Alerts improve the prescription of HF quadruple therapy: PROMPT-HF

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Physicians treating patients with heart failure and reduced ejection fraction (HFrEF) were more likely to prescribe an added drug class, out of the four class-directed medical treatment (GDMT) guidelines, when they were prompted by an alert in a patient’s electronic health record (EHR).

Clinicians treating more than 1000 outpatients with HFrEF in a large healthcare system were randomized to receive EHR prompts or no prompts.

At 30 days, more patients with an EHR alert than without (26% vs. 19%) were prescribed an additional class of GDMT: a beta-blocker; a renin-angiotensin-aldosterone system (RAAS) inhibitor, including an angiotensin-converting enzyme (ACEI) inhibitor, an angiotensin receptor antagonist (ARB), or an angiotensin receptor blocker angiotensin-neprilysin (ARNI); a mineralocorticoid receptor antagonist (MRA); or a sodium-glucose cotransporter-2 (SGLT2i) inhibitor.

Tariq Ahmad, MD, MH, presented these findings from the aptly named PROMPT-HF (Pragmatic Cluster-Randomized Study to Improve the Use of Guideline Directed Medical Therapy in Outpatients with Heart Failure), in one of the trials last-minute clinical session at the American College of Cardiology 2022 scientific session held in Washington, DC, and virtually. The study, with lead author Ghazi Lama, MD, PhD, has also been published online simultaneously in the April 3 times Journal of the American College of Cardiology.

“Four drugs have been shown to significantly improve heart failure outcomes, reduce hospitalizations and extend patient lives,” said Ahmad, of Yale University School of Medicine, New Haven, Connecticut, during the a press briefing after the session. The “HF guidelines just released yesterday show that they have the highest level of recommendation,” he noted.

“However, what we see in practice” is that “less than 5% of patients in the best case scenario are taking the right drugs, and if you look at the right drugs and the right doses, it’s almost less of 1%,” he said.

SGLT2is are the most underutilized of the four recommended drug classes, with the greatest potential to increase absorption.

Results from PROMPT-HF suggest that “this low-cost tool can be quickly integrated with EHRs into integrated healthcare systems and lead to widespread improvements in care for patients with heart failure,” Ahmad concluded.

“Important, Simple”

“It’s simple, beautiful” and “it can work in most settings,” commented Craig Beavers, PharmD, University of Kentucky College of Pharmacy, Lexington, the designated speaker at the press conference.

“It’s exciting to see that you can integrate our EHR and, instead of viewing it as a burden, use it as a tool,” he said.

“This study is really important,” said Mary Norine Walsh, MD, Ascension St. Vincent Heart Center, Indianapolis, the speaker assigned to the session. Therapeutic inertia is “something we see every day”.

“We do not use EPIC” the EHR system used in the trial, Walsh said in an email to lecoeur.org | Medscape Cardiology. “But many other guests of this type are in preparation, and I’m sure they will become more common, regardless of the EHR.”

She asked Ahmad what might explain the finding that a sizable number of patients “recoiled” from more to less of these four drug classes. Researchers are studying this, Ahmad replied, adding that the least prescribed drug class, SGLT2is, is extremely well tolerated.

Walsh further wondered if “warning fatigue” by busy clinicians might account for the lack of uptake. Ahmad noted that 79% of providers alerted agreed the alert was helpful, and anecdotally, several electrophysiologists said the prompts for suggested medications for the specific patient in front of them “guided me through.”

The main finding of the study “is that a personalized, automated system can actually change provider behavior,” said co-author F. Perry Wilson, MD, Yale University School of Medicine, and columnist at Medscape. lecoeur.org | Medscape Cardiology in an email.

The next step, he said, “is to see if this can improve clinical outcomes (like hospitalization or even death rates) in patients with HFrEF.”

test limits

“The test PROMPT-HF demonstrates the effectiveness of aid to integrated EHR decision in optimizing GDMT, Harriette GC Van Spall, MD, MPH, of McMaster University, Hamilton, Ontario, Canada, and his colleagues agree in an accompanying editorial, but they add that “some limitations should be considered.”

