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Rationale: Cardiac monitoring has often been identified as an area of overutilization and remains a limited resource in many hospitals. With the aim of reducing telemetry overuse, we added clinical decision support to our health system's telemetry order with guidance on appropriate indications for monitoring. The new order requires selection of an appropriate clinical indication. Aims and Objectives: In this study, we aimed to understand provider engagement with this tool by assessing concordance between selected indications within the order and the clinical presence of those conditions as documented within the patient chart. Methods: We randomly selected 100 telemetry orders from July to October 2022 across four different hospitals at NYU Langone Health. Two independent, blinded reviewers used a structured protocol to identify documentation of actual indications for telemetry in each selected chart. We calculated the rate of concordance between indications selected in the order and indications that were determined to be clinically present on chart review. Results: There were 30,839 telemetry orders placed during the study timeframe. Overall concordance between the selection within the order and the actual indication was 48% (95% confidence interval [CI], 38.21%−57.79%). We observed especially low concordance rates for vague indications, such as 'Other', and for 'Confirmed Stroke', which was the only indication allowing for indefinite telemetry. Conclusion: The overall low concordance suggests a disconnect between the support tool and clinical practice. Providers are more likely to select an indication that reduces downstream work regardless of a patient's true clinical indication. [ABSTRACT FROM AUTHOR]

Background: Evidence-based therapy for heart failure remains underutilized at hospital discharge, particularly for patients with heart failure who are hospitalized for another cause. We developed clinical decision support (CDS) to recommend an angiotensin converting enzyme (ACE) inhibitor during hospitalization to promote its continuation at discharge. The CDS was designed to be implemented in both interruptive and non-interruptive versions.Objectives: To compare the effectiveness and implementation of interruptive and non-interruptive versions of a CDS to improve care for heart failure.Methods: Hospitalizations of patients with reduced ejection fraction were pseudo-randomized to deliver interruptive or non-interruptive CDS alerts to providers based on even or odd medical record number. We compared discharge utilization of an ACE inhibitor or angiotensin receptor blocker (ARB) for these two implementation approaches. We also assessed adoption and implementation fidelity of the CDS.Results: Of 958 hospitalizations, interruptive alert hospitalizations had higher rates of discharge utilization of ACE inhibitors or ARBs than non-interruptive alert hospitalizations (79.6% vs. 74.2%, p = 0.05). Utilization was higher for interruptive alert versus non-interruptive alert hospitalizations which were principally for causes other than heart failure (79.8% vs. 73.4%; p = 0.05) but no difference was observed among hospitalizations with a principal heart failure diagnosis (85.9% vs.81.7%; p = 0.49). As compared to non-interruptive hospitalizations, interruptive alert hospitalizations were more likely to have had: an alert with any response (40.6% vs. 13.1%, p < 0.001), contraindications reported (33.1% vs 11.3%, p < 0.001), and an ACE inhibitor ordered within twelve hours of the alert (17.6% vs 10.3%, p < 0.01). The response rate for the interruptive alert was 1.7%, and a median (25th, 75th percentile) of 14 (5,32) alerts were triggered per hospitalization.Conclusions: A CDS implemented as an interruptive alert was associated with improved quality of care for heart failure. Whether the potential benefits of CDS in improving cardiovascular care were worth the high burden of interruptive alerts deserves further consideration. CLINICALTRIALS.Gov Identifier: NCT02858674. [ABSTRACT FROM AUTHOR]

Mineralocorticoid receptor antagonists (MRAs) are underprescribed for patients with heart failure with reduced ejection fraction (HFrEF). 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. 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). 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. 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) [Display omitted] [ABSTRACT FROM AUTHOR]