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Shah NN, Ghazi L, Yamamoto Y, Kumar S, Martin M, Simonov M, Riello Iii RJ, Faridi KF, Ahmad T, Wilson FP, Desai NR. Pragmatic Trial of Messaging to Providers About Treatment of Hyperlipidemia (PROMPT-LIPID): A Randomized Clinical Trial. Circ Cardiovasc Qual Outcomes 2024; 17:e010335. [PMID: 38634282 DOI: 10.1161/circoutcomes.123.010335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 02/15/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Lipid-lowering therapy (LLT) is underutilized for very high-risk atherosclerotic cardiovascular disease. PROMPT-LIPID (PRagmatic Trial of Messaging to Providers about Treatment of HyperLIPIDemia) sought to determine whether electronic health record (EHR) alerts improve 90-day LLT intensification in patients with very high-risk atherosclerotic cardiovascular disease. METHODS PROMPT-LIPID was a pragmatic trial in which cardiovascular and internal medicine clinicians within Yale New Haven Health (New Haven, CT) were cluster-randomized to receive an EHR alert with individualized LLT recommendations or no alert for outpatients with very high-risk atherosclerotic cardiovascular disease and LDL-C (low-density lipoprotein cholesterol), ≥70 mg/dL. The primary outcome was 90-day LLT intensification (change to high-intensity statin and addition of ezetimibe or PCSK9i [proprotein subtilisin/kexin type 9 inhibitors]). Secondary outcomes included LDL-C level, proportion of patients with LDL-C of <70 or < 55 mg/dL, rate of major adverse cardiovascular events, ED visit incidence, and 6-month mortality. Results were analyzed using logistic and linear regression clustered at the provider level. RESULTS The no-alert group included 47 clinicians and 1370 patients (median age, 71 years; 50.1% female, median LDL-C, 93 mg/dL); the alert group included 49 clinicians and 1130 patients (median age, 72 years; 47% female, median LDL-C 91, mg/dL). The primary outcome was observed in 14.1% of patients in the alert group as compared with 10.4% in the no-alert group. There were no differences in any secondary outcomes at 6 months. Among 542 patients whose clinicians (n=46) did not dismiss the EHR alert recommendations, LLT intensification was significantly greater (21.2% versus 10.4%, odds ratio, 2.33 [95% CI, 1.48-3.66]). CONCLUSIONS With a real-time, targeted, individualized EHR alert as compared with usual care, the proportion of patients with atherosclerotic cardiovascular disease with LLT intensification was numerically higher but not statistically significant. Among clinicians who did not dismiss the alert, there was a > 2-fold increase in LLT intensification. EHR alerts, coupled with strategies to reduce clinician dismissal, may help address persistent gaps in LDL-C management. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04394715, https://www.clinicaltrials.gov/ct2/show/study/NCT04394715.
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Affiliation(s)
- Nimish N Shah
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (N.N.S., K.F.F., T.A., F.P.W., N.R.D.)
| | - Lama Ghazi
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, AL (L.G.)
| | - Yu Yamamoto
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT (Y.Y., S.K., M.M., M.S., R.J.R., T.A., F.P.W., N.R.D.)
| | - Sanchit Kumar
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT (Y.Y., S.K., M.M., M.S., R.J.R., T.A., F.P.W., N.R.D.)
| | - Melissa Martin
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT (Y.Y., S.K., M.M., M.S., R.J.R., T.A., F.P.W., N.R.D.)
| | - Michael Simonov
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT (Y.Y., S.K., M.M., M.S., R.J.R., T.A., F.P.W., N.R.D.)
| | - Ralph J Riello Iii
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT (Y.Y., S.K., M.M., M.S., R.J.R., T.A., F.P.W., N.R.D.)
| | - Kamil F Faridi
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (N.N.S., K.F.F., T.A., F.P.W., N.R.D.)
| | - Tariq Ahmad
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (N.N.S., K.F.F., T.A., F.P.W., N.R.D.)
