Electronic Provider Notification to Facilitate the Recognition and Management of Severe Aortic Stenosis: a Randomized Clinical Trial

Background: Symptomatic severe aortic stenosis (AS) remains undertreated with high resultant mortality despite increased growth and availability of aortic valve replacement (AVR) since the advent of transcatheter therapies. We evaluate the impact of electronic provider notifications (EPN) on rates of AVR at 1-year. Methods: In a pragmatic cluster randomized clinical trial conducted within multicenter academic health system from March 2022 through November 2023, 285 providers who had ordered a transthoracic echocardiogram (TTE) with findings potentially indicative of severe AS with aortic valve area ≤ 1.0 cm 2 were enrolled. Providers were randomly assigned to receive EPN for each of their patients with severe AS on TTE or to usual care. Notifications highlighted the detection of severe AS and included patient-specific clinical guideline recommendations for its management. The primary endpoint was the proportion of patients with severe AS receiving AVR within 1-year of the index TTE. Results: A total of 144 providers were randomized to intervention and 141 to control, resulting in 496 and 443 patients assigned to each group, respectively. The patient cohort had mean age of 77±11 years, was 47% female, and had mean aortic valve area 0.8±0.1 cm 2 . Rates of AVR within 1-year were 48.2% with EPN versus 37.2% with usual care (OR 1.62; 95% CI 1.13-2.32; p=0.009) and 60.7% and 46.5%, respectively, amongst symptomatic patients (OR 1.77; 95% CI 1.17-2.65; p=0.006). Notification treatment effect was highest with EPN 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 within the inpatient setting (OR 2.49, 95% CI 1.44-4.31; p<0.001). Within 1-year, restricted mean survival time was longer with EPN in all (12 days; p=0.04) and symptomatic patients (23 days; p=0.01). Conclusions: In this first study of EPN in valvular heart disease, EPN increased rates of AVR for severe AS, lessened gender and age disparities in AVR utilization, and improved survival time. EPN may provide a simple, scalable intervention to raise awareness of critical TTE findings and improve the quality of care for severe AS.