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de Oliveira MT, Baptista R, Chavez-Leal SA, Bonatto MG. Heart failure management with β-blockers: can we do better? Curr Med Res Opin 2024; 40:43-54. [PMID: 38597068 DOI: 10.1080/03007995.2024.2318002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/08/2024] [Indexed: 04/11/2024]
Abstract
Heart failure (HF) is associated with disabling symptoms, poor quality of life, and a poor prognosis with substantial excess mortality in the years following diagnosis. Overactivation of the sympathetic nervous system is a key feature of the pathophysiology of HF and is an important driver of the process of adverse remodelling of the left ventricular wall that contributes to cardiac failure. Drugs which suppress the activity of the renin-angiotensin-aldosterone system, including β-blockers, are foundation therapies for the management of heart failure with reduced ejection fraction (HFrEF) and despite a lack of specific outcomes trials, are also widely used by cardiologist in patients with HF with preserved ejection fraction (HFpEF). Today, expert opinion has moved away from recommending that treatment for HF should be guided solely by the LVEF and interventions should rather address signs and symptoms of HF (e.g. oedema and tachycardia), the severity of HF, and concomitant conditions. β-blockers improve HF symptoms and functional status in HF and these agents have demonstrated improved survival, as well as a reduced risk of other important clinical outcomes such as hospitalisation for heart failure, in randomised, placebo-controlled outcomes trials. In HFpEF, β-blockers are anti-ischemic and lower blood pressure and heart rate. Moreover, β-blockers also reduce mortality in the setting of HF occurring alongside common comorbid conditions, such as diabetes, CKD (of any severity), and COPD. Higher doses of β-blockers are associated with better clinical outcomes in populations with HF, so that ensuring adequate titration of therapy to their maximal (or maximally tolerated) doses is important for ensuring optimal outcomes for people with HF. In principle, a patient with HF could have combined treatment with a β-blocker, renin-angiotensin-aldosterone system inhibitor/neprilysin inhibitor, mineralocorticoid receptor antagonist, and a SGLT2 inhibitor, according to tolerability.
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Affiliation(s)
- Mucio Tavares de Oliveira
- Heart Institute, Day Hospital and Infusion Center, University of Sao Paulo Medical School, Sao Paulo, Brazil
- Infusion Center and Day Hospital at Heart Institute (InCor), University of Sao Paulo, Sao Paulo, Brazil
| | - Rui Baptista
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Center for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
- Cardiology Department, Centro Hospitalar Entre Douro e Vouga, Santa Maria da Feira, Portugal
| | | | - Marcely Gimenes Bonatto
- Department of Heart Failure and Heart Transplant, Hospital Santa Casa de Misericórdia de, Curitiba, Brazil
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Harrington J, Rao VN, Leyva M, Oakes M, Mentz RJ, Bosworth HB, Pagidipati NJ. Improving Guideline-Directed Medical Therapy for Patients With Heart Failure With Reduced Ejection Fraction: A Review of Implementation Strategies. J Card Fail 2024; 30:376-390. [PMID: 38142886 DOI: 10.1016/j.cardfail.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 12/26/2023]
Abstract
Despite recent advances in the use of guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF), achievement of target GDMT use and up-titration to goal dosages continue to be modest. In recent years, a number of interventional approaches to improve the usage of GDMT have been published, but many are limited by single-center experiences with small sample sizes. However, strategies including the use of multidisciplinary teams, dedicated GDMT titration algorithms and clinician audits with feedback have shown promise. There remains a critical need for large, rigorous trials to assess the utility of differing interventions to improve the use and titration of GDMT in HFrEF. Here, we review existing literature in GDMT implementation for those with HFrEF and discuss future directions and considerations in the field.
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Affiliation(s)
- Josephine Harrington
- Department of Medicine, Division of Cardiology Duke University, Durham, NC; Duke Clinical Research Institute, Durham, NC.
| | - Vishal N Rao
- Department of Medicine, Division of Cardiology Duke University, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Monica Leyva
- Department of Population Health Sciences, Durham, NC
| | - Megan Oakes
- Department of Population Health Sciences, Durham, NC
| | - Robert J Mentz
- Department of Medicine, Division of Cardiology Duke University, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Hayden B Bosworth
- Department of Medicine, Division of Cardiology Duke University, Durham, NC; Department of Population Health Sciences, Durham, NC
| | - Neha J Pagidipati
- Department of Medicine, Division of Cardiology Duke University, Durham, NC; Duke Clinical Research Institute, Durham, NC
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3
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Driscoll A, Meagher S, Kennedy R, Currey J. Effect of Intensive Nurse-Led Optimization of Heart Failure Medications in Patients With Heart Failure: A Meta-analysis of Randomized Controlled Trials. J Cardiovasc Nurs 2024:00005082-990000000-00166. [PMID: 38227630 DOI: 10.1097/jcn.0000000000001068] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
BACKGROUND Prescribing of recommended medications for heart failure (HF) is suboptimal, leaving patients at a high risk of death or rehospitalization post discharge. Nurse-led titration (NLT) clinics are one strategy that could potentially improve the prescription of these medications. OBJECTIVE The aim of this article was to determine the effect of NLT clinics on all-cause mortality, all-cause or HF rehospitalizations, and adverse effects in patients with HF. METHODS We searched MEDLINE, EMBASE, Cochrane CENTRAL, International Clinical Trials Registry Platform, and ClinicalTrials.gov to identify randomized controlled trials comparing NLT of β-blocking agents, angiotensin receptor-neprilysin inhibitors, angiotensin-converting enzyme inhibitors, and/or angiotensin receptor blockers to optimization by another health professional in patients with HF. We used the fixed-effects Mantel-Haenszel method or meta-analyses. We assessed heterogeneity between studies using χ2 and I2. RESULTS Eight studies with 2025 participants were included. Participants in the NLT group experienced a lower rate of all-cause rehospitalizations (relative risk, 0.76, 95% confidence interval, 0.68-0.85; moderate quality of evidence) and less HF-related rehospitalizations (relative risk, 0.47; 95% confidence interval, 0.33-0.66; high quality of evidence) compared with the usual care group. All-cause mortality was lower in the NLT group (relative risk, 0.67; 95% confidence interval, 0.48-0.92; moderate quality of evidence) compared with the usual care group. Authors of one study reported no adverse events, and another study found one adverse event. CONCLUSION This meta-analysis indicates that NLT clinics may improve optimization of guideline-recommended medications with the potential to reduce rehospitalization and improve survival in a cohort of patients known for their poor outcomes.