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT (Y.Y., S.K., M.M., M.S., R.J.R., T.A., F.P.W., N.R.D.)
| | - F Perry Wilson
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (N.N.S., K.F.F., T.A., F.P.W., N.R.D.)
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT (Y.Y., S.K., M.M., M.S., R.J.R., T.A., F.P.W., N.R.D.)
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (N.N.S., K.F.F., T.A., F.P.W., N.R.D.)
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT (Y.Y., S.K., M.M., M.S., R.J.R., T.A., F.P.W., N.R.D.)
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Martyn T, Saef J, Khot UN, Martinez KA, Brophy TJ, West L, Cristiani C, Block-Beach H, Hohman JA, Sobol T, Brooksbank JA, Surratt MB, Babiuch C, Kapadia SR, Tang WHW, Estep JD, Starling RC. The utilization and impact of cardiovascular specialists on guideline-directed medical scores: An analysis of a diverse, multi-state, electronic health record-based registry. Eur J Heart Fail 2023; 25:2333-2336. [PMID: 37905370 DOI: 10.1002/ejhf.3067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 09/24/2023] [Accepted: 10/13/2023] [Indexed: 11/02/2023] Open
Affiliation(s)
- Trejeeve Martyn
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic, Cleveland, OH, USA
| | - Joshua Saef
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic, Cleveland, OH, USA
| | - Umesh N Khot
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic, Cleveland, OH, USA
| | - Kathryn A Martinez
- Primary Care Institute, Cleveland, OH, USA
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA
| | - Todd J Brophy
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic, Cleveland, OH, USA
| | - Lucianne West
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Cari Cristiani
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | | | - Jessica A Hohman
- Primary Care Institute, Cleveland, OH, USA
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA
| | - Tim Sobol
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic, Cleveland, OH, USA
| | - Jeremy A Brooksbank
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic, Cleveland, OH, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic, Cleveland, OH, USA
| | - Jerry D Estep
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston, FL, USA
| | - Randall C Starling
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic, Cleveland, OH, USA
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Beavers CJ, Jurgens CY. Best Practice: Using Pharmacist- and Nurse-Led Optimization in Heart Failure to Achieve Guideline-directed Medical Therapy Goals. J Card Fail 2023; 29:1014-1016. [PMID: 37236501 DOI: 10.1016/j.cardfail.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 05/18/2023] [Indexed: 05/28/2023]
Affiliation(s)
- Craig J Beavers
- University of Kentucky College of Pharmacy, Lexington, Kentucky.
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Ahmad T, Desai NR, Clark KAA. The EHR Has Exposed an Urgent Moral Imperative to Improve Heart Failure Care. J Am Coll Cardiol 2023; 81:1317-1319. [PMID: 37019577 DOI: 10.1016/j.jacc.2023.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 04/07/2023]
Affiliation(s)
- Tariq Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA.
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Katherine A A Clark
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Brooksbank JA, Faulkenberg KD, Tang WHW, Martyn T. Novel Strategies to Improve Prescription of Guideline-Directed Medical Therapy in Heart Failure. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2023; 25:93-110. [PMID: 37077616 PMCID: PMC10073621 DOI: 10.1007/s11936-023-00979-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2023] [Indexed: 04/07/2023]
Abstract
PURPOSE OF REVIEW To examine the emerging data for novel strategies being studied to improve use and dose titration of guideline-directed medical therapy (GDMT) for patients with heart failure (HF). RECENT FINDINGS There is mounting evidence to employ novel multi-pronged strategies to address HF implementation gaps. SUMMARY Despite high-level randomized evidence and clear national society recommendations, a large gap persists in use and dose titration of guideline-directed medical therapy (GDMT) in patients with heart failure (HF). Accelerating the safe implementation of GDMT has proven to reduce the morbidity and mortality associated with HF but remains an ongoing challenge for patients, clinicians, and health systems. In this review, we examine the emerging data for novel strategies to improve the use of GDMT including the use of multidisciplinary team-based approaches, nontraditional patient encounters, patient messaging/engagement, remote patient monitoring, and electronic health record (EHR)-based clinical alerts. While societal guidelines and implementation studies have focused on heart failure with reduced ejection fraction (HFrEF), expanding indications and evidence for the use of sodium glucose cotransporter2 (SGLT2i) will necessitate implementation efforts across the LVEF spectrum.
