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PROMPT-HF Trial: Electronic Alerts for HF Therapies
Quick Takes
- Tailored electronic health record alerts providing specific guidance on HF medical management leads to more initiation of guideline-directed medications compared to no alerts.
- This is a cost-effective and scalable intervention to improve HF care.
Study Questions:
Do targeted and tailored electronic health record (EHR) alerts recommending guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF) improve medication use?
Methods:
PROMPT-HF is a pragmatic, single health-system, EHR-based, cluster-randomized (by provider), comparative effectiveness trial. Retrospectively, the top 100 providers caring for HFrEF patients in the outpatient setting (physicians or advanced practice providers) were identified. These providers were randomized to receive a best practice alert (BPA) for patients with HFrEF or no alert at the time of an outpatient visit. Patients were enrolled from April 2021–October 2021.
Inclusion criteria for patients included age ≥18 years, left ventricular ejection fraction (LVEF) ≤40%, and not already on all four classes of GDMT for HFrEF (beta-blockers [BBs], renin-angiotensin-aldosterone system [RAAS] inhibitors, mineralocorticoid receptor antagonists [MRAs], sodium-glucose cotransporter-2 inhibitors [SGLT2i]). Exclusion criteria for patients included those who have opted out of EHR-based research and in hospice care. In addition, providers completed a pre- and post-study survey assessing knowledge and comfort levels. The post-study survey also assessed user experience with the BPA.
Alert information:
- BPA triggered when opening order entry module.
- Information provided: current LVEF, blood pressure, heart rate, serum potassium and creatinine levels, estimated glomerular filtration rate.
- Recommendations provided: All four classes of medication displayed. Medication classes missing were highlighted and allergies were noted. Links to an order set with missing medications and indications were provided.
The primary outcome was proportion of patients with an increase in the number of GDMT classes prescribed at 30 days. The secondary outcomes were increase in dose of currently prescribed GDMT, filling of prescriptions, total health care costs, hospitalizations, emergency department visits, and death.
Results:
There were 1,310 ambulatory patients with HFrEF enrolled, who were managed by the 100 providers randomized. The providers consisted of 69% physicians and 31% advanced practice providers. Patient characteristics were well-balanced between the intervention and control groups. At baseline, among all the patients, 84% were on a BB, 71% were on a RAAS inhibitor, 29% were on an MRA, and 11% were on an SGLT2i.
For the primary outcome, 25.7% of patients had an increase in the number of GDMT classes at 30 days in the alert arm compared to 18.7% in the no alert arm (adjusted relative risk, 1.41; 95% confidence interval [CI], 1.03-1.93; p = 0.03). The number needed to treat/alert was 14. Broken down by class for alert compared to no alert, increases were seen in 5.8 vs. 2.9% for BBs (p = 0.007), 7.7% vs. 7.0% for RAAS inhibitors (p = 0.22), 7.6 vs. 5.3% for MRAs (p = 0.20), and 9.8% vs. 7.5% for SGLT2i (p = 0.41).
For the additional outcomes, there was an increase in dose of current GDMT medications or start of a new class in 36.2% of patients in the alert group compared to 26.2% in the no alert group (adjusted RR, 1.39; 95% CI, 1.08-1.79; p = 0.010). There were no differences in 30-day rates of emergency department visits or hospitalization between the two groups. There were no differences in safety outcomes. For providers receiving alerts, 79% agreed or strongly agreed that the BPA was helpful in improving GDMT regimens.
Conclusions:
Targeted and tailored EHR BPAs for outpatient HFrEF visits led to significantly higher rates of GDMT initiation at 30 days compared with usual care (no BPAs).
Perspective:
GDMT for patients with HFrEF have proven benefits for morbidity and mortality. However, there exist real and substantial barriers to adequate initiation and titration of HFrEF therapies. Real-world data confirms that health care providers and systems need to do better in this area. Unfortunately, quality improvement efforts can prove to be costly without clear evidence for benefit. The authors sought to address this through a provider-level intervention using best practice alerts and therapeutic guidance built into the EHR. An intervention of this type utilizes the immerse power of EHR data and mechanics to have a broad reach across the health care system for little cost. As demonstrated in this study, these BPAs have a significant impact on provider practices and patient care.
These are very promising results and help providers overcome clinical inertia. Given that this study was limited to a single health care system, a specific EHR vendor, and to providers that frequently care for HFrEF patients, the generalizability of these findings is still unclear. The balance between these alerts and provider workflow/well-being were considered by the investigators, which is critical going forward with any BPA implementation.
Clinical Topics: Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure
Keywords: ACC22, ACC Annual Scientific Session, Adrenergic beta-Antagonists, Blood Pressure, Creatinine, Delivery of Health Care, Electronic Health Records, Emergency Service, Hospital, Glomerular Filtration Rate, Health Care Costs, Heart Failure, Mineralocorticoid Receptor Antagonists, Outpatients, Potassium, Quality Improvement, Renin-Angiotensin System, Secondary Prevention, Sodium-Glucose Transporter 2 Inhibitors, Stroke Volume, Ventricular Function, Left
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