Patient-specific Display of Treatment Information and Adherence to Clinical Practice Guideline Recommendations (PEER-APP): a dual center, blinded randomized controlled trial

Background: Compliance with clinical practice guideline recommendations is suboptimal in real-world clinical settings. The hypothesis of this trial was that patient-specific educational alerts on guideline recommendations for cardiology in-patients would improve adherence to guidelines compared to standard of care.

Methods: This dual center, superiority, blinded, randomized trial randomly assigned patients admitted as regular cardiology in-patients of a university hospital to an intervention group or standard of care. In the intervention group, 143 algorithm-generated educational alerts were automatically displayed in the hospital information system to study participants (i.e. treating physicians) during the entire hospitalization, in case a deviation from clinical practice guideline recommendations was detected. The primary endpoint was guideline adherence, defined as the ratio of guideline recommendations resolved at the time of discharge in relation to guideline recommendations not resolved at that time. As safety endpoint, the number of educational alerts acknowledged as incorrect by the treating physician were analyzed. All patients were included in the final analysis as intention to treat. A two-sided alpha level of 0.05 was used. This trial is registered at the WHO ICTRP (DRKS00030819).

Findings: Between Jan 10, 2023 and Jul 9, 2023, 1467 patients were randomized to the intervention and 1471 patients to the control group. The primary outcome indicating adherence to guidelines was higher in the intervention group with 4100 resolved versus 4325 non-resolved recommendations (48.7%) compared to the control group with 3883 resolved versus 4596 (45.8%) non-resolved recommendations (relative risk: 1.06, 95% CI: 1.03-1.10, p=0.0002).

Interpretation: The trial results suggest that algorithm-generated, automatically displayed educational alerts based on electronic health data can increase compliance with clinical practice guideline recommendations and should therefore be implemented in hospital information systems by default.