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Affiliation(s)
- Jeremy A. Brooksbank
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Euclid Ave, Cleveland, OH USA
| | | | - W. H. Wilson Tang
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Euclid Ave, Cleveland, OH USA
- George M. and Linda H. Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, OH USA
| | - Trejeeve Martyn
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Euclid Ave, Cleveland, OH USA
- George M. and Linda H. Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, OH USA
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Ghazi L, O'Connor K, Yamamoto Y, Fuery M, Sen S, Samsky M, Riello RJ, Huang J, Olufade T, McDermott J, Inzucchi SE, Velazquez EJ, Wilson FP, Desai NR, Ahmad T. Pragmatic trial of messaging to providers about treatment of acute heart failure: The PROMPT-AHF trial. Am Heart J 2023; 257:111-119. [PMID: 36493842 DOI: 10.1016/j.ahj.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/29/2022] [Accepted: 12/01/2022] [Indexed: 05/11/2023]
Abstract
Acute Heart failure (AHF) is among the most frequent causes of hospitalization in the United States, contributing to substantial health care costs, morbidity, and mortality. Inpatient initiation of guideline-directed medical therapy (GDMT) is recommended for patients with heart failure with reduced ejection fraction (HFrEF) to reduce the risk of cardiovascular death or HF hospitalization. However, underutilization of GDMT prior to discharge is pervasive, representing a valuable missed opportunity to optimize evidence-based care. The PRagmatic Trial Of Messaging to Providers about Treatment of Acute Heart Failure tests the effectiveness of an electronic health record embedded clinical decision support system that informs providers during hospital management about indicated but not yet prescribed GDMT for eligible AHF patients with HFrEF. PRagmatic Trial Of Messaging to Providers about Treatment of Acute Heart Failureis an open-label, multicenter, pragmatic randomized controlled trial of 1,012 patients hospitalized with HFrEF. Eligible patients randomized to the intervention group are exposed to a tailored best practice advisory embedded within the electronic health record that alerts providers to prescribe omitted GDMT. The primary outcome is an increase in the proportion of additional GDMT medication classes prescribed at the time of discharge compared to those in the usual care arm.
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Affiliation(s)
- Lama Ghazi
- Clinical and Translational Research Accelerator (CTRA), Yale School of Medicine, New Haven, CT, USA
| | - Kyle O'Connor
- Clinical and Translational Research Accelerator (CTRA), Yale School of Medicine, New Haven, CT, USA
| | - Yu Yamamoto
- Clinical and Translational Research Accelerator (CTRA), Yale School of Medicine, New Haven, CT, USA
| | - Michael Fuery
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Sounok Sen
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Marc Samsky
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Ralph J Riello
- Clinical and Translational Research Accelerator (CTRA), Yale School of Medicine, New Haven, CT, USA
| | | | | | | | - Silvio E Inzucchi
- Section of Endocrine & Metabolism, Yale School of Medicine, New Haven, CT, USA
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Francis Perry Wilson
- Clinical and Translational Research Accelerator (CTRA), Yale School of Medicine, New Haven, CT, USA
| | - Nihar R Desai
- Clinical and Translational Research Accelerator (CTRA), Yale School of Medicine, New Haven, CT, USA; Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Tariq Ahmad
- Clinical and Translational Research Accelerator (CTRA), Yale School of Medicine, New Haven, CT, USA; Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA.
