Impact of Visit Volume on the Effectiveness of Electronic Tools to Improve Heart Failure Care

Amrita Mukhopadhyay; Harmony R Reynolds; William C King; Lawrence M Phillips; Arielle R Nagler; Adam Szerencsy; Archana Saxena; Nathan Klapheke; Stuart D Katz; Leora I Horwitz; Saul Blecker

doi:10.1016/j.jchf.2023.11.002

Impact of Visit Volume on the Effectiveness of Electronic Tools to Improve Heart Failure Care

JACC Heart Fail. 2024 Apr;12(4):665-674. doi: 10.1016/j.jchf.2023.11.002. Epub 2023 Nov 15.

Authors

Affiliations

¹ Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA. Electronic address: amrita.mukhopadhyay@nyulangone.org.
² Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA.
³ Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA.
⁴ The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York, USA.
⁵ 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.
⁶ 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.
⁷ Medical Center Information Technology, New York University Langone Health, New York, New York, USA.
⁸ 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.
⁹ 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.

PMID: 38043045
DOI: 10.1016/j.jchf.2023.11.002

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).

Keywords: alerts; clinical decision support; electronic health record; heart failure; physician workload; visit volume.

MeSH terms

Adult
Heart
Heart Failure* / therapy
Humans
Mineralocorticoid Receptor Antagonists / therapeutic use
Stroke Volume
Ventricular Dysfunction, Left*

Substances

Mineralocorticoid Receptor Antagonists

Associated data

ClinicalTrials.gov/NCT05275920