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Ahmed M, Shafiq A, Zahid M, Dhawadi S, Javaid H, Rehman MEU, Chachar MA, Siddiqi AK. Clinical Outcomes With Nurse-Coordinated Multidisciplinary Care in Patients With Heart Failure: A Systematic Review and Meta-analysis. Curr Probl Cardiol 2024; 49:102041. [PMID: 37595855 DOI: 10.1016/j.cpcardiol.2023.102041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 08/15/2023] [Indexed: 08/20/2023]
Abstract
The American Heart Association (AHA) and the European Society of Cardiology (ESC) recommend nurse-inclusive multidisciplinary care for patients with heart failure (HF). However, there is no meta-analysis that focuses specifically on the impact of nurse-coordinated multidisciplinary care. Considering this literature gap, we conducted this review that seeks to systematically synthesize the current evidence available regarding the impact of nurse-coordinated multidisciplinary care on clinical outcomes in patients with HF. A comprehensive search was done using PubMed/Medline, Cochrane Library, and EMBASE from inception till July 2023 for randomized controlled trials (RCTs) comparing nurse-coordinated multidisciplinary care with usual care in adult patients (>18 years) with acute or chronic HF. Data about all-cause mortality, HF-related hospitalizations, and all-cause hospitalizations was extracted, pooled, and analyzed. Forrest plots were generated using the random effects model. A total of 30 RCTs were included in the analysis with a total of 7950 HF patients. Our pooled analysis demonstrated a significant reduction in all-cause mortality in HF patients who received nurse-coordinated multidisciplinary care (RR = 0.80, 95% CI: 0.72-0.88, P = 0.0001). Similarly, there was a significantly lesser risk of HF-related hospitalizations (RR = 0.56, 95% CI: 0.45-0.71, P = 0.00001) and all-cause hospitalizations (RR = 0.78, 95% CI: 0.70-0.87, P = 0.0001) among HF patients with nurse-coordinated multidisciplinary care as compared to the usual care. Nurse-coordinated multidisciplinary care significantly reduces the risk of all-cause mortality, HF-related hospitalizations, and all-cause hospitalizations in HF patients' posthospital discharge.
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Affiliation(s)
- Mushood Ahmed
- Department of Medicine, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Aimen Shafiq
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Maheen Zahid
- Department of Medicine, Liaquat University of Medical and Health Sciences, Hyderabad, Pakistan
| | - Siwar Dhawadi
- Department of Medicine, Faculty of Medicine Monastir, Mosastir, Tunisia
| | - Hira Javaid
- Department of Medicine, Allama Iqbal Medical College, Lahore, Pakistan
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5
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Veroniki AA, Soobiah C, Nincic V, Lai Y, Rios P, MacDonald H, Khan PA, Ghassemi M, Yazdi F, Brownson RC, Chambers DA, Dolovich LR, Edwards A, Glasziou PP, Graham ID, Hemmelgarn BR, Holmes BJ, Isaranuwatchai W, Legare F, McGowan J, Presseau J, Squires JE, Stelfox HT, Strifler L, Van der Weijden T, Fahim C, Tricco AC, Straus SE. Efficacy of sustained knowledge translation (KT) interventions in chronic disease management in older adults: systematic review and meta-analysis of complex interventions. BMC Med 2023; 21:269. [PMID: 37488589 PMCID: PMC10367354 DOI: 10.1186/s12916-023-02966-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 06/27/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Chronic disease management (CDM) through sustained knowledge translation (KT) interventions ensures long-term, high-quality care. We assessed implementation of KT interventions for supporting CDM and their efficacy when sustained in older adults. METHODS Design: Systematic review with meta-analysis engaging 17 knowledge users using integrated KT. ELIGIBILITY CRITERIA Randomized controlled trials (RCTs) including adults (> 65 years old) with chronic disease(s), their caregivers, health and/or policy-decision makers receiving a KT intervention to carry out a CDM intervention for at least 12 months (versus other KT interventions or usual care). INFORMATION SOURCES We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from each database's inception to March 2020. OUTCOME MEASURES Sustainability, fidelity, adherence of KT interventions for CDM practice, quality of life (QOL) and quality of care (QOC). Data extraction, risk of bias (ROB) assessment: We screened, abstracted and appraised articles (Effective Practice and Organisation of Care ROB tool) independently and in duplicate. DATA SYNTHESIS We performed both random-effects and fixed-effect meta-analyses and estimated mean differences (MDs) for continuous and odds ratios (ORs) for dichotomous data. RESULTS We included 158 RCTs (973,074 participants [961,745 patients, 5540 caregivers, 5789 providers]) and 39 companion reports comprising 329 KT interventions, involving patients (43.2%), healthcare providers (20.7%) or both (10.9%). We identified 16 studies described as assessing sustainability in 8.1% interventions, 67 studies as assessing adherence in 35.6% interventions and 20 studies as assessing fidelity in 8.7% of the interventions. Most meta-analyses suggested that KT interventions improved QOL, but imprecisely (36 item Short-Form mental [SF-36 mental]: MD 1.11, 95% confidence interval [CI] [- 1.25, 3.47], 14 RCTs, 5876 participants, I2 = 96%; European QOL-5 dimensions: MD 0.01, 95% CI [- 0.01, 0.02], 15 RCTs, 6628 participants, I2 = 25%; St George's Respiratory Questionnaire: MD - 2.12, 95% CI [- 3.72, - 0.51] 44 12 RCTs, 2893 participants, I2 = 44%). KT interventions improved QOC (OR 1.55, 95% CI [1.29, 1.85], 12 RCTS, 5271 participants, I2 = 21%). CONCLUSIONS KT intervention sustainability was infrequently defined and assessed. Sustained KT interventions have the potential to improve QOL and QOC in older adults with CDM. However, their overall efficacy remains uncertain and it varies by effect modifiers, including intervention type, chronic disease number, comorbidities, and participant age. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018084810.
