A new intervention to increase GDMT in heart failure exploits noncardiac admissions | Tech US News

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The small trial is addressing a critical part of implementation that has prevented lifesaving drugs from reaching patients who could benefit.

For patients with reduced ejection fraction (HFrEF) who are admitted to hospital for non-cardiology reasons, a system where their treating clinicians can connect directly with heart failure specialists not only increases the likelihood of initiation of guideline-directed therapy ( GDMT). but also improves discharge dose optimization.

Communication between heart failure specialists and doctors from other, non-cardiology disciplines is relatively rare. “Usual care typically consists of the primary care team reaching out to a general cardiology consult through a formal consultation if there is a clinical question that requires an answer or assistance,” lead author Vishal N. Rao, MD, MPH (Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC), TCTMD said. But if a cardiologist consultation isn’t necessary for a heart failure patient hospitalized for reasons such as pneumonia, complications from a fall, COVID-19 or kidney damage, he continued, it’s unlikely the medical team would ever talk to a cardiologist about patient care plan.

Study after study has shown that initiation and titration of life-saving heart failure drugs is improbable, so that it is not available strategies to improve GDMT are absolutely necessary.

According to Rao, his multidisciplinary team of cardiologists, internists, pharmacists and nurses were motivated to create a peer-to-peer communication system within their hospital’s electronic health record (EHR) to “best identify heart failure patients and move the needle on their clinical prognosis at every possible opportunity regarding medical care and frequent touch points. . . . Given the rising rates of patients with heart failure and high rates of hospitalization in general, we wanted to develop a study to improve the quality of care in our services beyond just cardiology.”

The physician-level peer-to-peer system developed for and used in this study was automatically embedded in their institution’s EHR. It contained a detailed note written by someone from the multidisciplinary heart failure team who provided GDMT recommendations and information on drug costs. The rounding physician also had the ability to call and speak to a heart failure physician, pharmacist, or nurse for follow-up consultation in real time.

Anand Shah, MD, MBA (Duke University School of Medicine), is scheduled to present the study at a poster later this week during the American Heart Association’s 2022 Scientific Sessions; the paper was published this week in Circulation: heart failure.

Sean Pinney, MD (University of Chicago, IL), who reviewed the study for TCTMD, said, “My immediate reaction was, Why didn’t I think of that?

“This is an excellent piece of implementation science that is critical for us to try to find new ways to increase the uptake and escalation of guideline-directed medical therapy,” he continued. “We have these therapies that have been shown to prolong life, improve life, and the real challenge for us now is to find ways to get these drugs to patients. The fact that they targeted medical-level admissions and provided peer-to-peer guidance was really fantastic.”

Increase in GDMT

For the study, Rao and colleagues identified patients with a pre-diagnosis of HFrEF who were admitted to their hospital between May and September 2021 for noncardiac reasons, although those with end-stage renal disease, hemodynamic instability, co-infection with COVID-19, and currently enrolled in hospice care was excluded.

Rao described the communication system as “essentially a virtual consultation notification and communication between different providers of different specialties” that provided patient information, including imaging, lab results and past medical history, to help clinicians assess potential eligibility for GDMT. In addition, there would be the option of engaging in a telephone consultation to discuss the patient’s eligibility for heart failure medications, estimated prescription drug costs, completion of prior authorizations or prescription coverage options, and transition and follow-up of care after discharge.

We have these therapies that have been shown to prolong life, improve life, and the real challenge for us now is to find ways to get these drugs to patients. Sean Pinney

Of the 91 patients enrolled, 52 were randomized to medical teams using the intervention (mean age 63 years; 23% female) and 39 to medical teams providing usual care (mean age 66 years; 26% female). The average ejection fraction was similar in both groups (33.1% vs. 31.2%; p = 0.28)

GDMT use at admission was similar for both groups, particularly for beta blockers (60% vs 67%; p = 0.49), ACE/ARB/ARNI inhibitors (62% vs. 53%; p = 0.40), mineralocorticoid antagonists (MRA; 33% vs. 26%; p = 0.51) and sodium glucose cotransporter 2 (SGLT2) inhibitors (20% vs. 16%; p = 0.64).

After randomization, the intervention cohort reported more initiation or continuation of GDMT during the study than those receiving usual care, particularly for ACE inhibitors/ARBs/ARNIs (71% vs. 49%; p = 0.04), MRA (40% vs. 21%; p = 0.05) and SGLT2 inhibitors (26% vs. 14%; p = 0.19).

Expressed as optimal medical therapy (OMT) score at discharge, outcomes increased for patients randomized to automated peer consultations and decreased for controls, even after adjustment for OMT score at admission (+0.44 vs -0.31; p = 0.041).

At 30 days, however, there was no difference in primary care physician follow-up rates between the intervention group and the usual care group (64% vs. 63%; p = 0.95) or heart failure specialist/general cardiologist (31% vs 33%; p = 0.85). No patient in the intervention cohort died, while the mortality rate in the usual care group was 7.7%.

Rao stated that this is a feasibility study to explore the possibility of implementing this type of virtual peer-to-peer consultation during non-cardiac patient visits, something that was initially expected to be a challenge. “We’ve been quite surprised by the overwhelmingly positive reception,” he said. “We opened it up to the entire department of medicine, including hospitalists, providers, and physicians and interns, and said, ‘If you don’t want to be a part of this, you don’t have to be.’” In the end, “nobody refused to participate, and actually a lot of people really wanted to know about it.”

As for the results, Rao called them “favorable” and “surprising”. The intervention was well-received and “certainly opened the door to our future endeavors, as we hope that this may be the type of mechanism that [we] can be added to other quality improvement-based strategies to engage providers and patients in routine heart failure care.

Rao said his team is planning future research to assess how individual providers feel about this type of intervention and whether it could be replicated and possibly scaled up at other institutions.

Direct decision support

Pinney said that in one of his previous roles, his team tried to design an automated intervention that provided guidance through the EHR to providers, “but it wasn’t very effective, in part because it’s really hard to write that kind of algorithm.” Where this study is successful, he continued, “he came up with [multidisciplinary] decision support directly to providers that was immediate and actionable.”

While I would expect the intervention to lead to more use of SGLT2 inhibitors, “I think it speaks to the challenge we have right now across the country trying to get these drugs to people,” Pinney said. “Some of it is overcoming knowledge gaps and some of it is overcoming inertia, but I think the unaffordable cost of drugs and the need for prior approvals are also significant hurdles to overcome. And I bet that also hindered the uptake of SGLT2 inhibitors.”

In thinking about how to scale up such an intervention, Pinney said he would like to see it work at other academic medical centers, as well as community hospitals and rural areas. He said that he is already thinking about how to legislate something similar in his institution.

Some of the challenges he expects to be hindered include the complexity of the patient population, provider persistence, the type of EHR and what it enables, and adequate staffing. “But it’s solvable,” Pinney said.

Finally, he said the study highlighted an additional barrier to adequate transitional care. “These low rates of primary care and cardiac follow-up at 30 days are not for lack of trying,” Pinney said. “You kind of fumble the ball at the one-yard line. You’ve taken all this time, you’ve invested resources—both EMR and human resources, medical expertise—in designing the intervention, adjusting it while they’re in the hospital, and then it just all falls apart because further dose titration doesn’t happen because they do not keep this further term. I think he succeeds in this contribution as well and points us in the right direction again. . . . We need to come up with a different kind of intervention to ensure that our transitional care plans are successful and that we get patients into doctor’s offices when they leave the hospital.”

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