EHR alert increases likelihood of prescribing MRA in patients with HFrEF

Building Electronic Tools To Enhance And Reinforce CArdiovascular REcommendations For Heart Failure (BETTER CARE-HF): A Pragmatic, Cluster-randomized Trial Comparing Two Ambulatory Clinical Decision Support Tools

News - Mar. 6, 2023

Presented at the ACC.23 by: Amrita Mukhopadhyay, MD - New York, NY, USA

Introduction and methods

It has been estimated that over two-thirds of patients eligible for MRA treatment are not prescribed this medication. The BETTER CARE-HF study investigated whether an alert or an inbox message delivered via electronic health record (EHR) systems to cardiologists who are seeing patients with HFrEF in an outpatient setting, will improve prescribing of MRA compared to usual care. The difference between the alert and messages is that the alerts are delivered for a single patient during a clinical encounter while inbox messages are delivered once a month for multiple patients at once.

The tree-arm, pragmatic, cluster randomized BETTER CARE-HF study randomized 2211 in a 1:1:1 ratio at the level of the cardiologist (60 cardiologists per arm). Cardiologists received either EHR alerts (n=755 patients), monthly inbox messages (n=812 patients), or no intervention (n=644 patients). To prevent so-called ‘alert fatigue’, alerts and messages were only sent for patients who were selected to be MRA eligible. Patients were eligible if they were ≥18 years of age, seen in an outpatient cardiology practice, had LVEF ≤40%, had not already a prescription for MRA, and had no contraindication for MRA.

The primary outcome was new MRA prescription during the study period of 6 months.

Main results

  • 29.6% of patients seen by a cardiologist who received an alert, 15.6% of patients seen by a cardiologist who received a monthly message, and 11.7% of patients seen by a cardiologist who received no intervention had been prescribed an MRA.
  • The alert thereby increased the likelihood of prescribing MRA therapy by 2.5x (RR 2.53, 95%CI 1.77-3.62, P<0.001), and the monthly inbox message increased that likelihood by 1.5x (RR 1.5, 95%CI 1.04-2.21, P=0.029), compared to receiving neither intervention.


An EHR-embedded and selective alert delivered during the clinical encounter increased the likelihood of prescribing MRA by 2.5x in MRA-eligible HFrEF patients in an outpatient cardiology setting.

-Our reporting is based on the information provided at the ACC.23/WCC-

This study was simultaneously published in J Am Coll Cardiol.

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