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Affiliation(s)
- Areti Angeliki Veroniki
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, 155 College Street, Toronto, ON Canada
| | - Charlene Soobiah
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, 155 College Street, Toronto, ON Canada
| | - Vera Nincic
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Yonda Lai
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Patricia Rios
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Heather MacDonald
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Paul A. Khan
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Marco Ghassemi
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Fatemeh Yazdi
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Ross C. Brownson
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, St. Louis, MO USA
- Department of Surgery and Alvin J. Siteman Cancer Center, Washington University School of Medicine, Washington University in St. Louis, 660 S. Euclid Avenue, St. Louis, MO USA
| | - David A. Chambers
- National Cancer Institute, 9609 Medical Center Drive, Rockville, MD USA
| | - Lisa R. Dolovich
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON Canada
- Department of Family Medicine David Braley Health Sciences Centre, McMaster University, 100 Main Street West, Hamilton, ON Canada
| | - Annemarie Edwards
- Canadian Partnership Against Cancer, 1 University Avenue, Toronto, ON Canada
| | - Paul P. Glasziou
- Faculty of Health Sciences and Medicine, Bond University, Robina, QLD 4226 Australia
| | - Ian D. Graham
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON Canada
- The Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON Canada
| | - Brenda R. Hemmelgarn
- Department of Medicine, University of Alberta, C MacKenzie Health Sciences Centre, WalterEdmonton, AB 2J2.00 Canada
| | - Bev J. Holmes
- The Michael Smith Foundation for Health Research (MSFHR), 200 - 1285 West Broadway, Vancouver, BC Canada
| | - Wanrudee Isaranuwatchai
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - France Legare
- Département de Médecine Familiale Et Médecine d’urgenceFaculté de Médecine, Université Laval Pavillon Ferdinand-Vandry1050, Avenue de La Médecine, Local 2431, Québec, QC Canada
- Axe Santé Des Populations Et Pratiques Optimales en Santé, Centre de Recherche du CHU de Québec 1050, Chemin Sainte-Foy, Local K0-03, Québec, QC Canada
| | - Jessie McGowan
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON Canada
| | - Justin Presseau
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON Canada
- The Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON Canada
| | - Janet E. Squires
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON Canada
- School of Nursing, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5 Canada
| | - Henry T. Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O’Brien Institute for Public Health, University of Calgary and Alberta Health Services, Calgary, AB Canada
| | - Lisa Strifler
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Trudy Van der Weijden
- Department of Family Medicine, Maastricht University, CAPHRI Care and Public Health Research Institute, Debeyeplein 1, Maastricht, The Netherlands
| | - Christine Fahim
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Andrea C. Tricco
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
- Epidemiology Division & Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
| | - Sharon E. Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, 155 College Street, Toronto, ON Canada
- Department of Geriatric Medicine, University of Toronto, Toronto, ON Canada
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Zheng J, Mednick T, Heidenreich PA, Sandhu AT. Pharmacist- and Nurse-Led Medical Optimization in Heart Failure: A Systematic Review and Meta-Analysis. J Card Fail 2023; 29:1000-1013. [PMID: 37004867 PMCID: PMC10524094 DOI: 10.1016/j.cardfail.2023.03.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Traditional approaches to guideline-directed medical therapy (GDMT) management often lead to delayed initiation and titration of therapies in patients with heart failure. This study sought to characterize alternative models of care involving nonphysician provider-led GDMT interventions and their associations with therapy use and clinical outcomes. METHODS We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies comparing nonphysician provider-led GDMT initiation and/or uptitration interventions vs usual physician care (PROSPERO ID: CRD42022334661). We queried PubMed, Embase, the Cochrane Library, and the World Health Organization International Clinical Trial Registry Platform for peer-reviewed studies from database inception to July 31, 2022. In the meta-analysis, we used RCT data only and leveraged random-effects models to estimate pooled outcomes. Primary outcomes were GDMT initiation and titration to target dosages by therapeutic class. Secondary outcomes included all-cause mortality and HF hospitalizations. RESULTS We reviewed 33 studies, of which 17 (52%) were randomized controlled trials with median follow-ups of 6 months; 14 (82%) trials evaluated nurse interventions, and the remainder assessed pharmacists' interventions. The primary analysis pooled data from 16 RCTs, which enrolled 5268 patients. Pooled risk ratios (RR) for renin-angiotensin system inhibitor (RASI) and beta-blocker initiation were 2.09 (95% CI 1.05-4.16; I2 = 68%) and 1.91 (95% CI1.35-2.70; I2 = 37%), respectively. Outcomes were similar for uptitration of RASI (RR 1.99, 95% CI 1.24-3.20; I2 = 77%) and beta-blocker (RR 2.22, 95% CI 1.29-3.83; I2 = 66%). No association was found with mineralocorticoid receptor antagonist initiation (RR 1.01, 95% CI 0.47-2.19). There were lower rates of mortality (RR 0.82, 95% CI 0.67-1.04; I2 = 12%) and hospitalization due to HF (RR 0.80, 95% CI 0.63-1.01; I2 = 25%) across intervention arms, but these differences were small and not statistically significant. Prediction intervals were wide due to moderate-to-high heterogeneity across trial populations and interventions. Subgroup analyses by provider type did not show significant effect modification. CONCLUSIONS Pharmacist- and nurse-led interventions for GDMT initiation and/or uptitration improved guideline concordance. Further research evaluating newer therapies and titration strategies integrated with pharmacist- and/or nurse-based care may be valuable.
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Affiliation(s)
- Jimmy Zheng
- Stanford University School of Medicine, Stanford, CA.
