Speaker
Ankeet S. Bhatt, MD, MBA, ScM
Associate Physician, Kaiser Permanente San Francisco Medical Center
Research Scientist, Kaiser Permanente Northern California Division of Research
Keywords
Heart Failure, Implementation Science, IMPLEMENT-HF
Key Points
- There are 4 drugs that modify 5 pathways, renin-angiotensin inhibition, neprilysin inhibition, SNS inhibition, aldosterone inhibition, and SGLT2 inhibition, that are the mainstays for treatment of heart failure with reduced ejection fraction (HFrEF).
- In modeling exercises, optimal implementation of these therapies, such as an ARNI, a beta blocker, an MRA, and an SGLT2 inhibitor, compared to conventional therapy (an ACEi or ARB plus a beta blocker) is estimated to afford more than 6 years of survival in a typical 55-year-old patient. This is compelling evidence that patients with HFrEF should be treated with this combination of therapies, but less than 5% of patients on are optimal guideline therapies for this condition.
- There is renewed interest in implementation science in cardiometabolic care to better understand optimal pathways for delivering these therapies in patients with HFrEF.
- The daily workflow consisted of a daily electronic health record (EHR) query that identified patients who had heart failure with reduced ejection fraction, who were admitted for any cause within sites in the healthcare system. Patients went through a screening by a study physician for eligibility. The physician-pharmacist team developed recommendations using an algorithm that was supported by the ACC, AHA clinical practice guidelines. They made only one suggestion a day for how to optimize the patient’s care, such as initiation of one therapy or an up titration of an existent therapy. The recommendations were communicated in the EHR as a note and the primary team received a page notification. The recommendations were at the discretion of the primary provider.
- There were substantial improvements in the intervention group of the pilot study and improved guideline medical therapy that indicated that the virtual nudge strategy might be beneficial and scalable to multiple entities within an integrated healthcare system.
- For the IMPLEMENT-HF Pivotal Study, 200 hospitalized patients were enrolled at 3 hospital sites in one integrated health care system, where patients either received the virtual care team intervention or usual care. The study team assessed the change in medical therapy from hospital admission to hospital discharge by assigning a guideline directed in-hospital medical therapy score.
- As compared to usual care, a virtual care team-guided strategy improved medical therapy optimization in hospitalized HFrEF patients across multiple hospitals in an integrated healthcare system. Benefits were consistent across most subgroups, including hospitalizations for non-HF indications and de-novo HF presentations.
Learn more
Read about the IMPLEMENT-HF study in JACC.
Discussion Themes
–How diverse were the settings where this was tested? The study team was interested in testing in a setting outside of a large academic hospital. Salem Hospital is affiliated with the health care system but is a community-based hospital. We need to test in systems that might have an enhanced usual care arm. Would this provide incremental value?
-What is going on at Mass General? It hasn’t been implemented in usual care yet but we hope that it will happen. There are a lot of programs that are aimed at this type of intervention at Kaiser but not one with a virtual intervention. It is something we are looking at seriously to see if we can run a small-scale version of this to see if it would be effective.
Tags
#pctGR, @Collaboratory1