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

Mukhopadhyay, Amrita; Reynolds, Harmony R; Phillips, Lawrence M; Nagler, Arielle R; King, William C; Szerencsy, Adam; Saxena, Archana; Aminian, Rod; Klapheke, Nathan; Horwitz, Leora I; Katz, Stuart D; Blecker, Saul
BACKGROUND:Mineralocorticoid receptor antagonists (MRA) are under-prescribed for patients with heart failure with reduced ejection fraction (HFrEF). OBJECTIVE:To compare effectiveness of two automated, electronic health record (EHR)-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 three-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. We included adult patients with HFrEF, no active MRA prescription, no contraindication to MRA, 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 EF 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 control (RR: 2.53, 95% CI: 1.77-3.62, p<0.0001), and improved MRA prescribing compared to the message (RR: 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, EHR-embedded alert increased MRA prescribing compared to both a message and usual care. Our findings highlight the potential for EHR-embedded tools to substantially increase prescription of life-saving therapies for HFrEF. (NCT05275920).
PMID: 36882134
ISSN: 1558-3597
CID: 5430312

Design and pilot implementation for the BETTER CARE-HF trial: A pragmatic cluster-randomized controlled trial comparing two targeted approaches to ambulatory clinical decision support for cardiologists

Mukhopadhyay, Amrita; Reynolds, Harmony R; Xia, Yuhe; Phillips, Lawrence M; Aminian, Rod; Diah, Ruth-Ann; Nagler, Arielle R; Szerencsy, Adam; Saxena, Archana; Horwitz, Leora I; Katz, Stuart D; Blecker, Saul
BACKGROUND:Beart failure with reduced ejection fraction (HFrEF) is a leading cause of morbidity and mortality. However, shortfalls in prescribing of proven therapies, particularly mineralocorticoid receptor antagonist (MRA) therapy, account for several thousand preventable deaths per year nationwide. Electronic clinical decision support (CDS) is a potential low-cost and scalable solution to improve prescribing of therapies. However, the optimal timing and format of CDS tools is unknown. METHODS AND RESULTS/RESULTS:We developed two targeted CDS tools to inform cardiologists of gaps in MRA therapy for patients with HFrEF and without contraindication to MRA therapy: (1) an alert that notifies cardiologists at the time of patient visit, and (2) an automated electronic message that allows for review between visits. We designed these tools using an established CDS framework and findings from semistructured interviews with cardiologists. We then pilot tested both CDS tools (n = 596 patients) and further enhanced them based on additional semistructured interviews (n = 11 cardiologists). The message was modified to reduce the number of patients listed, include future visits, and list date of next visit. The alert was modified to improve noticeability, reduce extraneous information on guidelines, and include key information on contraindications. CONCLUSIONS:The BETTER CARE-HF (Building Electronic Tools to Enhance and Reinforce CArdiovascular REcommendations for Heart Failure) trial aims to compare the effectiveness of the alert vs. the automated message vs. usual care on the primary outcome of MRA prescribing. To our knowledge, no study has directly compared the efficacy of these two different types of electronic CDS interventions. If effective, our findings can be rapidly disseminated to improve morbidity and mortality for patients with HFrEF, and can also inform the development of future CDS interventions for other disease states. (Trial registration: NCT05275920).
PMID: 36640860
ISSN: 1097-6744
CID: 5403312

Missed opportunities in medical therapy for patients with heart failure in an electronically-identified cohort

