Despite the implementation of a real-time warning system, targeted and tailored electronic health record (EHR) for patients with acute heart failure (AHF), the PROMPT-AHF trial did not find a significant increase in overall referral-directed medical therapy (GDMT). ) prescriptions upon discharge from the hospital.
The findings were published in European Heart Journal.
Patients hospitalized for ASZ are at particularly high risk of adverse clinical events and rarely receive an adequate number of GDMT prescriptions at hospital discharge, despite current evidence of their benefits and safety. Instead, it usually occurs during post-discharge care, which can delay or prevent patients from receiving prescriptions for life-saving therapies.
To determine whether an EHR-based alert system would increase the rate of GDMT prescribing at discharge, PROMPT-AHF—a pragmatic, multicenter, randomized clinical trial—automatically enrolled patients 48 hours after hospital admission if they met specific criteria for AHF hospitalization.
These criteria included:
- Be 18 years of age or older
- With N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels > 500 pg/ml
- with left ventricular ejection fraction ≤ 40%
- After administration of intravenous (IV) diuretics within 24 hours of hospital admission
- Do not take any of the 4 classes of GDMTs, including beta-blockers, angiotensin-converting enzyme (ACE-I) inhibitors/angiotensin receptor blockers (ARBs)/angiotensin-neprilysin receptor inhibitors (ARNIs), mineralocorticoid receptor antagonists (MRAs), and sodium-glucose cotransporter inhibitors 2 (SGLT2i)
Patients were excluded if they opted out of EHR-based research, were receiving hospice care, were unable to tolerate oral medication, were currently hospitalized in the intensive care unit, or were receiving IV inotropic agents.
Between May 2021 and November 2022, a total of 1012 patients were included in the study, of which 502 were in the intervention arm and 510 were in the control arm. The median age of participants was 74 years, with 26% female and 24% black. At the time of the alert, 85% of patients were already taking beta-blockers, 55% were on ACE-I/ARB/ARNI, 20% on MRA and 17% on SGLT2is.
In the intervention arm of the study, providers received an alert during order entry that included relevant patient characteristics and individualized GDMT recommendations with links to the order set.
The primary outcome of the study was the increase in the number of GDMT prescribed at discharge. Surprisingly, the results showed that the customized EHR alert system did not significantly affect prescribing, with both alert and no alert groups showing similar rates of GDMT prescribing at discharge (adjusted hazard ratio [RR]0.95; 0.81–1.12, P = 0.99)
However, patients randomized to the emergency arm were more likely to have increased MRA prescribing at discharge (adjusted RR, 1.54; 1.10–2.16; P = 0.01).
At the time of discharge, only 9 (11.2%) study patients were receiving all 4 classes of GDMT, suggesting that comprehensive evidence-based regimens for heart failure were not consistently prescribed.
The underlying reasons for these findings are not entirely clear, but one possible explanation suggested by the authors could be that these patients receive care from multiple health care providers whose primary goal may not be to increase adherence to GDMT during hospitalization with ASZ. This can be attributed to a variety of factors, such as the need to shorten hospital stays, addressing multiple co-morbidities, exposure to multiple EHR alerts, diffusion of responsibility among care providers, and the expectation that optimizing GDMT for chronic disease primarily falls under ambulatory care. According to the authors, these findings are consistent with established psychological concepts such as the bystander effect and the primacy of certain problems over others.
The authors also stated that the phenomenon of “alert fatigue” may be a key cause.
“This is likely due to a largely unregulated increase in alerts being used as clinical decision support tools to implement best practices,” they explained. “Our study highlights the importance of such alerts being studied in a randomized trial before their widespread implementation and with input from leading clinicians to achieve their stated purpose and reduce burnout.”
Overall, PROMPT-AHF showed that GDMT prescribing remains suboptimal at hospital discharge.
“Further refinement and improvement of such alerts and changes in physician incentives are needed to overcome barriers to implementation of GDMT during hospitalizations for AHF,” the study authors concluded.
Ghazi L, Yamamoto Y, Fuery M, et al. Electronic health record alerts for the management of heart failure with reduced ejection fraction in hospitalized patients: the PROMPT-AHF study. Eur Heart J. Published online August 31, 2023. doi:10.1093/eurheartj/ehad512
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