| | - Thomas Mednick
- Sutter Health, California Pacific Medical Center, San Francisco, CA
| | - Paul A Heidenreich
- Division of Cardiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
| | - Alexander T Sandhu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
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Dorsch MP, Sifuentes A, Cordwin DJ, Kuo R, Rowell BE, Arzac JJ, DeBacker K, Guidi JL, Hummel SL, Koelling TM. A Computable Algorithm for Medication Optimization in Heart Failure With Reduced Ejection Fraction. JACC. ADVANCES 2023; 2:100289. [PMID: 38939592 PMCID: PMC11198495 DOI: 10.1016/j.jacadv.2023.100289] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 12/05/2022] [Accepted: 01/30/2023] [Indexed: 06/29/2024]
Abstract
Background Guideline-directed medical therapy (GDMT) optimization can improve outcomes in heart failure with reduced ejection fraction. Objectives The objective of this study was to determine if a novel computable algorithm appropriately recommended GDMT. Methods Clinical trial data from the GUIDE-IT (Guiding Evidence-Based Therapy Using Biomarker Intensified Treatment in Heart Failure) and HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) trials were evaluated with a computable medication optimization algorithm that outputs GDMT recommendations and a medication optimization score (MOS). Algorithm-based recommendations were compared to medication changes. A Cox proportional-hazards model was used to estimate the associations between MOS and the composite primary end point for both trials. Results The algorithm recommended initiation of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, beta-blockers, and mineralocorticoid receptor antagonists in 52.8%, 34.9%, and 68.1% of GUIDE-IT visits, respectively, when not prescribed the drug. Initiation only occurred in 20.8%, 56.9%, and 15.8% of subsequent visits. The algorithm also identified dose titration in 48.8% of visits for angiotensin-converting enzyme inhibitor/angiotensin receptor blockers and 39.4% of visits for beta-blockers. Those increases only occurred in 24.3% and 36.8% of subsequent visits. A higher baseline MOS was associated with a lower risk of cardiovascular death or heart failure hospitalization (HR: 0.41; 95% CI: 0.21-0.80; P = 0.009) in GUIDE-IT and all-cause death and hospitalization (HR: 0.61; 95% CI: 0.44-0.84; P = 0.003) in HF-ACTION. Conclusions The algorithm accurately identified patients for GDMT optimization. Even in a clinical trial with robust protocols, GDMT could have been further optimized in a meaningful number of visits. The algorithm-generated MOS was associated with a lower risk of clinical outcomes. Implementation into clinical care may identify and address suboptimal GDMT in patients with heart failure with reduced ejection fraction.
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Affiliation(s)
- Michael P. Dorsch
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Aaron Sifuentes
- Department of Internal Medicine, Medical School, University of Michigan, Ann Arbor, Michigan, USA
| | - David J. Cordwin
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Rachel Kuo
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Brigid E. Rowell
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Juan J. Arzac
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Ken DeBacker
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Jessica L. Guidi
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, Medical School, University of Michigan, Ann Arbor, Michigan, USA
| | - Scott L. Hummel
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, Medical School, University of Michigan, Ann Arbor, Michigan, USA
- Ann Arbor Veterans Affairs Health System, Ann Arbor, Michigan, USA
| | - Todd M. Koelling
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, Medical School, University of Michigan, Ann Arbor, Michigan, USA
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8
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Verma A, Fonarow GC, Hsu JJ, Jackevicius CA, Mody FV, Amidi O, Goldberg S, Upparapalli D, Theodoropoulos K, Gregorio S, Chang DS, Bostrom K, Althouse AD, Ziaeian B. The design of the Dashboard Activated Services and Telehealth for Heart Failure (DASH-HF) study: A pragmatic quality improvement randomized implementation trial for patients with heart failure with reduced ejection fraction. Contemp Clin Trials 2022; 120:106895. [PMID: 36028192 PMCID: PMC9635621 DOI: 10.1016/j.cct.2022.106895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 07/14/2022] [Accepted: 08/20/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Gaps in the receipt and dosing of guideline-directed medical therapy (GDMT) persist for patients with heart failure with reduced ejection fraction (HFrEF) [1]. In 2020, the Veterans Affairs (VA) developed a heart failure (HF) specific population dashboard to monitor care quality and performance on standard HFrEF performance measures [2]. METHODS The Dashboard Activated Services and Telehealth for HF (DASH-HF) study is a pragmatic randomized quality improvement study designed to evaluate the utility of proactive population management clinics using the VA's HF dashboard to optimize GDMT for patients with HFrEF. Panel management telemedicine clinics incorporated multidisciplinary clinicians to perform chart review and impromptu telephone encounters to evaluate current HFrEF management and opportunities to optimize GDMT. The study will evaluate the efficacy of proactive panel management to usual care at 6 months as quantified by the GDMT optimization potential score. Secondary outcomes include hospitalizations, mortality, and clinician time per intervention. The study completed enrollment and randomization of 300 participants. The intervention was performed from September to December 2021. CONCLUSION DASH-HF will contribute to the literature by evaluating use of the existing VA dashboard to identify HF patients with the lowest adherence to GDMT and proactively target this group for the intervention. REGISTRATION https://clinicaltrials.gov/. Unique identifier: NCT05001165.
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Affiliation(s)
- Aradhana Verma
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Jeffrey J Hsu
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America; Division of Cardiology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States of America
| | - Cynthia A Jackevicius
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, CA, Department of Pharmacy, VA Greater Los Angeles Healthcare System, ICES, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Freny Vaghaiwalla Mody
- Division of Cardiology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States of America
| | - Omid Amidi
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Sarah Goldberg
- Division of Cardiology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States of America
| | - Deepti Upparapalli
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Kleanthis Theodoropoulos
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Stephanie Gregorio
- Department of Pharmacy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States of America
| | - Donald S Chang
- Division of Cardiology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States of America
| | - Kristina Bostrom
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America; Division of Cardiology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States of America
| | - Andrew D Althouse
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Boback Ziaeian
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America; Division of Cardiology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States of America.
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9
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A systematic review on the effectiveness and impact of clinical decision support systems for breathlessness. NPJ Prim Care Respir Med 2022; 32:29. [PMID: 35987745 PMCID: PMC9392800 DOI: 10.1038/s41533-022-00291-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/19/2022] [Indexed: 11/09/2022] Open
Abstract
AbstractBreathlessness is a common presenting symptom in practice. This systematic review aimed to evaluate the impact of CDSS on breathlessness and associated diseases in real-world clinical settings. Studies published between 1 January 2000 to 10 September 2021 were systematically obtained from 14 electronic research databases including CENTRAL, Embase, Pubmed, and clinical trial registries. Main outcomes of interest were patient health outcomes, provider use, diagnostic concordance, economic evaluation, and unintended consequences. The review protocol was prospectively registered in PROSPERO (CRD42020163141). A total of 4294 records were screened and 37 studies included of which 30 were RCTs. Twenty studies were in primary care, 13 in hospital outpatient/emergency department (ED), and the remainder mixed. Study duration ranged from 2 weeks to 5 years. Most were adults (58%). Five CDSS were focused on assessment, one on assessment and management, and the rest on disease-specific management. Most studies were disease-specific, predominantly focused on asthma (17 studies), COPD (2 studies), or asthma and COPD (3 studies). CDSS for COPD, heart failure, and asthma in adults reported clinical benefits such as reduced exacerbations, improved quality of life, improved patient-reported outcomes or reduced mortality. Studies identified low usage as the main barrier to effectiveness. Clinicians identified dissonance between CDSS recommendations and real-world practice as a major barrier. This review identified potential benefits of CDSS implementation in primary care and outpatient services for adults with heart failure, COPD, and asthma in improving diagnosis, compliance with guideline recommendations, promotion of non-pharmacological interventions, and improved clinical outcomes including mortality.