Mukhopadhyay, Amrita; Reynolds, Harmony R; Nagler, Arielle R; Phillips, Lawrence M; Horwitz, Leora I; Katz, Stuart D; Blecker, Saul
BACKGROUND:National registries reveal significant gaps in medical therapy for patients with heart failure and reduced ejection fraction (HFrEF), but may not accurately (or fully) characterize the population eligible for therapy. OBJECTIVE:We developed an automated, electronic health record-based algorithm to identify HFrEF patients eligible for evidence-based therapy, and extracted treatment data to assess gaps in therapy in a large, diverse health system. METHODS:In this cross-sectional study of all NYU Langone Health outpatients with EF ≤ 40% on echocardiogram and an outpatient visit from 3/1/2019 to 2/29/2020, we assessed prescription of the following therapies: beta-blocker (BB), angiotensin converting enzyme inhibitor (ACE-I)/angiotensin receptor blocker (ARB)/angiotensin receptor neprilysin inhibitor (ARNI), and mineralocorticoid receptor antagonist (MRA). Our algorithm accounted for contraindications such as medication allergy, bradycardia, hypotension, renal dysfunction, and hyperkalemia. RESULTS:We electronically identified 2732 patients meeting inclusion criteria. Among those eligible for each medication class, 84.8% and 79.7% were appropriately prescribed BB and ACE-I/ARB/ARNI, respectively, while only 23.9% and 22.7% were appropriately prescribed MRA and ARNI, respectively. In adjusted models, younger age, cardiology visit and lower EF were associated with increased prescribing of medications. Private insurance and Medicaid were associated with increased prescribing of ARNI (OR = 1.40, 95% CI = 1.02-2.00; and OR = 1.70, 95% CI = 1.07-2.67). CONCLUSIONS:We observed substantial shortfalls in prescribing of MRA and ARNI therapy to ambulatory HFrEF patients. Subspecialty care setting, and Medicaid insurance were associated with higher rates of ARNI prescribing. Further studies are warranted to prospectively evaluate provider- and policy-level interventions to improve prescribing of these evidence-based therapies.
PMID: 35927632
ISSN: 1471-2261
CID: 5285842

Update on guidance and best practices for nuclear cardiology laboratories during the coronavirus disease 2019 (COVID-19) pandemic: Emphasis on transition to chronic endemic state. An information statement from ASNC, IAEA, and SNMMI

Thompson, Randall C; Phillips, Lawrence M; Dilsizian, Vasken; Gutierrez, Diana Paez; Einstein, Andrew J; Crews, Suzanne F; Skali, Hicham; Jih, Felix Keng Yung; Dondi, Maurizio; Gimelli, Alessia; Bateman, Timothy M; Al-Mallah, Mouaz H; Ghesani, Munir; Dorbala, Sharmila; Calnon, Dennis A
PMID: 35499661
ISSN: 1532-6551
CID: 5215892

Is cost-effectiveness the "tie-breaker" when deciding between anatomic and functional evaluation in stable ischemic heart disease? [Editorial]

Riedy, Katherine; Phillips, Lawrence
PMID: 33754303
ISSN: 1532-6551
CID: 4836682

Implications of the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Chest Pain Guideline for Cardiovascular Imaging: A Multisociety Viewpoint [Editorial]

Blankstein, Ron; Shaw, Leslee J; Gulati, Martha; Atalay, Michael K; Bax, Jeroen; Calnon, Dennis A; Dyke, Christopher K; Ferencik, Maros; Heitner, Jonathan F; Henry, Timothy D; Hung, Judy; Knuuti, Juhani; Lindner, Jonathan R; Phillips, Lawrence M; Raman, Subha V; Rao, Sunil V; Rybicki, Frank J; Saraste, Antti; Stainback, Raymond F; Thompson, Randall C; Williamson, Eric; Nieman, Koen; Tremmel, Jennifer A; Woodard, Pamela K; Di Carli, Marcelo F; Chandrashekhar, Y S
PMID: 35512960
ISSN: 1876-7591
CID: 5213902

ASNC's thoughts on the AHA/ACC chest pain guidelines [Editorial]

Thompson, Randall C; Al-Mallah, Mouaz H; Beanlands, Rob S B; Calnon, Dennis A; Dorbala, Sharmila; Phillips, Lawrence M; Polk, Donna M; Soman, Prem
PMID: 34782993
ISSN: 1532-6551
CID: 5049032

ASNC Statements of Principles on the Issue of Multimodality Imaging

Thompson, Randall C; Calnon, Dennis A; Polk, Donna M; Al-Mallah, Mouaz H; Phillips, Lawrence M; Dorbala, Sharmila; Beanlands, Robert S B
PMID: 34494201
ISSN: 1532-6551
CID: 5152642

Predicting left ventricular dyssynchrony: Can nuclear cardiology bring us closer "In Sync"? [Editorial]

Kan, Karen; Phillips, Lawrence M
PMID: 32548714
ISSN: 1532-6551
CID: 4510752

Gaps in Medical Therapy for Patients with Heart Failure and Reduced Ejection Fraction (HFrEF) in a Large, Diverse, Electronically Identified Cohort [Meeting Abstract]

Mukhopadhyay, Amrita; Reynolds, Harmony; Phillips, Lawrence M.; Nagler, Arielle; Horwitz, Leora; Katz, Stuart D.; Blecker, Saul
ISSN: 0009-7322
CID: 5263712