In-Hospital Virtual Peer-to-Peer Consultation to Increase Guideline-Directed Medical Therapy for Heart Failure: A Pilot Randomized Trial

Abstract

Background: Guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) improves clinical outcomes and quality of life. Optimizing GDMT in the hospital is associated with greater long-term use in HFrEF. This study aimed to describe the efficacy of a multidisciplinary virtual HF intervention on GDMT optimization among patients with HFrEF admitted for any cause. Methods: In this pilot randomized, controlled study, consecutive patients with HFrEF admitted to non-cardiology medicine services for any cause were identified at a large academic tertiary care hospital between May to September 2021. Major exclusions were end-stage renal disease, hemodynamic instability, concurrent COVID-19 infection, and current enrollment in hospice care. Patients were randomized to a clinician-level virtual peer-to-peer consult intervention providing GDMT recommendations and information on medication costs vs. usual care. Primary endpoints included 1) proportion of patients with new GDMT initiation or use, and 2) changes to HF optimal medical therapy (OMT) scores which included target dosing (range 0-9). Results: Of 242 patients identified, 91 (38%) were eligible and randomized to intervention (N=52) or usual care (N=39). Baseline characteristics were similar between intervention and usual care (mean age 63 vs. 67 years, 23% vs. 26% female, 46% vs. 49% Black, mean EF 33% vs. 31%). GDMT use on admission was also similar. There were greater proportions of patients with GDMT initiation or continuation with the intervention compared with usual care. After adjusting for OMT score on admission, changes to OMT score at discharge were higher for the intervention group compared with usual care (+0.44 vs. -0.31, absolute difference +0.75, adjusted estimate 0.86 ± 0.42; p=0.041). Conclusions: Among eligible patients with HFrEF hospitalized for any cause on non-cardiology services, a multidisciplinary pilot virtual HF consultation increased new GDMT initiation and dose optimization at discharge.

Interventions for Optimization of Guideline-Directed Medical Therapy

“…Both studies found significant increases in prescription rates of GDMT at discharge, though findings were not consistent across studies. For instance, while IMPLEMENT-HF reported increases in β-blockers (93.4% vs 82.5%; P = .01) and MRAs (49.1% vs 21.0%; P = .02), Rao et al showed increases in ACEi, ARB, and ARNI prescriptions (71% vs 49%; P = .04).…”

“…The most common type of intervention was interdisciplinary interventions (n = 15). These studies were further categorized as interdisciplinary heart failure clinics, outpatient audits, or inpatient audits …”

“…Two RCTs studied implementation of inpatient audits, both of which used interdisciplinary teams to provide recommendations on GDMT optimization for patients admitted with HFrEF . Both studies found significant increases in prescription rates of GDMT at discharge, though findings were not consistent across studies.…”

Digital Solutions to Optimize Guideline-Directed Medical Therapy Prescriptions in Heart Failure Patients: Current Applications and Future Directions

“…The virtual care team consisted of cardiologists and pharmacists and the consultation was directed to clinicians of non-cardiology departments. [ 28 ]. In this single-center randomized controlled trial (RCT), an increase in the proportion of patients on angiotensin-converting enzyme inhibitors (ACE-I)/angiotensin receptor blockers (ARB)/ARNI was demonstrated.…”

Optimizing Heart Failure Therapy Requires All-Hands-on-Deck and a DASH of Technology

“…This approach resulted in increased utilization of renin-angiotensin-aldosterone system/neprilysin inhibitors and higher optimal medical therapy scores at discharge compared with the usual care group. 8 Bhatt and colleagues utilized an EHR-generated report to identify hospitalized patients eligible for GDMT optimization and a virtual care team (centralized physician and local pharmacist) to communicate recommendations for optimizing GDMT with the treating clinicians. This strategy led to intensification of GDMT and higher optimization scores compared with usual care.…”