Virtual Care Team Guided Management of Patients With Heart Failure During Hospitalization

doi:10.1016/j.jacc.2023.02.029

Journal of the American College of Cardiology

Volume 81, Issue 17, 2 May 2023, Pages 1680-1693

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https://doi.org/10.1016/j.jacc.2023.02.029 Get rights and content

Abstract

Background

Scalable and safe approaches for heart failure guideline-directed medical therapy (GDMT) optimization are needed.

Objectives

The authors assessed the safety and effectiveness of a virtual care team guided strategy on GDMT optimization in hospitalized patients with heart failure with reduced ejection fraction (HFrEF).

Methods

In a multicenter implementation trial, we allocated 252 hospital encounters in patients with left ventricular ejection fraction ≤40% to a virtual care team guided strategy (107 encounters among 83 patients) or usual care (145 encounters among 115 patients) across 3 centers in an integrated health system. In the virtual care team group, clinicians received up to 1 daily GDMT optimization suggestion from a physician-pharmacist team. The primary effectiveness outcome was in-hospital change in GDMT optimization score (+2 initiations, +1 dose up-titrations, −1 dose down-titrations, −2 discontinuations summed across classes). In-hospital safety outcomes were adjudicated by an independent clinical events committee.

Results

Among 252 encounters, the mean age was 69 ± 14 years, 85 (34%) were women, 35 (14%) were Black, and 43 (17%) were Hispanic. The virtual care team strategy significantly improved GDMT optimization scores vs usual care (adjusted difference: +1.2; 95% CI: 0.7-1.8; P < 0.001). New initiations (44% vs 23%; absolute difference: +21%; P = 0.001) and net intensifications (44% vs 24%; absolute difference: +20%; P = 0.002) during hospitalization were higher in the virtual care team group, translating to a number needed to intervene of 5 encounters. Overall, 23 (21%) in the virtual care team group and 40 (28%) in usual care experienced 1 or more adverse events (P = 0.30). Acute kidney injury, bradycardia, hypotension, hyperkalemia, and hospital length of stay were similar between groups.

Conclusions

Among patients hospitalized with HFrEF, a virtual care team guided strategy for GDMT optimization was safe and improved GDMT across multiple hospitals in an integrated health system. Virtual teams represent a centralized and scalable approach to optimize GDMT.

Central Illustration

Section snippets

Methods

IMPLEMENT-HF was a prospective implementation study among patients with HFrEF admitted to 3 hospitals within an integrated health care delivery system (Mass General Brigham, Boston, Massachusetts) from October 2021 through June 2022. Eligible patients were identified by an EHR-based query. To enhance pragmatism, allocation to a virtual care team guided strategy vs usual care was performed by birth month (6 months allocated to the control group; 6 months allocated to the intervention group).

Study cohort

Of 808 screened clinical encounters, 252 (31%) from 198 unique patients met inclusion criteria and were allocated to virtual care team guided strategy (107 encounters among 83 patients) or usual care (145 encounters among 115 patients) (Figure 1). Mean age was 69 ± 14 years, 85 (34%) were women, 183 (73%) were White, 35 (14%) were Black, 43 (17%) were Hispanic, and 30 (12%) were Spanish-speaking (Table 1). Baseline characteristics were generally balanced between study arms. Geographic

Discussion

In this prospective implementation trial, we found that a virtual care team guided strategy improved GDMT during hospitalization for patients with HFrEF across 3 hospitals in an integrated health care delivery system. A virtual care team guided strategy nearly doubled β-blocker prescriptions and nearly tripled MRA prescriptions in patients not previously on these treatments at hospital admission. In addition, the virtual care team guided strategy led to a 20% absolute improvement in net

Conclusions

A virtual care team guided strategy safely improved in-hospital HFrEF GDMT optimization across multiple hospitals in an integrated health care system without increasing hospital length of stay. This strategy represents a potential highly effective, scalable intervention that can lead to accelerated implementation of guideline concordant HFrEF care.

COMPETENCY IN PATIENT CARE AND PROCEDURAL SKILLS: A virtual care team guided strategy improves in-hospital medical therapy for patients with heart

Funding Support and Author Disclosures

Funding was provided by the Brigham Health Care Redesign Incubator and Startup Program, Brigham and Women’s Hospital, Mass General Brigham, Boston, Massachusetts. Dr Varshney has received consulting fees from Broadview Ventures. Dr Claggett has received consulting fees from Cardurion, Corvia, Cytokinetics, Intellia, and Novartis. Dr Eaton is employed at Brigham and Women’s hospital, but is also employed by Janssen Pharmaceuticals. Dr Cunningham has received consulting fees from Roche

Acknowledgments

The authors thank the Brigham Health Care Redesign Incubator and Startup Program (BCRISP) staff and mentors.

