Key Points:
- In the DETECT AS trial, 285 providers for 939 patients with severe aortic stenosis were randomized to receive an electronic provider notification (EPN) notifying the provider of the AHA/ACC guidelines for management vs. usual care.
- At one year, the rates of the primary outcome, aortic valve replacement within one year, were 48.2% in the EPN arm versus 37.2% in the usual care arm (OR: 1.62, 95% CI: 1.13-2.32).
- The impact of the EPN on rates of aortic valve replacement was greatest in patients >80 years of age, in women, and in patients who underwent echocardiogram in the inpatient setting.
Although it is well-known that symptomatic severe aortic stenosis (SSAS) is associated with high morbidity and mortality when untreated, there is often significant undertreatment of SSAS, particularly among women, the elderly and minority groups. Although the ACC and AHA have established the percentage of patients receiving an aortic valve replacement (AVR) within 90 days as a key quality metric, there are ongoing efforts to determine how to achieve this goal. In the DETECT AS trial, the trialists evaluate the impact of electronic provider notification (EPN) on rates of AVR within one year of a diagnostic transthoracic echocardiogram (TTE).
To be eligible for enrollment, a provider had to have a patient with an aortic valve area of 1.0 cm2 or less on TTE. At that point, the provider would be randomized to receive the EPN vs. control. If a given provider was already randomized, additional patients for that provider would automatically be randomized to receive the same intervention. Patients were excluded from enrollment if they had a history of prior aortic valve replacement or did not have a primary care doctor, cardiologist, or TTE-ordering physician within the Mass General Brigham healthcare system. For those patients who were randomized to receive the EPN, the provider would receive a personalized notification via email and the electronic health record based on the patient’s aortic valve gradient and left ventricular systolic function. The primary endpoint was the proportion of patients with severe aortic stenosis who received an AVR within one year of the original TTE.
The study enrolled 285 providers and a total of 939 patients within the Mass General Brigham system. The mean age of patients was 77 years old and 47% of patients were female. At one year, 48.2% patients in the EPN arm had undergone aortic valve replacement compared to 37.2% in the usual care arm (OR: 1.62, 95% CI: 1.13-2.32). In the subset of patients with symptomatic severe aortic stenosis, the treatment effect was even more robust at 60.7% in the EPN arm vs. 47.5% in the usual care arm (OR 1.77; 95% CI 1.17-2.65; p=0.006). Among subgroups, the treatment effect of EPN was most prominent in patients >80 years of age (OR 2.00; 95% CI 1.17-3.41; p=0.01), in women (OR 2.78; 95% CI 1.69-4.57; p<0.001) and when index TTE was performed in the inpatient setting (OR 2.49, 95% CI 1.44-4.31; p<0.001). There was a higher restricted mean survival time in the EPN arm compared to the usual care arm (p=0.04), although there was no impact on heart failure hospitalizations. Finally, the use of the EPN was associated with higher rates of referral to specialists from primary care (63.4 vs. 39.5%; p = 0.004) and higher rates of pursuing additional diagnostic testing (41 vs. 31.2%; p = 0.02).
One important limitation of the study design is that it may not be generalizable to broader healthcare systems since it was conducted entirely within the Mass General Brigham system. In addition, it is possible that providers in the usual care arm became aware of the trial and changed practice patterns based on awareness. In conclusion, this single-center study highlights the potential benefit of an EPN for increasing rates of AVR after diagnosis of aortic stenosis. It will be helpful for future studies to further evaluate the impact of EPN in other practice settings and in a more diverse patient population.