Electronic health record alerts for management of heart failure with reduced ejection fraction in hospitalized patients: the PROMPT-AHF trial

Background and Aims 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.Methods 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.Results 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 & beta;-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.Conclusions 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. Structured Graphical Abstract Electronic Health Record-Based Alerting Did Not Lead to Significantly Higher Rates of Guideline-Directed Medical Therapy in Patients Hospitalized for Acute Heart Failure PROMPT-AHF (pragmatic trial of messaging to providers about the treatment of acute heart failure) was a pragmatic, multicenter, electronic health record-based, and cluster-randomized comparative effectiveness trial. A total of 1012 patients with heart failure with reduced ejection fraction were randomized to either a best practice alert exposure or usual care. The alert notified providers of guideline-directed medical therapy (GDMT) recommendations individualized to their patients with heart failure with reduced ejection fraction who were not receiving all recommended medication classes and displayed key patient characteristics. The study found equivalent increases in the addition of GDMT medication classes added to both the alert arm and usual care arms (34% in both; P = .99). There was a significant increase in the prescription of MRA [adjusted RR: 1.54 (1.10, 2.16), P = .01) in the alert arm. Further refinement and improvement of such alerts are needed that can overcome barriers to the implementation of GDMT during hospitalizations for acute heart failure.