PROMPT-HF Studies Customized Alert in EHR for Improved Guideline Adherence for HF Treatment

April 3, 2022—The American College of Cardiology (ACC) announced that findings from the PROMPT-HF trial were presented at the ACC.22 annual meeting held April 2-4 in Washington, DC, and simultaneously published by Lama Ghazi, MD, et al in the Journal of the American College of Cardiology (JACC).

As reported in the ACC press release, the findings suggest, "Targeted and tailored clinical decision support prompts in the electronic health record (EHR) can accelerate adoption of underutilized therapies for patients with heart failure (HF)."

According to ACC, the cluster randomized trial enrolled 100 clinicians in the Yale New Haven Health system who were seeing the greatest number of patients with HF with reduced ejection fraction (HFrEF). Half of the clinicians were assigned to begin receiving customized alerts for the Yale New Haven Epic EHR system, while the other half were not.

The alert was programmed and developed based on consultations with clinicians and behavioral economics experts and occurred when clinicians were inputting follow-up orders after a patient visit. It listed the medications and doses patients had been prescribed along with what they should be taking based on guideline-directed medical therapy (GDMT) for beta blockers, ACE inhibitors/ARBs/angiotensin receptor-neprilysin inhibitors, mineralocorticoid receptor antagonist medications and SGLT2 inhibitors. Clinicians were able to adjust dosing or prescribe additional medications during the same patient visit.

As noted in the ACC press release, the study met its primary endpoint of an increase in GDMT prescribed at 30 days post randomization. Additionally, the investigators stated that it is the first to show significant improvements in the use of GDMT for HF using a low-cost, scalable intervention to prompt clinicians to prescribe recommended medications.

Over the course of approximately 7 months, clinicians saw 1,310 patients with HFrEF. At the end of the trial period, 26% of patients whose clinicians received the alerts had an increase in the number of prescribed GDMT compared with 19% of those patients whose physicians did not receive alerts (P = .03). Patients in the clinician alert group were also more likely to receive an increase in the dosage for medications they were currently taking.

"The results were quite remarkable," commented Tariq Ahmad, MD, in the ACC press release. "We were able to dramatically increase the number of guideline-directed medical therapies used in a very rapid fashion." Dr. Ahmad, who is the study's lead investigator, is Chief of the Yale Heart Failure Program at Yale School of Medicine and Yale New Haven Health in New Haven, Connecticut.

The ACC press release further reported that in an evaluation, 80% of participating clinicians reported finding the alerts to be "very helpful." Although the trial did not assess clinical health outcomes, investigators said that increasing the use of GDMT is highly likely to lead to direct health improvements.

Dr. Ahmad and colleagues noted that further research is needed to compare the improvements in care achieved through electronic record alerts in various patient populations based on socioeconomic, racial and ethnic demographics, types and severity of HF, and other relevant clinical variables.

"There is a huge gap between our knowledge [on HF treatments] and the implementation of this knowledge," said Dr. Ahmad said. "We felt that one of the reasons why past trials have been negative is that they're not integrated into the usual clinical flow. When a clinician is seeing a patient, that is an opportune time to remind them to put patients on the right medications. 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."

In a related editorial comment in JACC, Harriette G.C. Van Spall, MD, Gregg C. Fonarow, MD, and Mamas A. Mamas, MBBCh, advised, "PROMPT-HF illustrates how trials embedded in health care systems can leverage digital health technology to identify, recruit, and randomize participants; deliver interventions; collect outcomes; and use the resulting evidence to inform health care processes and improve outcomes iteratively, whilst informing recruitment strategies and interventions for future trials. This culture of continuous knowledge generation and implementation, in which interventions are seamlessly embedded in the care process and new knowledge is used to guide future care, may finally prompt improvements in HF care."