Cluster-Randomized Trial Comparing Ambulatory Decision Support Tools to Improve Heart Failure Care

Area of Science:

• Cardiology
• Health Informatics
• Clinical Trial Research

Background:

• Mineralocorticoid receptor antagonists (MRAs) are crucial for treating heart failure with reduced ejection fraction (HFrEF) but are frequently underprescribed.
• Addressing the underprescription of MRAs in HFrEF is essential for improving patient outcomes.

Purpose of the Study:

• To evaluate the effectiveness of two automated, electronic health record (EHR)-embedded tools in increasing MRA prescribing for eligible HFrEF patients.
• To compare the impact of an EHR alert system versus a patient messaging system against usual care on MRA prescription rates.

Main Methods:

• A pragmatic, cluster-randomized trial (BETTER CARE-HF) involving 2,211 adult patients with HFrEF across a large health system.
• Three arms were compared: an EHR-embedded alert during patient encounters, a message about multiple patients between encounters, and usual care (control).
• Patients were cluster-randomized by cardiologist, with 60 cardiologists per arm.

Main Results:

• New MRA prescriptions were initiated in 29.6% of patients in the alert arm, 15.6% in the message arm, and 11.7% in the control arm.
• The EHR alert significantly increased MRA prescribing compared to usual care (relative risk: 2.53) and the message system (relative risk: 1.67).
• The number needed to treat with the alert to achieve one additional MRA prescription was 5.6.

Conclusions:

• Automated, patient-specific EHR-embedded alerts are effective in increasing MRA prescribing for HFrEF.
• These findings demonstrate the significant potential of EHR-integrated tools to enhance the uptake of guideline-directed medical therapies for heart failure.
• The BETTER CARE-HF trial provides evidence for implementing technology to improve cardiovascular care.