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10
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Amiya E. Social Inequalities in Non-ischemic Cardiomyopathies. Front Cardiovasc Med 2022; 9:831918. [PMID: 35321101 PMCID: PMC8934878 DOI: 10.3389/fcvm.2022.831918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
Heart failure (HF) has various characteristics, such as etiology, clinical course, and clinical characteristics. Several studies reported the clinical findings of the characteristics of non-ischemic cardiomyopathy. There have been issues with genetic, biochemical, or pathophysiological problems. Some studies have been conducted on non-ischemic cardiomyopathy and social factors, for instance, racial disparities in peripartum cardiomyopathy (PPCM) or the social setting of hypertrophic cardiomyopathy. However, there have been insufficient materials to consider the relationship between social factors and clinical course in non-ischemic cardiomyopathies. There were various methodologies in therapeutic interventions, such as pharmacological, surgical, or rehabilitational, and educational issues. However, interventions that could be closely associated with social inequality have not been sufficiently elucidated. We will summarize the effects of social equality, which could have a large impact on the development and progression of HF in non-ischemic cardiomyopathies.
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Affiliation(s)
- Eisuke Amiya
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
- Department of Therapeutic Strategy for Heart Failure, University of Tokyo, Tokyo, Japan
- *Correspondence: Eisuke Amiya
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11
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Zhou Y, Zeng Y, Wang S, Li N, Wang M, Mordi IR, Ren Y, Zhou Y, Zhu Y, Tian H, Sun X, Chen X, An Z, Lang CC, Li S. Guideline Adherence of β-blocker Initiating Dose and its Consequence in Hospitalized Patients With Heart Failure With Reduced Ejection Fraction. Front Pharmacol 2021; 12:770239. [PMID: 34899323 PMCID: PMC8660072 DOI: 10.3389/fphar.2021.770239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 10/27/2021] [Indexed: 02/05/2023] Open
Abstract
Background: We aim to investigate the guideline adherence of β-blocker (BB) initiating dose in Chinese hospitalized patients with heart failure with reduced ejection fraction (HFrEF) and whether the adherence affected the in-hospital outcomes. Methods: This was a retrospective study of patients hospitalized with HFrEF who had initiated BBs during their hospitalization. We defined adherence to clinical practice guidelines as initiating BB with standard dose and non-adherence to guidelines if otherwise, and examined the association between adherence to guidelines and in-hospital BB-related adverse events. Subgroup analyses based on sex, age, coronary heart disease, and hypertension were performed. Results: Among 1,104 patients with HFrEF initiating BBs during hospitalization (median length of hospitalization, 12 days), 304 (27.5%) patients received BB with non-adherent initiating dose. This non-adherence was related to a higher risk (hazard ratio [95% confidence interval]) of BB dose reduction or withdrawal (1.78 [1.42 to 2.22], P < 0.001), but not significantly associated with risks of profound bradycardia, hypotension, cardiogenic shock requiring intravenous inotropes, and severe bronchospasm requiring intravenous steroid during hospitalization. Conclusion: This study identified that over a fourth of patients had received BBs with an initiating dose that was not adherent to guidelines in Chinese hospitalized patients with HFrEF, and this non-adherence was associated with BB dose reduction or withdrawal during hospitalization.
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Affiliation(s)
- Yiling Zhou
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Yuping Zeng
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Si Wang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Nan Li
- The Informatic Center, West China Hospital, Sichuan University, Chengdu, China
| | - Miye Wang
- The Informatic Center, West China Hospital, Sichuan University, Chengdu, China
| | - Ify R. Mordi
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Scotland, United Kingdom
| | - Yan Ren
- Cochrane China Center, MAGIC China Center, Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Youlian Zhou
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Ye Zhu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Haoming Tian
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Sun
- Cochrane China Center, MAGIC China Center, Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoping Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhenmei An
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Chim C. Lang
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Scotland, United Kingdom
| | - Sheyu Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
- Cochrane China Center, MAGIC China Center, Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
- Engineering Research Center of Medical Information Technology, Ministry of Education, West China Hospital, Sichuan University, Chengdu, China
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Scotland, United Kingdom
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12
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Implementing Nonphysician Provider Guideline-Directed Medical Therapy Heart Failure Clinics: A Multi-National Imperative. J Card Fail 2021; 27:896-906. [PMID: 34364666 DOI: 10.1016/j.cardfail.2021.06.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 01/01/2023]
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13
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No inferioridad de la titulación de enfermera de insuficiencia cardiaca en comparación con la de cardiólogo de insuficiencia cardiaca. Ensayo aleatorizado multicéntrico ETIFIC. Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.04.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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14
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Puwanant S, Sinphurmsukskul S, Krailak L, Nakaviroj P, Boonbumrong N, Siwamogsatham S, Chettakulanurak K, Ariyachaipanich A, Boonyaratavej S. The impact of the coronavirus disease and Tele-Heart Failure Clinic on cardiovascular mortality and heart failure hospitalization in ambulatory patients with heart failure. PLoS One 2021; 16:e0249043. [PMID: 33755715 PMCID: PMC7987182 DOI: 10.1371/journal.pone.0249043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 03/09/2021] [Indexed: 12/21/2022] Open
Abstract
Background We sought to investigate the impact of the COVID-19 pandemic and the Tele-HF Clinic (Tele-HFC) program on cardiovascular death, heart failure (HF) rehospitalization, and heart transplantation rates in a cohort of ambulatory HF patients during and after the peak of the pandemic. Methods Using the HF clinic database, we compared data of patients with HF before, during, and after the peak of the pandemic (January 1 to March 17 [pre-COVID], March 17 to May 31 [peak-COVID], and June 1 to October 1 [post-COVID]). During peak-COVID, all patients were managed by Tele-HFC or hospitalization. After June 1, patients chose either a face-to-face clinic visit or a continuous tele-clinic visit. Results Cardiovascular death and medical titration rates were similar in peak-COVID compared with all other periods. HF readmission rates were significantly lower in peak-COVID (8.7% vs. 2.5%, p<0.001) and slightly increased (3.5%) post-COVID. Heart transplant rates were substantially increased in post-COVID (4.5% vs. peak-COVID [0%], p = 0.002). After June 1, 38% of patients continued with the Tele-HFC program. Patients managed by the Tele-HFC program for <6 months were less likely to have HF with reduced ejection fraction (73% vs. 54%, p = 0.005) and stage-D HF (33% vs. 14%, p = 0.001), and more likely to achieve the target neurohormonal blockade dose (p<0.01), compared with the ≥6-month Tele-HFC group. Conclusions HF rehospitalization and transplant rates significantly declined during the pandemic in ambulatory care of HF. However, reduction in these rates did not affect subsequent 5-month hospitalization and cardiovascular mortality in the setting of Tele-HFC program and continuum of advanced HF therapies.
