Virtual Care Team Optimized Heart Failure Medications During Hospitalization

NEW ORLEANS -- Heart failure medication regimens improved when a virtual specialist team provided recommendations for optimization each day that patients with heart failure with reduced ejection fraction (HFrEF) were in the hospital for any reason, the IMPLEMENT-HF trial showed.

Guideline-directed medical therapy (GDMT) improved significantly compared with usual care, with an adjusted difference of +1.2 points (95% CI 0.7-1.8) on a scale where uptitration of one medication was 1 point and initiation of a medication was 2 points.

The proportion of patients who initiated a new medication was 44% with once-daily virtual care team nudges to their treating physicians compared with 23% with usual care, while the proportions with dose intensification of at least one GDMT were 50% and 28%, respectively (both P=0.001).

This translated to a number-needed-to-intervene of 5, reported Ankeet S. Bhatt, MD, MBA, MSc, of Brigham and Women's Hospital and Harvard Medical School in Boston, during the American College of Cardiology annual meeting.

"This strategy represents a potential highly effective, scalable intervention that can lead to accelerated implementation of guideline-concordant HFrEF care," the group concluded in their study, which was published in the Journal of the American College of Cardiology.

It was a middle-of-the-road solution -- more than some of the modestly effective automated prompts but less than the high-intensity in-hospital interventions with large effect sizes, commented Biykem Bozkurt, MD, PhD, of Baylor College of Medicine in Houston.

"This study allows us to connect the dots between a strategy platform that includes the EMR [electronic medical record] alerts that we have heard in former studies, such as the PROMPT-HF study, as well as the recently published STRONG-HF trial, which entailed face-to-face weekly visits," she said during a panel discussion at the session. "This is somewhere in between."

Now that there's evidence of how much difference these medications make in outcomes, "the imperative is there," commented Clyde Yancy, MD, MSc, of Northwestern University's Feinberg School of Medicine in Chicago and past president of the American Heart Association.

However, the implementation science for how to get it done in the clinic is still in a nascent state, he noted. "The idea that we're using a still unstructured field to provide these important answers lets us know we have yet another frontier we need to transverse if we're going to see best outcomes for heart failure patients."

"We have some schools of thought that we should give everything we know simultaneously in low doses and move forward from there," he continued. "But what if there's a problem? Do you stop everything and start over? There's another school of thought that you should do this sequentially. Then in what order?"

He suggested looking at interventions like Bhatt's as "candidate projects, version 1.0," but not yet the solution.

The trial included 252 encounters with 198 adults (mean age 69 years, 34% women, 14% Black) hospitalized with previously or newly diagnosed HFrEF (left ventricular ejection fraction [LVEF] ≤40%) outside of the ICU. The three participating hospitals were part of an integrated healthcare system, with one academic medical center and two teaching community hospitals.

Eligible patients were identified daily through the electronic health record and assigned to an intervention group based on birth month as a type of randomization.

Virtual care teams at each site included a centralized physician, study staff, and pharmacist who used the medical chart data to provide once-daily recommendations to the treating care teams regarding GDMT optimization. They used an algorithm based on national guidelines, randomized trial evidence, package inserts, and expert consensus documents. Their aim was getting patients without contraindications onto all four classes known to benefit HFrEF patients -- beta-blockers, angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs)/angiotensin receptor-neprilysin inhibitor (ARNIs), mineralocorticoid receptor antagonists (MRAs), and SGLT2 inhibitors -- and doing so early, with progressive dose uptitration and switching to preferred agents within classes.

The virtual care team issued as few as zero and as many as eight recommendations per patient encounter, with 43% getting one recommendation and 43% getting two or more recommendations for optimization during hospitalization.

The virtual care team had no interaction with patients.

Comparing admission to discharge, patients' regimens were scored with GDMT discontinuation deducting 2 points, down-titration deducting 1 point, switching from an ACE inhibitor or ARB to an ARNI added 1 point, and switching within the same drug class categorized as uptitration or down-titration based on percent target dose. Scores could range from -8 to +8.

At admission, only 10% of patients were on three-drug heart failure regimens, and just 9% were taking the recommended four. The proportion newly on triple or quadruple therapy rose significantly in the intervention group compared with usual care (34% vs 12%, P<0.001).

By discharge, new initiation was significantly increased in the intervention group for beta-blockers (81% vs 44%, P=0.005) and MRAs (32% vs 11%, P=0.001).

The virtual care team strategy was similarly beneficial in heart failure cases identified de novo during hospitalization versus those who presented with established HFrEF, as well as in encounters for acute heart failure versus those for other admission reasons.

However, the intervention was less effective for the 17% of participants of Hispanic heritage and for those who spoke Spanish, findings which the researchers said "highlight the need to identify reasons for inequities and enhanced, appropriate support for non-English-speaking patients in future implementation studies."

Hypotension and other safety events were equally common between groups. There was no prolongation of hospital length of stay, which averaged 6 days in both arms of the study.

One limitation to the study was the inclusion of only one healthcare system.

While large, complex healthcare delivery systems with standardized processes and workflows, including a unified electronic health record, are increasingly common, generalizability to "other hospital types, geographies, and populations with greater complexity (e.g., co-existing valvular heart disease, severe biventricular dysfunction) requires additional study," Bhatt's group noted.

Also, contamination in which an individual clinician might have cared for patients in both study arms was possible, although this would have biased the study toward the null, Bhatt noted.

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