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Cited by (16)

Medical Therapy Before, During and After Hospitalization in Medicare Beneficiaries With Heart Failure and Diabetes: Get With The Guidelines – Heart Failure Registry
2024, Journal of Cardiac Failure
Patients hospitalized with heart failure (HF) and diabetes mellitus (DM) are at risk for worsening clinical status. Little is known about the frequency of therapeutic changes during hospitalization. We characterized the use of medical therapies before, during and after hospitalization in patients with HF and DM.
We identified Medicare beneficiaries in Get With The Guidelines-Heart Failure (GWTG-HF) hospitalized between July 2014 and September 2019 with Part D prescription coverage. We evaluated trends in the use of 7 classes of antihyperglycemic therapies (metformin, sulfonylureas, GLP-1RA, SGLT2-inhibitors, DPP-4 inhibitors, thiazolidinediones, and insulins) and 4 classes of HF therapies (evidence-based β-blockers, ACEi or ARB, MRA, and ARNI). Medication fills were assessed at 6 and 3 months before hospitalization, at hospital discharge and at 3 months post-discharge.
Among 35,165 Medicare beneficiaries, the median age was 77 years, 54% were women, and 76% were white; 11,660 (33%) had HFrEF (LVEF ≤ 40%), 3700 (11%) had HFmrEF (LVEF 41%–49%), and 19,805 (56%) had HFpEF (LVEF ≥ 50%). Overall, insulin was the most commonly prescribed antihyperglycemic after HF hospitalization (n = 12,919, 37%), followed by metformin (n = 7460, 21%) and sulfonylureas (n = 7030, 20%). GLP-1RA (n = 700, 2.0%) and SGLT2i (n = 287, 1.0%) use was low and did not improve over time. In patients with HFrEF, evidence-based beta-blocker, RASi, MRA, and ARNI fills during the 6 months preceding HF hospitalization were 63%, 62%, 19%, and 4%, respectively. Fills initially declined prior to hospitalization, but then rose from 3 months before hospitalization to discharge (beta-blocker: 56%–82%; RASi: 51%–57%, MRA: 15%–28%, ARNI: 3%–6%, triple therapy: 8%–20%; P < 0.01 for all). Prescription rates 3 months after hospitalization were similar to those at hospital discharge.
In-hospital optimization of medical therapy in patients with HF and DM is common in participating hospitals of a large US quality improvement registry.
New models for heart failure care delivery
2024, Progress in Cardiovascular Diseases
Heart failure (HF) is a common disease with increasing prevalence around the world. There is high morbidity and mortality associated with poorly controlled HF along with increasing costs and strain on healthcare systems due to a high rate of rehospitalization and resource utilization. Despite the establishment of clear evidence-based guideline directed medical therapies (GDMT) proven to improve HF morbidity and mortality, there remains significant clinical inertia to optimizing HF patients on GDMT. Only a minority of HF patients are prescribed on all four classes of GDMT. To bridge the gap between the vulnerable population of HF patients and lifesaving GDMT, HF implementation is of increasing importance. HF implementation involves strategies and techniques to improve GDMT optimization along with other modalities to improve HF management. HF implementation meets patients where they are, including at the time of acute decompensation in the inpatient setting, at the vulnerable discharge stage, and at the chronic management stage in the outpatient setting. Inpatient HF implementation strategies include protocolized rapid titration of GDMT, site-level audit-and-feedback, virtual GDMT optimization teams, and electronic health record notifications and alerts. Discharge HF implementation strategies include education at patient and provider levels, discharge summaries, and HF transitional programs. Outpatient HF implementation strategies include digital innovations such as electronic health record utilization and mobile applications, population level strategies such as registries and clinical dashboards), changes in HF team structure and member roles, remote monitoring with implanted devices and telemonitoring, and hospital at home care model. With a growing population of HF patients, there is an increasing need for novel and creative HF implementation and monitoring methods.
Uptake of Sodium-Glucose Cotransporter-2 Inhibitors in Hospitalized Patients With Heart Failure: Insights From the Veterans Affairs Healthcare System
2024, Journal of Cardiac Failure
The use of sodium-glucose cotransporter-2 inhibitors (SGLT2is) in Veterans Affairs (VA) patients hospitalized with heart failure (HF) has not been reported previously.
VA electronic health record data were used to identify patients hospitalized for HF (primary or secondary diagnosis) from 01/2019–11/2022. Patients with SGLT2i allergy, advanced/end-stage chronic kidney disease (CKD) or advanced HF therapies were excluded. We identified factors associated with discharge SGLT2i prescriptions for patients hospitalized due to HF in 2022. We also compared SGLT2i and angiotensin receptor-neprilysin inhibitor (ARNI) prescription rates. Hospital-level variations in SGLT2i prescriptions were assessed via the median odds ratio.
