Tariq Ahmad, MD, MPH, associate professor of medicine (cardiovascular medicine) and director of the Yale Heart Failure Program, and his colleagues will present the results of a new study (called PROMPT-HF) at the annual meeting of the American College of Cardiology (ACC) on April 3, 2022.
The trial tested the efficacy of an alert system that allows clinicians to prescribe optimal therapies to heart failure patients during an office visit.
Heart failure is the most common driver of morbidity, mortality, and healthcare expenses in the United States. Current guidelines from the ACC recommend four types of therapy for patients with heart failure with reduced ejection fraction. Yet, despite excellent evidence that these therapies save lives, the vast majority of patients with heart failure are not prescribed these medications.
We talked to Ahmad about the alert and its implications.
Q: What are the current options for treating heart failure?
A: There have been few effective treatments for heart failure until very recently. In the last few decades, several medications have been developed that can quite dramatically reduce the risk of death and hospitalization. These include beta-blockers, ACE-I/ARB/ARNI, MRAs and SGLT2 inhibitors. If you put patients on all four of these medications, the impact on reduction in mortality and rates of hospitalization is very dramatic. Yet when we’ve looked at national data on how many patients who should be on these medications are actually prescribed them it's less than 5%.
Q: Why are patients not getting optimal care if we know what works?
A: There are a few reasons for this. First, the majority of people with heart failure are not even seen by cardiologists, much less heart failure specialists. So, there is a strong possibility that their doctor may be unaware of the guidelines. Second, heart failure patients can seem stable when they are seen in clinic, so there might be no strong nudge to add or change medications.
Third, we still do not have a high degree of accountability for when patients with heart failure are not on optimal medical therapies.
Q: Can you explain how the alert works?
A: We developed a "smart" alert for clinicians. When a patient comes into the clinic, their blood pressure, heart rate, and any medications they are taking are all entered into their electronic health record (EHR).
When the doctor sees them and looks at the information in their EHR, they get a pop-up saying that, based on the patient’s vital signs and history, these are the medications that they should be on. And then you can click on a link that allows you to prescribe those medications right there in the context of a usual clinical visit.
Q: Why was Yale the ideal place to implement this alert system?
A: Yale is one of the largest integrated healthcare systems in the country, and all the hospitals across Yale New Haven Health share the same electronic health record. Our team created a dashboard that's updated every day with details about every single patient with the diagnosis of heart failure within our system. Last I checked, we had about 28,000 patients with a diagnosis of heart failure.
When we looked at what percentage of them were on the right medications, we found that the numbers at Yale and patient characteristics were almost identical to the national registries. So, we believe that what works at Yale should most likely work across the country. We could easily and rapidly scale this electronic intervention to any health system that has an electronic health record, which is now the vast majority of clinics in the United States.
In addition to Ahmad, other Yale contributors on “Electronic Alerts to Improve Heart Failure Therapy in Outpatient Practice: A Cluster Randomized Trial” include Lama Ghazi, MD, PhD; Yu Yamamoto, MS; Ralph J. Riello III, PharmD; Claudia Coronel-Moreno, MPH; Melissa Martin, MA; Kyle D. O’Connor, MS; Michael Simonov, MD; Silvio E. Inzucchi, MD; Eric J. Velazquez, MD; F. Perry Wilson, MD, MSCE; and Nihar R. Desai, MD, MPH, from Yale School of Medicine and Ravi Dhar, PhD, from Yale School of Management. Additional contributors include Joanna Huang, PharmD; Temitope Olufade, PhD, MPH; and James McDermott, PhD from AstraZeneca Wilmington, Del. The study was run out of Yale's Clinical and Translational Research Accelerator (CTRA), which runs multiple trials evaluating clinical decision support and digital health interventions. For more information, visit the CTRA website.