Medical therapy

Personalized digital alert enhances guideline-directed medical therapy for heart failure

According to a study presented at the American College of Cardiology’s 71st Annual scientific session.

The study, which met its primary endpoint of an increase in the number of guideline-directed medical therapy (GDMT) classes prescribed 30 days after randomization, is the first randomized trial to show significant improvements in use of GDMT for heart failure using a low-cost, scalable intervention to prompt clinicians to prescribe recommended medications.

The results were quite remarkable. We were able to dramatically increase the number of guideline-directed medical therapies being used very quickly.”

Tariq Ahmad, MD, head of the Yale Heart Failure Program, Yale School of Medicine and Yale New Haven Health and lead study author

Heart failure is a condition in which the heart muscle becomes too weak to pump blood efficiently. Four types of drugs, when used together, have been shown to significantly improve health outcomes for patients with heart failure with reduced ejection fraction (HFrEF), a type of heart failure in which the heart does not constrict as hard as it should. However, the use of this therapy has remained low despite attempts to improve adherence to guidelines.

“There is a huge gap between our knowledge [on heart failure treatments] and implementing that knowledge,” Ahmad said. “We felt that one of the reasons the earlier trials were negative is that they are not integrated into the usual clinical flow. When a clinician sees a patient, it’s a good time to remind them to put patients on the right medications.”

For the study, the researchers consulted with physicians and partnered with experts in behavioral economics to determine the specific point in the clinical workflow when an alert would be most helpful. They then designed and programmed Yale New Haven Health’s EHR Epic system with the alert, which occurred when clinicians entered follow-up orders after a patient visit. The alert listed the medications and doses prescribed for the patient as well as what they should take based on medical directives. Doctors could then easily adjust the dosage or prescribe additional drugs to fill in the gaps during the same patient visit.

To assess the impact of the alert, the researchers recruited 100 clinicians from the Yale New Haven Health System who were seeing the highest number of patients with HFrEF. Half of the clinicians were instructed to start receiving Epic alerts and the other half were not. The study lasted about seven months, during which enrolled physicians saw 1,310 patients with HFrEF.

After the trial, more than a quarter of patients whose doctors received the alerts saw an increase in the number of medical treatment courses prescribed as directed, a significant improvement over patients whose doctors did not receive alerts (slightly less than 19% of them had an increase in their number of medications). This results in an addition of medication for every 14 alerts received. Patients whose doctors received alerts were also more likely to receive an increase in the dosage of medications they were currently taking. In one evaluation, 80% of participating clinicians said they found the alerts “very helpful.”

The four types of drugs that were studied are beta-blockers, angiotensin converting enzyme (ACEi) inhibitors/angiotensin receptor blockers (ARBs)/ angiotensin-neprilysin (RNAi) receptor blockers, mineralocorticoid receptor antagonists (MRAs) and sodium-glucose cotransporter-2 (SGLT2i) blockers. These drugs, known collectively as the four pillars of heart failure treatment, have been shown to be complementary effective in improving survival and quality of life for patients with HFrEF.

Although the study did not assess clinical health outcomes, the researchers said increased use of guideline-compliant medications is very likely to lead to direct health improvements.

“Anything that increases the use of these drugs and the dosage of these drugs has definitely been shown to improve medical outcomes,” Ahmad said. “I have no doubt that if you could do this on a larger scale, it would lead to dramatic improvements in patient survival and reduced hospitalizations.”

Ahmad said the trial took place at the same time as a broader effort to encourage adherence to heart failure treatment guidelines throughout the healthcare system. He suggested that the relative impact of implementing EHR alerts could be even greater in the absence of such an effort.

The researchers plan to make the alert system code available to all health systems that want to use it. Noting that the Yale New Haven Health System serves a patient population with a similar demographic profile to the United States as a whole and that the Epic EHR system is the most common EHR system in the country, Ahmad said that Study results should be generalizable and feasible for other health care. systems to be implemented on a large scale.

“Any facility or practice that has Epic would be able to do this very easily,” Ahmad said. “If we could implement this across the country, we could very quickly improve the use of these life-saving therapies.”

This study was simultaneously published online in the Journal of the American College of Cardiology at the time of presentation. The study was funded by AstraZeneca.

Ahmad will be available to the media at a press conference on Sunday, April 3 at 11:15 a.m. ET / 3:15 p.m. UTC in room 103AB.

Ahmad will present the study, “A Cluster-RandomizedPRagmatic Trial Aimed to ImprOving Use of Guideline DirectedMedical Therapy in OutPatienTs withHeartFailure:PROMPT-HF,” on Sunday, April 3 at 9:45 a.m. ET/1:45 p.m. UTC in the Main Tent, Room D.


American College of Cardiology