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Mukhopadhyay A, Reynolds HR, King WC, Phillips LM, Nagler AR, Szerencsy A, Saxena A, Klapheke N, Katz SD, Horwitz LI, Blecker S. Impact of Visit Volume on the Effectiveness of Electronic Tools to Improve Heart Failure Care. JACC. HEART FAILURE 2024; 12:665-674. [PMID: 38043045 DOI: 10.1016/j.jchf.2023.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/06/2023] [Accepted: 11/08/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND Electronic health record (EHR) tools can improve prescribing of guideline-recommended therapies for heart failure with reduced ejection fraction (HFrEF), but their effectiveness may vary by physician workload. OBJECTIVES This paper aims to assess whether physician workload modifies the effectiveness of EHR tools for HFrEF. METHODS This was a prespecified subgroup analysis of the BETTER CARE-HF (Building Electronic Tools to Enhance and Reinforce Cardiovascular Recommendations for Heart Failure) cluster-randomized trial, which compared effectiveness of an alert vs message vs usual care on prescribing of mineralocorticoid antagonists (MRAs). The trial included adults with HFrEF seen in cardiology offices who were eligible for and not prescribed MRAs. Visit volume was defined at the cardiologist-level as number of visits per 6-month study period (high = upper tertile vs non-high = remaining). Analysis at the patient-level used likelihood ratio test for interaction with log-binomial models. RESULTS Among 2,211 patients seen by 174 cardiologists, 932 (42.2%) were seen by high-volume cardiologists (median: 1,853; Q1-Q3: 1,637-2,225 visits/6 mo; and median: 10; Q1-Q3: 9-12 visits/half-day). MRA was prescribed to 5.5% in the high-volume vs 14.8% in the non-high-volume groups in the usual care arm, 10.3% vs 19.6% in the message arm, and 31.2% vs 28.2% in the alert arm, respectively. Visit volume modified treatment effect (P for interaction = 0.02) such that the alert was more effective in the high-volume group (relative risk: 5.16; 95% CI: 2.57-10.4) than the non-high-volume group (relative risk: 1.93; 95% CI: 1.29-2.90). CONCLUSIONS An EHR-embedded alert increased prescribing by >5-fold among patients seen by high-volume cardiologists. Our findings support use of EHR alerts, especially in busy practice settings. (Building Electronic Tools to Enhance and Reinforce Cardiovascular Recommendations for Heart Failure [BETTER CARE-HF]; NCT05275920).
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Affiliation(s)
- Amrita Mukhopadhyay
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA.
| | - Harmony R Reynolds
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - William C King
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Lawrence M Phillips
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Arielle R Nagler
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York, USA
| | - Adam Szerencsy
- Medical Center Information Technology, New York University Langone Health, New York, New York, USA; Division of Hospital Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Archana Saxena
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA; Medical Center Information Technology, New York University Langone Health, New York, New York, USA
| | - Nathan Klapheke
- Medical Center Information Technology, New York University Langone Health, New York, New York, USA
| | - Stuart D Katz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Leora I Horwitz
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA; Division of Hospital Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Saul Blecker
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA; Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
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Benimetskaya KS, Provatorov SI, Ezhov MV, Krivosheev YS, Gavrilko AD, Uranov AE, Mikheenko IL, Kovalev EA, Ponomarenko AV, Shangina AM, Efremova YE, Kolmakova TE, Matveeva MA, Dolgusheva YA, Alekseeva IA, Osokina AK, Nozadze DN, Atyunina IV, Paleev FN, Meshkova MA, Sharapova YA, Losik DV. Retrospective Analysis of Lipid-Lowering and Antiplatelet Therapy Regimen by Clinical Decision Support Service Based on Real-World Data from Electronic Medical Records "Intellect 3 Study". KARDIOLOGIIA 2023; 63:46-56. [PMID: 38088112 DOI: 10.18087/cardio.2023.11.n2555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 07/31/2023] [Indexed: 12/18/2023]
Abstract
Aim To evaluate prescription of lipid-lowering and antithrombotic therapy in clinical practice and to compare differences in recommendations using the clinical decision support service (CDSS).Material and methods Electronic medical records (EMR) of 300 patients from the Chazov National Medical Research Center of Cardiology, as well as from medical organizations controlled by the Department of Health of the Lipetsk Region and the Ministry of Health of the Voronezh Region, were analyzed for the period of August - December 2022, during the pilot implementation of CDSS. Retrospective information about the prescription of lipid-lowering and antithrombotic therapy from the EMR was compared with the CDSS guidelines under the expert supervision based on digitized clinical and laboratory profiles of patients. The study primary endpoint was a change in the initially prescribed lipid-lowering and / or antithrombotic therapy as per CDSS guidelines.Results Overall 292 patients were included in the final analysis; 46 (15.7 %) were from the primary prevention group and 246 (84.3 %) from the secondary prevention group. In group 1, the lipid-lowering therapy recommended by the CDSS differed by 50 % (p<0.001) from the baseline therapy recorded in the EMR. In the secondary prevention group, 78.9 % (p<0.001) differences were found in the lipid-lowering therapy recommended in the CDSS guidelines compared to the prescriptions in the EMR. In 76.8 % (p<0.001) of patients, antithrombotic therapy was significantly different from the baseline therapy in the EMR.Conclusion The use of CDSS may improve the practice of choosing lipid-lowering and antithrombotic therapy for prevention of cardiovascular complications.
