June 18, 2026Journal of the American College of Cardiology76 citationsOpen Access
Cluster-Randomized Trial Comparing Ambulatory Decision Support Tools to Improve Heart Failure Care
Key Result
An automated EHR-embedded alert during patient encounters significantly increased new MRA prescribing compared to usual care (29.6% vs 11.7%; RR 2.53; 95% CI 1.77-3.62; P<0.0001) in HFrEF patients.
Key Points
- This study aimed to evaluate the effectiveness of automated tools compared to usual care for MRA prescribing in heart failure patients.
- 3-arm, cluster-randomized trial design comparing alert, message, and usual care interventions.
- Included patients with heart failure with reduced ejection fraction, no MRA prescription, and no contraindications.
- Patients were cluster-randomized by cardiologist (60 per arm) in a large health system.
- New MRA prescribing rates were 29.6% for the alert arm, 15.6% for the message arm, and 11.7% for usual care.
- The alert intervention increased MRA prescribing relative to usual care (relative risk: 2.53; 95% CI: 1.77–3.62; P < 0.0001).
- The alert also outperformed the message intervention (relative risk: 1.67; 95% CI: 1.21–2.29; P = 0.002).
Study Design
Type
RCT (n=2,211)
Randomization
Cluster-randomized
Multicenter
Yes
Structured PICO
Does an automated EHR-embedded alert or message improve new MRA prescribing in adult patients with HFrEF?
P
Population
2,211 adult patients with HFrEF, no active MRA prescription, and no contraindications, managed by an outpatient cardiologist.
I
Intervention
Automated, electronic health record-embedded alert during individual patient encounters OR a message about multiple patients between encounters
C
Comparator
Usual care
O
Outcome
New MRA prescribing
An automated, patient-specific EHR alert significantly increased MRA prescribing for eligible HFrEF patients compared to usual care or bulk messaging.
Main Result
Relative Risk: 2.53 (95% CI 1.77–3.62)
Absolute Event Rate: 29.6% vs 11.7%
Number Needed to Treat: 5.6
p-value: p=<0.0001
Abstract
BACKGROUND Mineralocorticoid receptor antagonists (MRAs) are underprescribed for patients with heart failure with reduced ejection fraction (HFrEF). OBJECTIVES 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. METHODS 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). RESULTS 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. CONCLUSIONS 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) (J Am Coll Cardiol 2023;81:1303–1316) © 2023 by the American College of Cardiology Foundation.
Expert Takes4 quotes
1/4
“This is a really important study, because despite overwhelming evidence for more than a decade favoring MRA use for patients with HFrEF there is an incredibly large treatment gap. MRAs can reduce all-cause death in people with HFrEF by 25%-30%, as well as reduce hospitalizations for heart failure, at a cost of less than $50 a year.”
Gregg C. Fonarow, Interim chief of cardiology, UCLAUniversity of California, Los Angelesauto_pipelineSupportiveView source
Cite This Study
Mukhopadhyay et al. (2023) conducted an RCT in Heart failure with reduced ejection fraction (HFrEF) (n=2,211). Automated EHR-embedded alert during individual patient encounters vs. Usual care and message about multiple patients between encounters was evaluated on New MRA prescribing (RR 2.53, 95% CI 1.77-3.62, p=<0.0001). An automated EHR-embedded alert during patient encounters significantly increased new MRA prescribing compared to usual care (29.6% vs 11.7%; RR 2.53; 95% CI 1.77-3.62; P<0.0001) in HFrEF patients.