A system of personalized alerts via an electronic health record (EHR) network failed to boost discharge prescriptions for guideline-directed medical therapy (GDMT) for patients hospitalized with heart failure (HF) with reduced ejection fraction in a randomized trial conducted at several centers in the same healthcare system.
The results of the PROMPT-AHF trial, which assigned such patients to have or not have the GDMT-promoting physician nudges as part of their in-hospital management, were “not entirely surprising,” Tariq Ahmad of Yale School of Medicine, New Haven, Connecticut, told theheart.org/Medscape Cardiology.
“We have created an environment in the hospital that makes care quite fractured for patients with heart failure,” he said. “They are cared for by many different clinicians, which leads to well-known behaviors such as diffusion of responsibility.”
Moreover, many clinicians focus on stabilizing patients “rather than starting them on a comprehensive set of medications, which most think should be done after discharge,” Ahmad added.
“Importantly, there has been a logarithmic increase in alerts while patients are hospitalized that has caused clinician burnout and is leading to even very important alerts being ignored.”
Likely as a result, the trial saw no significant difference between the alert and no-alert groups in how often the number of GDMT prescriptions rose by at least one drug class, whether beta blockers, renin-angiotensin system inhibitors, mineralocorticoid receptor antagonists, or SGLT2 inhibitors. That happened for 34% of patients in both groups, reported Ahmad on May 22 at Heart Failure Association of the European Society of Cardiology (HFA-ESC) 2023.
Nor was there a difference in the secondary endpoint of increased number of GDMT meds or escalated dosage of prescribed GDMT drugs.
GDMT “Uncommon” in AHF
In an earlier trial in outpatients with chronic HF, conducted by many of the same researchers, use of a targeted EHR-based alert system was associated with significantly higher rates of GDMT prescriptions 30 days after discharge compared to usual care, Ahmad observed in his presentation.
Because GDMT is similarly “uncommon” among patients hospitalized with acute HF, the team designed the current trial, a test of the hypothesis that a similar system of nudges would lead to higher rates of prescriptions of the four core GDMT drug classes.
The study enrolled 920 adults with acute HF, an EF 40% or lower (their median was 28%), and NT-proBNP levels higher than 500 pg/mL. The patients received IV diuretics for the first 24 in-hospital hours and were not taking medications from any of the four core HF drug classes. Their mean age was 74, 36% were women, and 25% were Blacks.
Physicians of patients who were randomly assigned to the intervention received the alerts as they entered information that involved ejection fraction, blood pressure, potassium levels, heart rate, glomerular filtration rate, and meds they were currently or should be taking, “along with an order set that made ordering those medications very easy,” Ahmad said.
“There was absolutely no evidence that the alert made any difference. There were zero patients on all four classes of GDMT at baseline, and at the time of discharge, only 11.2% of patients were on all four pillars ― essentially, 1 in 9 patients,” Ahmad said. Nor were there any subgroup differences in age, sex, race, ejection fraction, type of health insurance, or whether care was provided by a cardiologist or noncardiologist physician.
The study was limited by having been conducted within a single healthcare network using only the Epic EHR system. The alerts did not go exclusively to cardiologists, and patient preferences were not considered in the analysis. Also, the study’s alerts represented only some of the many that were received by the clinicians during the course of the trial.
Better Incentives Needed
“We believe this shows that refinement of the nudges is needed, as well as changes to clinician incentives to overcome barriers to implementation of GDMT during hospitalizations for AHF,” Ahmad said.
Responding do a post-presentation question on whether the post-discharge phase might be a more effective time to intervene with nudges, Ahmad observed that many clinicians who care for patients in the hospital assume that someone else will have the patient receive appropriate meds after discharge. “But we know that things that are started in the hospital tend to stick better.
“I do think that a lot of the clinicians were thinking, ‘I’m just going to get this patient out and someone in the outside will get them on GDMT.’ ” he said.
In the United States. there are many incentives to reduce hospital length of stay and to expedite discharge so more beds are available for incoming patients, Ahmad observed. “I think it’s a combination of these kinds of perverse incentives that are not allowing us to get patients on appropriate GDMT during hospitalization.”
Furthermore, Ahmad told theheart.org/Medscape Cardiology, “additions to the EHR should be evaluated in an evidence-based manner. However, the opposite has occurred, with an unregulated data tsunami crushing clinicians, which has been bad for both the clinicians and for patients.”
The study was funded by AstraZeneca. Ahmad discloses receiving research funding from and consulting for AstraZeneca; and receiving research funding from Boehringer Ingelheim, Cytokinetics, and Relypsa. Three other co-authors are employees of AstraZeneca.
Heart Failure Association of the European Society of Cardiology (HFA-ESC) 2023. Presented May 22, 2023.
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