A total of 69,680 patients were hospitalized due to HF; 10.3% were prescribed SGLT2i at discharge (4.4% newly prescribed, 5.9% continued preadmission therapy). SGLT2i prescription increased over time and was higher in patients with HFrEF and primary HF. Among 15,762 patients hospitalized in 2022, SGLT2i prescription was more likely in patients with diabetes (adjusted odds ratio [aOR] 2.27; 95% confidence interval [CI]: 2.09–2.47) and ischemic heart disease (aOR 1.14; 95% CI: 1.03–1.26). Patients with increased age (aOR 0.77 per 10 years; 95% CI: 0.73–0.80) and lower systolic blood pressure (aOR 0.94 per 10 mmHg; 95% CI: 0.92–0.96) were less likely to be prescribed SGLT2i, and SGLT2i prescription was not more likely in patients with CKD (aOR 1.07; 95% CI 0.98–1.16). The adjusted median odds ratio suggested a 1.8-fold variation in the likelihood that similar patients at 2 random VA sites were prescribed SGLT2i (range 0–21.0%). In patients with EF ≤ 40%, 30.9% were prescribed SGLT2i while 26.9% were prescribed ARNI (P < 0.01).
One-tenth of VA patients hospitalized for HF were prescribed SGLT2i at discharge. Opportunities exist to reduce variation in SGLT2i prescription rates across hospitals and to promote its use in patients with CKD and older age.
Bridging gaps and optimizing implementation of guideline-directed medical therapy for heart failure
2024, Progress in Cardiovascular Diseases
Despite robust scientific evidence and strong guideline recommendations, there remain significant gaps in initiation and dose titration of guideline-directed medical therapy (GDMT) for heart failure (HF) among eligible patients. Reasons surrounding these gaps are multifactorial, and largely attributed to patient, healthcare professionals, and institutional challenges. Concurrently, HF remains a predominant cause of mortality and hospitalization, emphasizing the critical need for improved delivery of therapy to patients in routine clinical practice. To optimize GDMT, various implementation strategies have emerged in the recent decade such as in-hospital rapid initiation of GDMT, improving patient adherence, addressing clinical inertia, improving affordability, engagement in quality improvement registries, multidisciplinary clinics, and EHR-integrated interventions. This review highlights the current use and barriers to optimal utilization of GDMT, and proposes novel strategies aimed at improving GDMT in HF.
Access to Heart Failure Services in Canada: Findings of the Heart and Stroke National Heart Failure Resources and Services Inventory
2023, Canadian Journal of Cardiology
The rising incidence of heart failure (HF) in Canada necessitates commensurate resources dedicated to its management. Several health system partners launched an HF Action Plan to understand the current state of HF care in Canada and address inequities in access and resources.
A national Heart Failure Resources and Services Inventory (HF-RaSI) was conducted from 2020 to 2021 of all 629 acute care hospitals and 20 urgent care centres in Canada. The HF-RaSI consisted of 44 questions on available resources, service,s and processes across acute care hospitals and related ambulatory settings.
HF-RaSIs were completed by 501 acute care hospitals and urgent care centres, representing 94.7% of all HF hospitalisations across Canada. Only 12.2% of HF care was provided by hospitals with HF expertise and resources, and 50.9% of HF admissions were in centres with minimal outpatient or inpatient HF capabilities. Across all Canadian hospitals, 28.7% did not have access to B-type natriuretic peptide testing, and only 48.1% had access to on-site echocardiography. Designated HF medical directors were present at 21.6% of sites (108), and 16.2% sites (81) had dedicated inpatient interdisciplinary HF teams. Among all of the sites, 28.1% (141) were HF clinics, and of those, 40.4% (57) had average wait times from referral to first appointment of more than 2 weeks.
Significant gaps and geographic variation in delivery and access to HF services exist in Canada. This study highlights the need for provincial and national health systems changes and quality improvement initiatives to ensure equitable access to the appropriate evidence-based HF care.
En raison de l’incidence croissante de l’insuffisance cardiaque (IC) au Canada, des ressources proportionnelles doivent être accordées à la prise en charge de cette maladie. Plusieurs partenaires du système de santé ont lancé un plan d’action sur l’IC afin de comprendre l’état actuel des soins de l’IC au Canada et pour remédier aux iniquités sur le plan de l’accès et des ressources.
Un inventaire international des ressources et services pour l’insuffisance cardiaque (HF-RaSI, de l’anglais Heart Failure Resources and Services Inventory) a été réalisé de 2020 à 2021 auprès des 629 hôpitaux de soins aigus et dans les 20 centres de soins d’urgence du Canada. Le HF-RaSI comprenait 44 questions sur les ressources et services disponibles ainsi que sur les processus en place dans les hôpitaux de soins aigus et les milieux de soins ambulatoires associés.