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Shah NN, Ghazi L, Yamamoto Y, Martin M, Simonov M, Riello RJ, Faridi KF, Ahmad T, Wilson FP, Desai NR. Rationale and design of a pragmatic trial aimed at improving treatment of hyperlipidemia in outpatients with very high risk atherosclerotic cardiovascular disease: A pragmatic trial of messaging to providers about treatment of hyperlipidemia (PROMPT-LIPID). Am Heart J 2022; 253:76-85. [PMID: 35841944 PMCID: PMC9936562 DOI: 10.1016/j.ahj.2022.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 05/20/2023]
Abstract
BACKGROUND Despite guideline recommendations to optimize low-density lipoprotein cholesterol (LDL-C) reduction with intensification of lipid-lowering therapy (LLT) in patients with atherosclerotic cardiovascular disease (ASCVD), few of these patients achieve LDL-C < 70 mg/dL in practice. PURPOSE We developed a real-time, targeted electronic health record (EHR) alert with embedded ordering capability to promote intensification of evidence based LLT in outpatients with very high risk ASCVD. METHODS We designed a pragmatic, multicenter, single-blind, cluster randomized trial to test the effectiveness of an EHR-based LLT intensification alert. The study will enroll about 100 providers who will be randomized to either receive the alert or undergo usual care for outpatients with high risk ASCVD with LDL-C > 70 mg/dL. Total enrollment will include 2,500 patients. The primary outcome will be the proportion of patients with LLT intensification at 90 days. Secondary outcomes include achieved LDL-C at 6 months and the proportion of patients with LDL-C < 70 mg/dL or < 55 mg/dL at 6 months. RESULTS Enrollment of 1,250 patients (50% of goal) was reached within 47 days (50% women, mean age 72, median LDL-C 91). At baseline, 71%, 9%, and 3% were on statins, ezetimibe, or proprotein convertase subtilisin/kexin type 9 inhibitors, respectively. CONCLUSIONS PRagmatic Trial of Messaging to Providers about Treatment of HyperLIPIDemia has rapidly reached 50% enrollment of patients with very high risk ASCVD, demonstrating low baseline LLT utilization. This pragmatic, EHR-based trial will determine the effectiveness of a real-time, targeted EHR alert with embedded ordering capability to promote LLT intensification. Findings from this low-cost, widely scalable intervention to improve LDL-C may have important public health implications. TRIAL REGISTRATION clinicaltrials.gov NCT04394715.
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Affiliation(s)
| | - Lama Ghazi
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT
| | - Yu Yamamoto
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT
| | - Melissa Martin
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT
| | - Michael Simonov
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT
| | - Ralph J Riello
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT
| | | | - Tariq Ahmad
- Section of Cardiovascular Medicine, New Haven, CT; Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT
| | - F Perry Wilson
- Section of Cardiovascular Medicine, New Haven, CT; Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT
| | - Nihar R Desai
- Section of Cardiovascular Medicine, New Haven, CT; Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT.
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Ahmad T, Desai NR, Velazquez EJ. SGLT2 Inhibitors Should Be Considered for All Patients With Heart Failure. J Am Coll Cardiol 2022; 80:1311-1313. [PMID: 36041913 DOI: 10.1016/j.jacc.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/04/2022] [Indexed: 10/15/2022]
Affiliation(s)
- Tariq Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA.
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Ghazi L, Yamamoto Y, Riello RJ, Coronel-Moreno C, Martin M, O’Connor KD, Simonov M, Huang J, Olufade T, McDermott J, Dhar R, Inzucchi SE, Velazquez EJ, Wilson FP, Desai NR, Ahmad T. Electronic Alerts to Improve Heart Failure Therapy in Outpatient Practice: A Cluster Randomized Trial. J Am Coll Cardiol 2022; 79:2203-2213. [DOI: 10.1016/j.jacc.2022.03.338] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 10/18/2022]
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