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Affiliation(s)
- Sarinya Puwanant
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Cardiac Center, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- * E-mail:
| | - Supanee Sinphurmsukskul
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Cardiac Center, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Laddawan Krailak
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Cardiac Center, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Pavinee Nakaviroj
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Cardiac Center, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Noppawan Boonbumrong
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Cardiac Center, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Sarawut Siwamogsatham
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Cardiac Center, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Krailerk Chettakulanurak
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Cardiac Center, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Aekarach Ariyachaipanich
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Cardiac Center, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Smonporn Boonyaratavej
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Cardiac Center, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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15
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Wong JA, Roberts JD, Healey JS. The Optimal Timing of Primary Prevention Implantable Cardioverter-Defibrillator Referral in the Rapidly Changing Medical Landscape. Can J Cardiol 2021; 37:644-654. [PMID: 33549824 DOI: 10.1016/j.cjca.2021.01.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/28/2021] [Accepted: 01/28/2021] [Indexed: 12/28/2022] Open
Abstract
The use of implantable cardioverter-defibrillators (ICDs) significantly reduces the risk of mortality in patients with heart failure with reduced ejection fraction (HFrEF). Current guidelines, which are based on seminal clinical trials published nearly 2 decades ago, recommend that patients be on optimal medical therapy for HF for a minimum of 3 months before referral for prophylactic ICD. This waiting period allows for left ventricular reverse remodelling and improvement in HF symptoms, which may render primary prevention ICD implantation unnecessary. However, medical therapy for HFrEF has significantly evolved since the publication of these landmark trials. Given the plethora of medical therapy options now available for HFrEF, it is appropriate to reassess the duration of this waiting period. In the present review, we examine the landmark randomised trials in primary prevention of sudden cardiac death in patients with HFrEF, summarise the novel medical therapies (sacubitril-valsartan, sodium-glucose cotransporter 2 inhibitors, ivabradine, vericiguat, and omecamtiv mecarbil) that have emerged since the publication of those trials, discuss the optimal timing of ICD referral, and review subtypes of nonischemic cardiomyopathy where timing of ICD insertion is guided by alternative criteria. With the steps now needed to optimise medical therapy for HFrEF, in terms of both classes of drugs and doses of each agent, it can easily take up to 6 months to achieve optimisation. Following that, waiting periods of 3 months for ischemic cardiomyopathy and 6 months for nonischemic cardiomyopathy may be required to allow adequate reverse remodelling before reevaluating for ICD implantation.
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Affiliation(s)
- Jorge A Wong
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jason D Roberts
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jeff S Healey
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
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16
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Allen LA, Venechuk G, McIlvennan CK, Page RL, Knoepke CE, Helmkamp LJ, Khazanie P, Peterson PN, Pierce K, Harger G, Thompson JS, Dow TJ, Richards L, Huang J, Strader JR, Trinkley KE, Kao DP, Magid DJ, Buttrick PM, Matlock DD. An Electronically Delivered Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure With Reduced Ejection Fraction: The EPIC-HF Trial. Circulation 2020; 143:427-437. [PMID: 33201741 DOI: 10.1161/circulationaha.120.051863] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Major gaps exist in the routine initiation and dose up-titration of guideline-directed medical therapies (GDMT) for patients with heart failure with reduced ejection fraction. Without novel approaches to improve prescribing, the cumulative benefits of heart failure with reduced ejection fraction treatment will be largely unrealized. Direct-to-consumer marketing and shared decision making reflect a culture where patients are increasingly involved in treatment choices, creating opportunities for prescribing interventions that engage patients. METHODS The EPIC-HF (Electronically Delivered, Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure with Reduced Ejection Fraction) trial randomized patients with heart failure with reduced ejection fraction from a diverse health system to usual care versus patient activation tools-a 3-minute video and 1-page checklist-delivered electronically 1 week before, 3 days before, and 24 hours before a cardiology clinic visit. The tools encouraged patients to work collaboratively with their clinicians to "make one positive change" in heart failure with reduced ejection fraction prescribing. The primary endpoint was the percentage of patients with GDMT medication initiations and dose intensifications from immediately preceding the cardiology clinic visit to 30 days after, compared with usual care during the same period. RESULTS EPIC-HF enrolled 306 patients, 290 of whom attended a clinic visit during the study period: 145 were sent the patient activation tools and 145 were controls. The median age of patients was 65 years; 29% were female, 11% were Black, 7% were Hispanic, and the median ejection fraction was 32%. Preclinic data revealed significant GDMT opportunities, with no patients on target doses of β-blocker, sacubitril/valsartan, and mineralocorticoid receptor antagonists. From immediately preceding the cardiology clinic visit to 30 days after, 49.0% in the intervention and 29.7% in the control experienced an initiation or intensification of their GDMT (P=0.001). The majority of these changes were made at the clinician encounter itself and involved dose uptitrations. There were no deaths and no significant differences in hospitalization or emergency department visits at 30 days between groups. CONCLUSIONS A patient activation tool delivered electronically before a cardiology clinic visit improved clinician intensification of GDMT. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03334188.