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Affiliation(s)
- K S Benimetskaya
- Zelman Institute of Medicine and Psychology, Novosibirsk State University, Novosibirsk
| | - S I Provatorov
- Chazov National Medical Research Center of Cardiology, Moscow
| | - M V Ezhov
- Chazov National Medical Research Center of Cardiology, Moscow
| | | | | | - A E Uranov
- Scientific group of ООО "MedicBook", Novosibirsk
| | | | - E A Kovalev
- Scientific group of ООО "MedicBook", Novosibirsk
| | | | - A M Shangina
- Chazov National Medical Research Center of Cardiology, Moscow
| | - Yu E Efremova
- Chazov National Medical Research Center of Cardiology, Moscow
| | - T E Kolmakova
- Chazov National Medical Research Center of Cardiology, Moscow
| | - M A Matveeva
- Chazov National Medical Research Center of Cardiology, Moscow
| | - Yu A Dolgusheva
- Chazov National Medical Research Center of Cardiology, Moscow
| | - I A Alekseeva
- Chazov National Medical Research Center of Cardiology, Moscow
| | - A K Osokina
- Chazov National Medical Research Center of Cardiology, Moscow
| | - D N Nozadze
- Chazov National Medical Research Center of Cardiology, Moscow
| | - I V Atyunina
- Chazov National Medical Research Center of Cardiology, Moscow
| | - F N Paleev
- Chazov National Medical Research Center of Cardiology, Moscow
| | | | | | - D V Losik
- Scientific group of LLC "MedicBook", Novosibirsk
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Mukhopadhyay A, Reynolds HR, Phillips LM, Nagler AR, King WC, Szerencsy A, Saxena A, Aminian R, Klapheke N, Horwitz LI, Katz SD, Blecker S. Cluster-Randomized Trial Comparing Ambulatory Decision Support Tools to Improve Heart Failure Care. J Am Coll Cardiol 2023; 81:1303-1316. [PMID: 36882134 PMCID: PMC10807493 DOI: 10.1016/j.jacc.2023.02.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/06/2023] [Accepted: 02/06/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Mineralocorticoid receptor antagonists (MRAs) are underprescribed for patients with heart failure with reduced ejection fraction (HFrEF). OBJECTIVES This study sought to compare effectiveness of 2 automated, electronic health record-embedded tools vs usual care on MRA prescribing in eligible patients with HFrEF. METHODS BETTER CARE-HF (Building Electronic Tools to Enhance and Reinforce Cardiovascular Recommendations for Heart Failure) was a 3-arm, pragmatic, cluster-randomized trial comparing the effectiveness of an alert during individual patient encounters vs a message about multiple patients between encounters vs usual care on MRA prescribing. This study included adult patients with HFrEF, no active MRA prescription, no contraindication to MRAs, and an outpatient cardiologist in a large health system. Patients were cluster-randomized by cardiologist (60 per arm). RESULTS The study included 2,211 patients (alert: 755, message: 812, usual care [control]: 644), with average age 72.2 years, average ejection fraction 33%, who were predominantly male (71.4%) and White (68.9%). New MRA prescribing occurred in 29.6% of patients in the alert arm, 15.6% in the message arm, and 11.7% in the control arm. The alert more than doubled MRA prescribing compared to usual care (relative risk: 2.53; 95% CI: 1.77-3.62; P < 0.0001) and improved MRA prescribing compared to the message (relative risk: 1.67; 95% CI: 1.21-2.29; P = 0.002). The number of patients with alert needed to result in an additional MRA prescription was 5.6. CONCLUSIONS An automated, patient-specific, electronic health record-embedded alert increased MRA prescribing compared to both a message and usual care. These findings highlight the potential for electronic health record-embedded tools to substantially increase prescription of life-saving therapies for HFrEF. (Building Electronic Tools to Enhance and Reinforce Cardiovascular Recommendations-Heart Failure [BETTER CARE-HF]; NCT05275920).
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Affiliation(s)
- Amrita Mukhopadhyay
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Harmony R. Reynolds
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Lawrence M. Phillips
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Arielle R. Nagler
- Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York, USA
| | - William C. King
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Adam Szerencsy
- Medical Center Information Technology, New York University Langone Health, New York, New York, USA
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Archana Saxena
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
- Medical Center Information Technology, New York University Langone Health, New York, New York, USA
| | - Rod Aminian
- Medical Center Information Technology, New York University Langone Health, New York, New York, USA
| | - Nathan Klapheke
- Medical Center Information Technology, New York University Langone Health, New York, New York, USA
| | - Leora I. Horwitz
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Stuart D. Katz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Saul Blecker
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
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