PROMPT-HF: Tailored EHR Prompts Can Improve Prescription of GDMT in Heart Failure

Ahmad Tariq, MD

Results of the PROMPT-HF trial suggest implementation of an electronic alert system into a clinician’s electronic health record (EHR) resulted in significantly more prescriptions for guideline-directed medications for heart failure.

With the trial meeting its primary endpoint, which was an increase in the number of guideline-direct medical therapy (GDMT) classes prescribed at 30 days, it becomes the first randomized trial to show significant improvements in use of GDMT using an intervention that pushes electronic prompts clinicians to prescribe recommended medication classes.

“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.”

Although improving adherence to optimal prescription of GDMT is an issue among many conditions, few fields see such a discrepancy between rates of prescription and proven clinical benefit of therapies as the treatment of heart failure. Even with the massive revelation of SGLT2 inhibitors cardiorenal protective benefits, improving the rate of prescription for these agents has become a formidable task.

Presented at the American College of Cardiology’s 71st Annual Scientific Sessions, PROMPT-HF was a pragmatic, EHR-based, cluster-randomized comparative effectiveness trial conducted in a group of 100 clinicians managing patients with heart failure with reduced ejection fraction. Clinicians included in the trial were randomized to usual care or to a real-time, targeted, and tailored EHR-based alerting system within the Epic EHR used by the healthcare system. Investigators noted the alert system was designed to notify provers of individualized GDMT recommendations based on patient characteristics.

The primary endpoint for the study was an increase in the number of GDMT classes prescribed at 30 days. Secondary outcomes of interest included increases in dose of currently prescribed GDMT, filling of prescriptions, total health care costs, hospitalizations, emergency department visits, and death. Investigators noted providers were also surveyed to assess user experience with the alert and knowledge of guidelines.

Between April 2021 and October 2021, the 100 enrolled providers, which was 69% physicians and 31% advanced practice providers, care for a population of 1310 patients. Investigators pointed out patient characteristics were well-balanced between the study groups at baseline. At baseline, 84% we’re receiving beta-blockers, 71% were reaching an ACE/ARB or ARNI, 29% were receiving an MRA, and 11% were receiving an SGLT2 inhibitor. During the study period, 75% of patients triggered 1 alert, 17% triggered 2 alerts, and 8% triggered 3 or more alerts.

Upon analysis, results suggested the primary outcome occurred in 25.7% of the alert arm compared to 18.7% in the no alert arm (aRR, 1.41 [95% CI, 1.03-1.93]; P=.03). Results suggested numerical increases were observed for each GDMT class in both study arms, with greater increases seen among those in the alert group. Investigators pointed out the number needed to alert for 1 patient to have a GDMT class addition was 14.

Investigators also pointed out an increase in dose or addition of a GDMT class was observed in 36.2% of the alert arm and 26.2% of the no alert arm (aRR, 1.39 [95% CI, 1.08-1.79]; P=.01). The number needed to alert for this outcome was 10. No significant difference was observed between the study arms for rate of emergency department visits or hospitalizations at 30-days. Additionally, no significant differences were observed for safety outcomes between either arm.

When assessing survey responses, investigators found 79% of clinicians agreed or strongly agreed the prompts were effective at enabling improved prescription of GDMT. Of these clinicians, 25% accepted the recommendations made by the prompt, 48% said they will address the suggested interventions in the future, 14% indicated that the patients do not meet the criteria, and the remaining did not acknowledge the alerts. Investigators noted the most prominent reasons for forgoing a recommendation were hypotension, renal failure/decompensation, intolerability, and patient refusal.

“Anything that increases use of these medications and dosing of these medications has been definitively shown to improve medical outcomes,” Ahmad added. “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.”

This study, “Pragmatic Trial Aimed at Improving Use of Guideline Directed Medical Therapy in Outpatients With HF,” was presented at ACC.22 and simultaneously published in the Journal of the American College of Cardiology.