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Affiliation(s)
- Larry A Allen
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Grace Venechuk
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Colleen K McIlvennan
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Robert L Page
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora (R.L.P., K.E.T.)
| | | | - Laura J Helmkamp
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Prateeti Khazanie
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Pamela N Peterson
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.).,Denver Health Medical Center, CO (P.N.P.)
| | - Kenneth Pierce
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Geoffrey Harger
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Jocelyn S Thompson
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Tristan J Dow
- University of Colorado Health Poudre Valley Hospital, Loveland (T.J.D., L.R.)
| | - Lance Richards
- University of Colorado Health Poudre Valley Hospital, Loveland (T.J.D., L.R.)
| | - Janice Huang
- University of Colorado Health Memorial Hospital, Colorado Springs (J.H., J.R.S.)
| | - James R Strader
- University of Colorado Health Memorial Hospital, Colorado Springs (J.H., J.R.S.)
| | - Katy E Trinkley
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.).,University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora (R.L.P., K.E.T.)
| | - David P Kao
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - David J Magid
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Peter M Buttrick
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Daniel D Matlock
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
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17
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Artanian V, Ross HJ, Rac VE, O'Sullivan M, Brahmbhatt DH, Seto E. Impact of Remote Titration Combined With Telemonitoring on the Optimization of Guideline-Directed Medical Therapy for Patients With Heart Failure: Internal Pilot of a Randomized Controlled Trial. JMIR Cardio 2020; 4:e21962. [PMID: 33141094 PMCID: PMC7671843 DOI: 10.2196/21962] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/22/2020] [Accepted: 09/30/2020] [Indexed: 12/21/2022] Open
Abstract
Background To improve health outcomes in patients with heart failure, guideline-directed medical therapy (GDMT) should be optimized to target doses. However, GDMT remains underutilized, with less than 25% of patients receiving target doses in clinical practice. Telemonitoring could provide reliable and real-time physiological data for clinical decision support to facilitate remote GDMT titration. Objective This paper aims to present findings from an internal pilot study regarding the effectiveness of remote titration facilitated by telemonitoring. Methods A 2-arm randomized controlled pilot trial comparing remote titration versus standard care in a heart function clinic was conducted. Patients were randomized to undergo remote medication titration facilitated by data from a smartphone-based telemonitoring system or standard titration performed during clinic visits. Results A total of 42 patients with new-onset (10/42, 24%) and existing (32/42, 76%) heart failure and a mean age of 55.29 (SD 11.28) years were randomized between January and June 2019. Within 6 months of enrollment, 86% (18/21) of patients in the intervention group achieved optimal doses versus 48% (10/21) of patients in the control group. The median time to dose optimization was 11.0 weeks for the intervention group versus 18.8 weeks for the control group. The number of in-person visits in the intervention group was 54.5% lower than in the control group. Conclusions The results of this pilot study suggest that remote titration facilitated by telemonitoring has the potential to increase the proportion of patients who achieve optimal GDMT doses, decrease time to dose optimization, and reduce the number of clinic visits. Remote titration may facilitate optimal and efficient titration of patients with heart failure while reducing the burden for patients to attend in-person clinic visits. Trial Registration ClinicalTrials.gov NCT04205513; https://clinicaltrials.gov/ct2/show/NCT04205513 International Registered Report Identifier (IRRID) RR2-10.2196/preprints.19705
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Affiliation(s)
- Veronica Artanian
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Heather J Ross
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.,Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Valeria E Rac
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.,Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Mary O'Sullivan
- Peter Munk Cardiac Centre, Division of Cardiology, University Health Network, Toronto, ON, Canada
| | - Darshan H Brahmbhatt
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Peter Munk Cardiac Centre, Division of Cardiology, University Health Network, Toronto, ON, Canada.,National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Emily Seto
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, ON, Canada
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18
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Venechuk GE, Khazanie P, Page RL, Knoepke CE, Helmkamp LJ, Peterson PN, Pierce K, Thompson JS, Huang J, Strader JR, Dow TJ, Richards L, Trinkley KE, Kao DP, McIlvennan CK, Magid DJ, Buttrick PM, Matlock DD, Allen LA. An Electronically delivered, Patient-activation tool for Intensification of medications for Chronic Heart Failure with reduced ejection fraction: Rationale and design of the EPIC-HF trial. Am Heart J 2020; 229:144-155. [PMID: 32866454 DOI: 10.1016/j.ahj.2020.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Heart failure with reduced ejection fraction (HFrEF) benefits from initiation and intensification of multiple pharmacotherapies. Unfortunately, there are major gaps in the routine use of these drugs. Without novel approaches to improve prescribing, the cumulative benefits of HFrEF treatment will be largely unrealized. Direct-to-consumer marketing and shared decision making reflect a culture where patients are increasingly involved in treatment choices, creating opportunities for prescribing interventions that engage patients. HYPOTHESIS Encouraging patients to engage providers in HFrEF prescribing decisions will improve the use of guideline-directed medical therapies. DESIGN The Electronically delivered, Patient-activation tool for Intensification of Chronic medications for Heart Failure with reduced ejection fraction (EPIC-HF) trial randomizes patients with HFrEF to usual care versus patient-activation tools-a 3-minute video and 1-page checklist-delivered prior to cardiology clinic visits that encourage patients to work collaboratively with their clinicians to intensify HFrEF prescribing. The study assesses the effectiveness of the EPIC-HF intervention to improve guideline-directed medical therapy in the month after its delivery while using an implementation design to also understand the reach, adoption, implementation, and maintenance of this approach within the context of real-world care delivery. Study enrollment was completed in January 2020, with a total 305 patients. Baseline data revealed significant opportunities, with <1% of patients on optimal HFrEF medical therapy. SUMMARY The EPIC-HF trial assesses the implementation, effectiveness, and safety of patient engagement in HFrEF prescribing decisions. If successful, the tool can be easily disseminated and may inform similar interventions for other chronic conditions.
