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Brief Report
September 16, 2020

Remote Optimization of Guideline-Directed Medical Therapy in Patients With Heart Failure With Reduced Ejection Fraction

Author Affiliations
  • 1Cardiovascular Medicine Innovation Program, Brigham and Women’s Hospital, Boston, Massachusetts
  • 2Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts
  • 3Laboratory of Computer Science, Massachusetts General Hospital, Boston
JAMA Cardiol. 2020;5(12):1430-1434. doi:10.1001/jamacardio.2020.3757
Key Points

Question  Can a remote, algorithm-driven, navigator-administered medication optimization program enhance implementation of guideline-directed medical therapy in heart failure with reduced ejection fraction?

Findings  In this case-control study of 1028 patients, in 3 months, patients participating in the remote intervention experienced significant increases from baseline in the use and dosages of renin-angiotensin system antagonists and β-blockers but not mineralocorticoid receptor antagonists. Similar changes were not seen in a usual-care comparator group over the same period.

Meaning  Remote titration of guideline-directed medical therapy by navigators using encoded algorithms may represent an effective strategy for closing the gap between guidelines and clinical practice in patients with heart failure with reduced ejection fraction.

Abstract

Importance  Optimal treatment of heart failure with reduced ejection fraction (HFrEF) is scripted by treatment guidelines, but many eligible patients do not receive guideline-directed medical therapy (GDMT) in clinical practice.

Objective  To determine whether a remote, algorithm-driven, navigator-administered medication optimization program could enhance implementation of GDMT in HFrEF.

Design, Setting, and Participants  In this case-control study, a population-based sample of patients with HFrEF was offered participation in a quality improvement program directed at GDMT optimization. Treating clinicians in a tertiary academic medical center who were caring for patients with heart failure and an ejection fraction of 40% or less (identified through an electronic health record–based search) were approached for permission to adjust medical therapy according to a sequential titration algorithm modeled on the current American College of Cardiology/American Heart Association heart failure guidelines. Navigators contacted participants by telephone to direct medication adjustment and conduct longitudinal surveillance of laboratory tests, blood pressure, and symptoms under supervision of a pharmacist, nurse practitioner, and heart failure cardiologist. Patients and clinicians declining to participate served as a control group.

Exposures  Navigator-led remote optimization of GDMT compared with usual care.

Main Outcomes and Measures  Proportion of patients receiving GDMT in the intervention and control groups at 3 months.

Results  Of 1028 eligible patients (mean [SD] values: age, 68 [14] years; ejection fraction, 32% [8%]; and systolic blood pressure, 122 [18] mm Hg; 305 women (30.0%); 892 individuals [86.8%] in New York Heart Association class I and II), 197 (19.2%) participated in the medication optimization program, and 831 (80.8%) continued with usual care as directed by their treating clinicians (585 [56.9%] general cardiologists; 443 [43.1%] heart failure specialists). At 3 months, patients participating in the remote intervention experienced significant increases from baseline in use of renin-angiotensin system antagonists (138 [70.1%] to 170 [86.3%]; P < .001) and β-blockers (152 [77.2%] to 181 [91.9%]; P < .001) but not mineralocorticoid receptor antagonists (51 [25.9%] to 60 [30.5%]; P = .14). Doses for each category of GDMT also increased from baseline in the intervention group. Among the usual-care group, there were no changes from baseline in the proportion of patients receiving GDMT or the dose of GDMT in any category.

Conclusions and Relevance  Remote titration of GDMT by navigators using encoded algorithms may represent an efficient, population-level strategy for rapidly closing the gap between guidelines and clinical practice in patients with HFrEF.

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