麻豆传媒

WASHINGTON -- A large health system took advantage of its electronic health records (EHR) software to increase utilization of guideline-directed medical therapy (GDMT) in the outpatient setting.

In the PROMPT-HF study, clinicians randomized to a clinical decision-support intervention got electronic alerts every time they accessed the EHR of a heart failure outpatient not on one of four GDMT medication classes. The tool provided individualized guidance on prescribing GDMT, explained Tariq Ahmad, MD, MPH, of Yale School of Medicine in New Haven, Connecticut.

Within 30 days of the intervention, 26% of their patients were prescribed at least one more class of GDMT medication, a significant improvement over the 19% increase for non-prompted clinicians (adjusted RR 1.41, 95% CI 1.03-1.93) who were subject to other efforts by Yale-New Haven Health System to improve medical therapy for heart failure during the study period, Ahmad reported at the American College of Cardiology (ACC) meeting. The study was published simultaneously in the (JACC).

"This low-cost intervention can be rapidly integrated into clinical care and accelerate adoption of high-value therapies in heart failure," according to Ahmad's group.

"If you scaled this beyond one health system, you could see even more benefits," predicted ACC discussant Craig Beavers, PharmD, of the University of Kentucky in Lexington.

It's important to look at the EHR-embedded alerts as a tool instead of as a burden, he said at the ACC press conference.

"PROMPT-HF illustrates how trials embedded in healthcare systems can leverage digital health technology to identify, recruit, and randomize participants; deliver interventions; collect outcomes; and use the resulting evidence to inform healthcare processes and improve outcomes iteratively, whilst informing recruitment strategies and interventions for future trials," according to Harriette Van Spall, MD, MPH, of McMaster University in Hamilton, Ontario, Canada, and colleagues in a JACC .

"Whether the effectiveness of the alert system can be sustained over time, whether it diminishes due to alert fatigue, and whether it closes disparities in care between age, gender, and race or ethnicity groups will require further study," they wrote.

GDMT comprises medications proven to reduce hospitalizations and mortality in heart failure. However, it is underutilized in real-world practice; a variety of institutional, clinician, and patient factors are thought to contribute to such therapeutic inertia.

At baseline, PROMPT-HF participants were on beta-blockers in 84% of cases, renin-angiotensin-aldosterone system inhibitors in 71%, mineralocorticoid receptor antagonists in 29%, and SGLT-2 inhibitors in 11%, Ahmad and colleagues reported.

Between alert and no-alert groups, around 6% of patients actually reduced the number of GDMT classes they were on over the course of the study -- a "not insignificant" number that may be related to issues of medication intolerance and cost, suggested ACC past president Mary Norine Walsh, MD, of St. Vincent Heart Center in Indianapolis, at the session.

Ahmad agreed and said his group is in the process of investigating the predictors of GDMT uptake and loss in the trial.

Participants in the cluster-randomized were 100 clinicians -- nurse practitioners, physician assistants, and physicians -- assigned to EHR alerts or usual care. During office visits, they saw 1,310 people with heart failure with reduced ejection fraction (median age 72 years, 31% women, 18% Black).

Patients were well balanced between the two study groups.

Ahmad's group found that it took alerting 14 people to result in prescription of one additional GDMT class. Nearly four in five participating clinicians said that the EHR alert was effective at enabling improved prescription of medical therapy for heart failure, Ahmad said.

The EHR alerts made no difference in patient mortality, emergency department (ED) visits, or hospitalizations via the ED over 30 days. Safety outcomes were also similar between groups.

Limiting the study's generalizability was the fact that it was conducted at a single academic health system using a specific EHR software. Ahmad also acknowledged that uptitration of GDMT dosing was not a primary endpoint, and that follow-up duration should be extended.

The is ongoing and should be completed in a few months, Ahmad said. "There are a lot of alerts" in the inpatient setting, where the issue of alert fatigue is especially important, he said.