They note for example, the study did not report number of clinical encounters. Of the 79% of clinicians who said the alerts were helpful, only 25% implemented the recommendations, 14% reported that patients were not suitable candidates, and the remainder delayed treatment changes (49% %) or ignored the alert (12%). , representing missed opportunities to improve care.

The proportion of patients with an increase in GDMT classes at 30 days was modest, and less than 8% of patients were prescribed all four classes of agents, they write.

Only 9% of patients in the alert group were newly initiated to SGLT2i, despite a very modest initial prescription rate of 11%, and a large majority of patients in both groups did not benefit from changes in the number of GDMT courses. prescribed, according to the editorialists. report.

Outpatients with HFreEF

For the study, researchers randomized the top 100 providers caring for HFrEF patients at outpatient internal medicine and cardiology practices and clinics affiliated with Yale New Haven Health System in 2020.

Fifty providers with 685 patients and 50 providers with 625 similar patients were randomized to alert and non-alert groups.

When a clinician opened the control entry for a patient in the alert group, he saw the last left ventricular ejection fraction (LVEF), blood pressure, heart rate, and serum potassium levels and of creatinine, which are used when considering medications for patients with HF.

If a patient is currently prescribed GDMT in four classes, specific drugs have been posted. Classes missing drugs were highlighted in bold red and the EHR provided direct links to the available drugs in these classes, as well as indications of the Food and Drug Administration of the United States.

The provider could answer a) “I will adjust the medications”, b) “Medical changes not clinically indicated” or c) “Defer for another reason. »

Patients had a mean age of 72 years, 31% were female, and 18% were black, which is similar to the nationally representative CHAMP-HF population.

At baseline, most patients were on beta-blocker (84%) or on ACEi/ARA/ARNI (71%), but less than a third (29%) were on ARM and only 11% were on SGLT2i.

The primary endpoint, an increase in the number of GDMT classes prescribed within 30 days of baseline, occurred in more patients with than without alerts in their EHR (adjusted relative risk [RR], 1.41; 95% CI, 1.03 – 1.93; P = .03).

The number of patients who needed to be alert in their EHR to achieve a class of drugs was added 14.

Dismissal Alert, Obstacles to Adoption

In his blog Trials and Fibrillations with Dr John Mandrola, Mandrola writes about PROMPT-HF, saying “there are just too many [EHR] alerts, and we are too accustomed to ignore. Click on alerts figured prominently in a criminal malpractice case underway at Vanderbilt. ”

It’s “a great point,” Wilson agreed. “These systems need to be rigorously evaluated, ideally in a randomized trial, lest a proliferation of alerts render all alerts obsolete.” If the alerts have no effect, they should be abandoned.

Alert “dismissal” is common, even in PROMPT, Wilson added. “That said, we’ve spoken to providers who dismiss the alert, only to come back later and order the drugs, perhaps because prescribing was not part of their workflow at the moment.”

According to Walsh, clinicians may ignore the prompts for several reasons, including a previous drug intolerance. “The EHR can’t know everything about the patient that the clinician does. »

Wilson identified barriers to adoption as cost, particularly for SGLT-2is, which has no generic equivalents, lack of knowledge, inexperience with some of these agents, and clinical inertia.

“We are often loath to change anything when a patient is well, and such gentle nudges like PROMPT’s could help improve care even among those who are relatively stable,” he said. . “The best we can do here is look at the empirical data. Does the alert increase the use of GDMT? The answer appears to be yes.”

The study was funded by AstraZeneca. Ahmad and Wilson have no relevant financial information. Disclosures by other authors are listed with the publication. Walsh has no relevant financial information. Van Spall is funded by the Institutes of Health and Heart and Stroke Foundation of Canada. Revelations by other columnists are listed with the publication.

American College of Cardiology (ACC) 2022 Annual Scientific Session: Abstract 406-12. Presented April 3, 2022.

J Am Coll Cardiol. Published online April 3, 2022. Summary, Editorial

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