are observing less uniform heart failure prescribing, and new guidelines for treatment and prevention were released during ACC 2022.

As Ahmad and colleagues noted, HFrEF pharmacotherapy is comprised of 4 medication classes associated with reduced hospitalization and mortality risk: beta blockers, Renin-Angiotensin-Aldosterone System (RAAS) inhibitors, mineralocorticoid receptor antagonists (MRAs), and SGLT-2 inhibitors.

“Despite compelling evidence supporting their clinical use, real-world data shows persistent suboptimal adoption of these treatments, demonstrating an unmet need to identify and overcome barriers to implementation,” investigators wrote. “Efforts aimed at optimizing GDMT in patients with HFrEF are abundant across hospitals and healthcare systems, but there is limited evidence to support whether such resource-intensive interventions have any demonstrable benefit.”

The team identified EHR best practice alerts (BPAs) as an individualized, cost-effective and rapidly scalable strategy for emphasizing guideline-directed treatment. The alert provided clinicians guideline-directed therapy recommendations for patients with HFrEF not receiving any of the 4 key medication classes, while also providing key insights into the patients’ characteristics.

Investigators sought to interpret the use of a timely recommendations alert for HFrEF treatment tailored to patients’ status and its impact on prescription rates versus usual care. The primary outcome was increase in number of guideline-directed therapy classes prescribed at 30 days post-randomization.

Ahmad and colleagues randomized 100 clinicians from a clinic seeing the most HFrEF patients to either alert-based or usual care. A total of 1310 ambulatory patients with HFrEF were enrolled over 7 months. Median patient age was 72; approximately one-third (31%) were female and 18% were Black.

Median patient left ventricular ejection fraction (LVEF) was 32% at baseline. Additionally, 84% were receiving beta blockers, 71% were receiving RAAS inhibitors, 28% were receiving MRAs and just 11% were receiving SGLT-2 inhibitors at baseline.

Investigators observed a significant greater proportion of patients receiving additional components of guideline-directed therapy when treated with clinicians using the alert (n = 176 [25.7%]) than those being treated by clinicians with usual care (n = 117 [18.7%]), indicating a relative risk of 1.38 (95% CI, 1.01 – 1.87; P = .04). The number needed to alert for 1 patient to have an addition of a guideline-directed therapy class was 14.

The team additionally observed a 3.6% increase in beta blocker prescription, 4.5% increase for RAAS inhibitors, 5.1% for MRAs, and 9.0% for SGLT-2 inhibitors among clinicians using the alert. They found no significant differences in rates of emergency department visits or hospitalizations at 30 days across either arm, as well as no significant safety outcome differences.

In describing clinician feedback, investigators noted a majority of those who used the alert system found it helpful for optimizing treatment strategies.

“This low-cost tool can be rapidly embedded into the EHR at integrated health care systems and lead to widespread improvements in the care of heart failure patients,” they concluded.

The study, “Pragmatic Trial Aimed at Improving Use of Guideline Directed Medical Therapy in Outpatients With HF,” was presented at ACC 2022.