Le HF-RaSI a été rempli par 501 hôpitaux de soins aigus et centres de soins d’urgence, lesquels représentent 94,7 % de toutes les hospitalisations pour cause d’IC au Canada. Seuls 12,2 % des soins de l’IC ont été fournis par des hôpitaux ayant une expertise et des ressources en IC, et 50,9 % des admissions en raison de l’IC ont eu lieu dans des centres ayant une capacité minimale en clinique externe ou en hospitalisation pour cause d'IC. Parmi tous les hôpitaux canadiens, 28,7 % n’avaient pas accès à une analyse de peptides natriurétiques de type B et seuls 48,1 % disposaient d'appareils d'échocardiographie. Un directeur médical responsable de l’IC et une équipe interdisciplinaire spécialisée étaient respectivement présents dans 21,6 % (108) et 16,2 % (81) des centres pour les patients hospitalisés. Parmi tous les centres, 28,1 % (141) étaient des cliniques d’IC, et parmi celles-ci, 40,4 % (57) présentaient un temps d’attente moyen entre l’orientation et la première consultation de plus de deux semaines.
Il existe des lacunes et des variations géographiques importantes dans l’administration et l’accès aux soins de l’IC au Canada. Cette étude souligne la nécessité d’apporter des changements aux systèmes de santé provinciaux et nationaux et de lancer des initiatives d’amélioration de la qualité afin d’assurer un accès équitable à des soins adéquats de l’IC fondés sur des données probantes.
Prognosis, characteristics, and provision of care for patients with the unspecified heart failure electronic health record phenotype: a population-based linked cohort study of 95262 individuals
2023, eClinicalMedicine
Whether the accuracy of the phenotype ascribed to patients in electronic health records (EHRs) is associated with variation in prognosis and care provision is unknown. We investigated this for heart failure (HF, characterised as HF with preserved ejection fraction [HFpEF], HF with reduced ejection fraction [HFrEF] and unspecified HF).
We included individuals aged 16 years and older with a new diagnosis of HF between January 2, 1998 and February 28, 2022 from linked primary and secondary care records in the Clinical Practice Research Datalink in England. We investigated the provision of guideline-recommended diagnostic investigations and pharmacological treatments. The primary outcome was a composite of HF hospitalisation or all-cause death, and secondary outcomes were time to HF hospitalisation, all-cause death and death from cardiovascular causes. We used Kaplan–Meier curves and log rank tests to compare survival across HF phenotypes and adjusted for potential confounders in Cox proportional hazards regression analyses.
Of a cohort of 95,262 individuals, 1271 (1.3%) were recorded as having HFpEF, 10,793 (11.3%) as HFrEF and 83,198 (87.3%) as unspecified HF. Individuals recorded as unspecified HF were older with a higher prevalence of dementia. Unspecified HF, compared to patients with a recorded HF phenotype, were less likely to receive specialist assessment, echocardiography or natriuretic peptide testing in the peri-diagnostic period, or receive angiotensin-converting enzyme inhibitors, beta blockers or mineralocorticoid receptor antagonists up to 12 months after diagnosis (risk ratios compared to HFrEF, 0.64, 95% CI 0.63–0.64; 0.59, 0.58–0.60; 0.57, 0.55–0.59; respectively) and had significantly worse outcomes (adjusted hazard ratios compared to HFrEF, HF hospitalisation and death 1.66, 95% CI 1.59–1.74; all-cause mortality 2.00, 1.90–2.10; cardiovascular death 1.77, 1.65–1.90).
Our findings suggested that absence of specification of HF phenotype in routine EHRs is inversely associated with clinical investigations, treatments and survival, representing an actionable target to mitigate prognostic and health resource burden.
Japan Research Foundation for Healthy Aging and British Heart Foundation.

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^∗: Drs Bhatt and Varshney contributed equally to this work.

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Original InvestigationVirtual Care Team Guided Management of Patients With Heart Failure During Hospitalization

Abstract

Background

Objectives

Methods

Results

Conclusions

Central Illustration

Section snippets

Methods

Study cohort

Discussion

Conclusions

Funding Support and Author Disclosures

Acknowledgments

Lancet

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol HF

J Am Coll Cardiol

Lancet

J Card Fail

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

Am J Cardiol

J Am Coll Cardiol

2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the ACC/AHA joint committee on clinical practice guidelines

J Am Coll Cardiol

Global disparities in prescription of guideline-recommended drugs for heart failure with reduced ejection fraction

Eur Heart J

Safety, Tolerability and Efficacy of Rapid Optimization, Helped by NT-proBNP and GDF-15, of Heart Failure Therapies (STRONG-HF): rationale and design for a multicentre, randomized, parallel-group study

Eur J Heart Fail

Original Investigation
Virtual Care Team Guided Management of Patients With Heart Failure During Hospitalization