Leveraging Implementation Science to Improve Prescription of Guideline-Based Therapies

Presented at the 2023 American College of Cardiology Scientific Sessions, the Building Electronic Tools to Enhance and Reinforce CArdiovascular REcommendations for Heart Failure (BETTER CARE-HF) trial found that automated electronic health record (EHR)-embedded alerts increased prescription rates of mineralocorticoid receptor antagonists versus a message or usual care.

Guideline-directed medical therapy (GDMT) comprises four classes of medications recommended by professional societies for the management of heart failure, including mineralocorticoid receptor antagonists (MRAs). However, despite robust evidence of life saving benefit in patients with reduced ejection fraction heart failure, MRAs remain disproportionately underutilized. Methods to improve implementation remains an area of active investigation, with clinical decision support (CDS) tools being one such intervention under study.

In this pragmatic, cluster-randomized three-arm trial, Dr. Amrita Mukhopadhyay and colleagues from NYU School of Medicine cluster randomized 2,211 patients at the level of the cardiologist (N = 60 per arm) to receive EHR-based alerts during individual patient encounters, messages about several patients between encounters, or usual care. They included patients with HFrEF, no active MRA prescription, no contraindication to MRA use, and an outpatient cardiologist in the larger health system. The primary outcome was the proportion of patients in each arm prescribed MRA at the end of the study period.

The BETTER CARE-HF trial included 2,211 patients in total which were predominantly older White men with HFrEF (average age 72.2 years, average LVEF 33%, 71.4% male, 68.9% White). Overall the intervention was effective with rates of MRA newly prescribed in 29.6%, 15.6%, and 11.7% of patients in the EHR alert arm, message arm, and control arm, respectively, with a calculated number needed to alert of 5.6 for each additional MRA prescription compared to usual care. The secondary outcome of percent of patients prescribed non-MRA GDMT showed no difference between arms. EHR-embedded clinical decision support alert tools may be a cost-effective, rapidly scalable, high-value option to increase prescription of GDMT pharmacotherapy for patients with HFrEF.

This study has several caveats to bear in mind. Given its single-center design requiring patients to already be established with providers prior to enrollment, results should be interpreted with caution for patients without established cardiovascular care. BETTER CARE-HF also enrolled predominantly White males, leaving opportunity for future studies to identify optimal implementation strategies across more diverse populations. MRA prescription rates remained below 30% in all arms of the study, highlighting the overall low prescription rates in patients even after EHR-embedded alerts.

“It is crucial that we deploy strategies to overcome inertia in use and dosing of GDMT. This is an important study that utilizes clinical decision support systems within the electronic health record to prompt clinicians to prescribe MRAs,” commented Dr. Bhavadharini Ramu, an ACC panelist and cardiologist from the Medical University of South Carolina.

Dr. Saahil Jumkhawala is a resident at Rutgers New Jersey Medical School and served as a CardioNerds Conference Scholar for the American College of Cardiology 2023 Scientific Sessions.

References:

Mukhopadhyay, A., Reynolds, H. R., Phillips, L. M., Nagler, A. R., King, W. C., Szerencsy, A., … & Blecker, S. (2023). Cluster-Randomized Trial Comparing Ambulatory Decision Support Tools to Improve Heart Failure Care. Journal of the American College of Cardiology.