Interrupting providers with clinical decision support to improve care for heart failure

Abstract

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 (25^th, 75^th 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.

Keywords: Clinical decision support; Comparative effectiveness; Heart failure.

Figure 1.

Screenshots of clinical decision support (CDS) tool. (A) Interruptive version of CDS; (B) location of non-interruptive version of CDS, highlighted with red box; clicking the link in the non-interruptive alert would take the user to a screen similar to the interruptive alert.

Figure 2.

Compliance with angiotensin receptor enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for interruptive versus non-interruptive clinical decision support (CDS) alert hospitalizations in the overall cohort and subgroups with principal and secondary heart failure (HF) discharge diagnoses.