Ghazi Lama, Yamamoto Yu, Fuery Michael, O'Connor Kyle, Sen Sounok, Samsky Marc, Riello Ralph J, Dhar Ravi, Huang Joanna, Olufade Temitope, McDermott James, Inzucchi Silvio E, Velazquez Eric J, Wilson Francis Perry, Desai Nihar R, Ahmad Tariq
School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA.
Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA.
Eur Heart J. 2023 Oct 21;44(40):4233-4242. doi: 10.1093/eurheartj/ehad512.
Patients hospitalized for acute heart failure (AHF) continue to be discharged on an inadequate number of guideline-directed medical therapies (GDMT) despite evidence that inpatient initiation is beneficial. This study aimed to examine whether a tailored electronic health record (EHR) alert increased rates of GDMT prescription at discharge in eligible patients hospitalized for AHF.
Pragmatic trial of messaging to providers about treatment of acute heart failure (PROMPT-AHF) was a pragmatic, multicenter, EHR-based, and randomized clinical trial. Patients were automatically enrolled 48 h after admission if they met pre-specified criteria for an AHF hospitalization. Providers of patients in the intervention arm received an alert during order entry with relevant patient characteristics along with individualized GDMT recommendations with links to an order set. The primary outcome was an increase in the number of GDMT prescriptions at discharge.
Thousand and twelve patients were enrolled between May 2021 and November 2022. The median age was 74 years; 26% were female, and 24% were Black. At the time of the alert, 85% of patients were on β-blockers, 55% on angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, 20% on mineralocorticoid receptor antagonist (MRA) and 17% on sodium-glucose cotransporter 2 inhibitor. The primary outcome occurred in 34% of both the alert and no alert groups [adjusted risk ratio (RR): 0.95 (0.81, 1.12), P = .99]. Patients randomized to the alert arm were more likely to have an increase in MRA [adjusted RR: 1.54 (1.10, 2.16), P = .01]. At the time of discharge, 11.2% of patients were on all four pillars of GDMT.
A real-time, targeted, and tailored EHR-based alert system for AHF did not lead to a higher number of overall GDMT prescriptions at discharge. Further refinement and improvement of such alerts and changes to clinician incentives are needed to overcome barriers to the implementation of GDMT during hospitalizations for AHF. GDMT remains suboptimal in this setting, with only one in nine patients being discharged on a comprehensive evidence-based regimen for heart failure.
尽管有证据表明住院期间启动指南指导的药物治疗（GDMT）有益，但因急性心力衰竭（AHF）住院的患者出院时接受的GDMT数量仍然不足。本研究旨在探讨定制的电子健康记录（EHR）警报是否能提高因AHF住院的符合条件患者出院时GDMT的处方率。
急性心力衰竭治疗向提供者发送信息的实用试验（PROMPT-AHF）是一项实用、多中心、基于EHR的随机临床试验。如果患者符合AHF住院的预先指定标准，将在入院后48小时自动入组。干预组患者的提供者在医嘱录入时收到警报，其中包含相关患者特征以及个性化的GDMT建议，并带有指向医嘱集的链接。主要结局是出院时GDMT处方数量的增加。
2021年5月至2022年11月期间共纳入1012例患者。中位年龄为74岁；26%为女性，24%为黑人。在发出警报时，85%的患者正在使用β受体阻滞剂，55%正在使用血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂/血管紧张素受体脑啡肽酶抑制剂，20%正在使用盐皮质激素受体拮抗剂（MRA），17%正在使用钠-葡萄糖协同转运蛋白2抑制剂。警报组和无警报组中均有34%出现主要结局[调整风险比（RR）：0.95（0.81，1.12），P = 0.99]。随机分配到警报组的患者更有可能增加MRA的使用[调整RR：1.54（1.10，2.16），P = 0.01]。出院时，11.2%的患者使用了GDMT的所有四个支柱药物。
基于EHR的针对AHF的实时、有针对性且定制的警报系统并未导致出院时总体GDMT处方数量增加。需要进一步完善和改进此类警报，并改变临床医生的激励措施，以克服AHF住院期间实施GDMT的障碍。在这种情况下，GDMT仍然不理想，只有九分之一的患者出院时接受了基于循证的全面心力衰竭治疗方案。
