Virtual care team model improves prescribing of heart failure drugs: IMPLEMENT-HF
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Key takeaways:
- A virtual care team strategy improved prescribing of recommended HF drugs for inpatients.
- The beneficial effects did not come at the expense of adverse events or increased hospital length of stay.
NEW ORLEANS — A virtual care team-guided strategy improved guideline-directed medical therapy for inpatients with HF with reduced ejection fraction across multiple hospitals in an integrated health care system, researchers reported.
Despite strong evidence and endorsement by clinical practice guidelines, implementation of guideline-directed medical therapy (GDMT) for HFrEF remains incomplete, Ankeet S. Bhatt, MD, MBA, ScM, clinical fellow in the division of cardiology at Brigham and Women’s Hospital and Harvard Medical School, said during a featured clinical research presentation at the American College of Cardiology Scientific Session. Hospitalization, regardless of the admission indication, may represent a potentially attractive setting for therapeutic optimization, Bhatt said.
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“However, prior HF implementation trials have generally excluded two populations: those with HF but admitted for other reasons, and those with de novo presentations of HF during their index clinical encounter,” Bhatt said.
Finding a ‘middle strategy’
Implementation trials conducted in patients with HFrEF typically involve one of two types of models — highly electronic clinical decision support algorithms, which are scalable to large populations but lead to concerns about “alert fatigue,” and in-person care support models, which have demonstrated large effects on implementation outcomes and even improvements in clinical outcomes, Bhatt said.
“However, these strategies are resource-intense and may not be applicable to other care settings,” Bhatt said. “We were interested in whether there might be a middle strategy. The one we selected was a virtual care team. We drew inspiration from other in-hospital care teams, like that of an antibiotic stewardship team, and an anticoagulation management service.”
In a multicenter implementation trial, Bhatt and colleagues allocated 252 hospital encounters for patients with HF with a left ventricular EF of 40% or lower to a virtual care team-guided strategy (107 encounters among 83 patients) or usual care (145 encounters among 115 patients) across three centers in an integrated health system. The mean age of patients was 69 years; 34% were women; 14% were Black and 17% were Hispanic. In the virtual care team group, clinicians received up to one daily GDMT optimization suggestion from a physician-pharmacist team.
The primary effectiveness outcome was in-hospital change in GDMT optimization score. In-hospital safety outcomes were adjudicated by an independent clinical events committee.
The findings were simultaneously published in the Journal of the American College of Cardiology.
Intervention improves drug initiation rates
The virtual care team strategy improved GDMT scores vs. usual care (adjusted difference, 1.2; 95% CI, 0.7-1.8; P < .001). Assessing initiation of specific therapies, prescribing of beta-blockers, in particular, nearly doubled for patients allocated to the virtual care team group vs. usual care, with prescribing rates among treatment-naive patients of 81% and 44%, respectively (P = .005). Similarly, rate of new prescriptions for mineralocorticoid antagonist therapy was higher in the virtual care group vs. usual care (32% vs. 11%; P = .001).
New initiations of GDMT (44% vs. 23%; P = .001) and intensifications of therapy (50% vs. 28%; P = .001) were higher in the virtual care team group, translating to a number needed to intervene of five encounters, Bhatt said.
Bhatt noted that the primary endpoint was an in-hospital implementation outcome; whether medication durability persists outside of the hospital setting after use of a virtual care team requires further study, he said. Additionally, the researchers observed an important treatment interaction in subgroup analyses in which Hispanic and predominantly Spanish-speaking patients derived less benefit from the virtual care intervention.
In-hospital adverse events (P = .3) and length of stay did not differ between the groups.
“Virtual care teams represent an effective, scalable and safe approach to HFrEF therapeutic optimization,” Bhatt said.
Reference:
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Bhatt AS, et al. Featured Clinical Research III. Presented at: American College of Cardiology Scientific Session; March 4-6, 2023; New Orleans (hybrid meeting).
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