Virtual Care Team Guided Management of Hospitalized HF Patients
- Identification of patients with HFrEF can be done virtually, improving efficiency to starting patients on appropriate medications for HFrEF.
- Communication with the primary team during hospitalization for HF patients can improve guideline-directed medical therapy prior to discharge.
Can a virtual care team improve guideline-directed medical therapy (GDMT) utilization in hospitalized patients with heart failure with reduced ejection fraction (HFrEF)?
IMPLEMENT-HF (Implementation of Medical Therapy in Hospitalized Patients With Heart Failure With Reduced Ejection Fraction) was designed as a prospective multi-institutional study in an integrated health system to evaluate the effectiveness and safety of a virtual care team. Patients were identified via electronic health records (EHRs). Daily, weekday screening was conducted by a centralized study physician via chart review across all three institutions at Mass General Brigham integrated health system. Patients were identified by previous echocardiogram in the last 12 months, or with de novo presentation of HFrEF at time of documentation.
Exclusion criteria included patients admitted to the intensive care unit, inotropic or mechanical circulatory support use during admission, acute coronary syndrome, stroke or major cardiovascular surgery within 30 days, systolic blood pressure <90 mm Hg in the preceding 24 hours, severe uncorrected valvular disease or moderate or greater right ventricular dysfunction on the most recent echocardiogram, admission for coronavirus disease 2019, or physician discretion.
The virtual care team guided intervention consisted of a centralized physician and study staff and local pharmacist at each site. Primary treating teams caring for patients allocated to the intervention group received up to once daily recommendations for GDMT optimization using an evidence-based algorithm. Final care optimization suggestions were communicated by progress notes in the EHR. Text messages were sent to the primary care team with a summary of what was placed in the patients’ chart. The virtual teams never saw the patients or conducted physical exams.
A total of 252 hospital encounters in patients with left ventricular EF ≤40% were randomized to a virtual care team guided strategy (107 encounters among 83 patients) or usual care (145 encounters among 115 patients). Among 252 encounters, 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 scores versus usual care (adjusted difference, +1.2; 95% confidence interval, 0.7-1.8; p < 0.001). New initiations (44% vs. 23%; p = 0.001) and intensifications of ≥1 GDMT (50% vs. 28%; p = 0.001) were higher in the virtual care team group, translating to a number-needed-to-intervene of five encounters. Overall, 23 (21%) in the virtual care team group and 40 (28%) in usual care experienced ≥1 safety events (p = 0.30). Acute kidney injury, bradycardia, hypotension, and hyperkalemia were similar between groups.
This study showed an improvement in GDMT during hospitalizations for patients with HFrEF with the use of virtual care teams. The teams communicated with the primary team via daily text messaging, with final recommendations being placed in the patients’ EHR. This allowed the intervention team to screen patients and determine medication needs that were consistent with HF guidelines. The study supported that virtual teams can be an efficient method to improve GDMT and medication titration for hospitalized patients.
Increasing the use of GDMT for patients with HFrEF who are hospitalized is challenging. Having a core group of HF experts reviewing patient charts and communicating recommendations with primary teams can be a safe and effective method to improve GDMT. Even though this was a single integrated health system with three hospitals of various sizes, this study supports the use of a virtual team of experts, without being labor intensive. Hopefully over time, members of the primary teams would become more confident in prescribing all classifications of medications for patients without reminders from the virtual experts.
Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Implantable Devices, Acute Heart Failure, Echocardiography/Ultrasound
Keywords: Acute Kidney Injury, Bradycardia, Echocardiography, Electronic Health Records, Heart Failure, Hospitalization, Hyperkalemia, Hypotension, Patient Care Team, Pharmacists, Stroke Volume, Text Messaging, Ventricular Dysfunction
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