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19
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Babione JN, Ocampo W, Haubrich S, Yang C, Zuk T, Kaufman J, Carpendale S, Ghali W, Altabbaa G. Human-centred design processes for clinical decision support: A pulmonary embolism case study. Int J Med Inform 2020; 142:104196. [DOI: 10.1016/j.ijmedinf.2020.104196] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/19/2020] [Accepted: 05/22/2020] [Indexed: 12/30/2022]
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20
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Joseph J, P S S, James J, Abraham S, Abdullakutty J. Guideline-directed medical therapy in heart failure patients: impact of focused care provided by a heart failure clinic in comparison to general cardiology out-patient department. Egypt Heart J 2020; 72:53. [PMID: 32833163 PMCID: PMC7445219 DOI: 10.1186/s43044-020-00088-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/07/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The usage of guideline-directed medical therapy (GDMT) in the treatment of heart failure (HF) has shown to reduce morbidity and mortality. However, majority of the HF patients do not receive GDMT or do not achieve the target dose. Literature has shown that the patients who are managed in HF clinics receive GDMT and target doses of disease-modifying drugs (DMD) when compared to those treated in other general cardiology outpatient departments (OPD's). It was a retrospective hospital-based study in which patients treated in HF clinic and other cardiology OPD in the year of 2017 were included (200 patients in each arm). The aim of this study was to assess the impact of heart failure clinics in medication therapy management including usage of guideline-directed medical therapy, if target dose specified by the guideline is achieved and time to reach target dose in comparison to other general cardiology OPD's. IRB and IEC approval were obtained before the commencement of the study. Data relevant to the study were obtained from the electronic medical record (EMR) and were compared between the study groups to see for the adherence to guideline and achievement of target doses. Data storage and analysis were performed using SPSS Version 24. A significance level of 5% was used. RESULTS The usage of GDMT was higher in HF clinic when compared to other cardiology OPD (81% vs 55%, P = 0.001). A significantly higher number of patients in HF clinic achieved target dose when compared to other cardiology OPD (58% vs 29% -betablockers, 45% vs 9% -ACEI/ARB/ARNI, P = 0.000). Moreover, the number of eligible patients receiving DMD was found to be higher in HF clinic (98% vs 85% -betablockers, 69% vs 44% -ACEI/ARB/ARNI, 76% vs 44% -MRA). Also, the patients in HF clinic attained the target doses faster when compared to other cardiology OPD. In addition, there was better improvement in ejection fraction, as well as decreased rate of rehospitalisation and mortality in patients managed in HF clinic. CONCLUSION HF clinics were compared with other cardiology OPD for various parameters and it was observed that HF clinics were better than other cardiology OPD in maintaining the medication therapy management.
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Affiliation(s)
- Jeeva Joseph
- Department of Pharmacy Practice, Nirmala College of Pharmacy, Muvattupuzha, Ernakulam Dist, Kerala, 686661 India
| | - Stephy P S
- Department of Pharmacy Practice, Nirmala College of Pharmacy, Muvattupuzha, Ernakulam Dist, Kerala, 686661 India
| | - Jude James
- Department of Pharmacy Practice, Nirmala College of Pharmacy, Muvattupuzha, Ernakulam Dist, Kerala, 686661 India
| | - Suja Abraham
- Department of Pharmacy Practice, Nirmala College of Pharmacy, Muvattupuzha, Ernakulam Dist, Kerala, 686661 India
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21
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Oyanguren J, Garcia-Garrido L, Nebot-Margalef M, Latorre-García P, Torcal-Laguna J, Comín-Colet J, Roure J, González-Costello J, Manito N, García-Pinilla JM, Sánchez-Paule Y, Varela-Román A, Moure M, Segovia-Cubero J, Soria T, Arana-Arri E, Lekuona I. Noninferiority of heart failure nurse titration versus heart failure cardiologist titration. ETIFIC multicenter randomized trial. ACTA ACUST UNITED AC 2020; 74:533-543. [PMID: 32591295 DOI: 10.1016/j.rec.2020.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 04/16/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION AND OBJECTIVES Beta-blockers, angiotensin-converting enzyme inhibitors (ACE inhibitors), angiotensin-II-receptor-blockers (ARB), and mineralocorticoid-receptor antagonists decrease mortality and heart failure (HF) hospitalizations in HF patients with reduced left ventricular ejection fraction. The effect is dose-dependent. Careful titration is recommended. However, suboptimal doses are common in clinical practice. This study aimed to compare the safety and efficacy of dose titration of the aforementioned drugs by HF nurses vs HF cardiologists. METHODS ETIFIC was a multicenter (n=20) noninferiority randomized controlled open label trial. A total of 320 hospitalized patients with new-onset HF, reduced ejection fraction and New York Heart Association II-III, without beta-blocker contraindications were randomized 1:1 in blocks of 4 patients each stratified by hospital: 164 to HF nurse titration vs 156 to HF cardiologist titration (144 vs 145 analyzed). The primary endpoint was the beta-blocker mean relative dose (% of target dose) achieved at 4 months. Secondary endpoints included ACE inhibitors, ARB, and mineralocorticoid-receptor antagonists mean relative doses, associated variables, adverse events, and clinical outcomes at 6 months. RESULTS The mean±standard deviation relative doses achieved by HF nurses vs HF cardiologists were as follows: beta-blockers 71.09%±31.49% vs 56.29%±31.32%, with a difference of 14.8% (95%CI, 7.5-22.1), P <.001; ACE inhibitors 72.61%±29.80% vs 56.13%±30.37%, P <.001; ARB 44.48%±33.47% vs 43.51%±33.69%, P=.93; and mineralocorticoid-receptor antagonists 71%±32.12% vs 70.47%±29.78%, P=.86; mean±standard deviation visits were 6.41±2.82 vs 2.81±1.58, P <.001, while the number (%) of adverse events were 34 (23.6) vs 30 (20.7), P=.55; and at 6 months HF hospitalizations were 1 (0.69) vs 9 (5.51), P=.01. CONCLUSIONS ETIFIC is the first multicenter randomized trial to demonstrate the noninferiority of HF specialist-nurse titration vs HF cardiologist titration. Moreover, HF nurses achieved higher beta-blocker/ACE inhibitors doses, with more outpatient visits and fewer HF hospitalizations. Trial registry number: NCT02546856.
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Affiliation(s)
- Juana Oyanguren
- Servicio de Cardiología, Hospital Universitario Galdakao-Usansolo, OSI Barrualde-Galdakao-Osakidetza, Servicio Vasco de Salud, Galdakao, Bizkaia, Spain; BIOCRUCES, Instituto de Investigación Sanitaria, Bizkaia, Spain.
| | - Lluisa Garcia-Garrido
- Unidad de Insuficiencia Cardiaca, Servicio de Cardiología, Hospital Universitario Dr. Josep Trueta, Girona, Spain; Institut d'Investigació Biomèdica de Girona Dr. Josep Trueta (IDIBGI), Girona, Spain
| | - Magdalena Nebot-Margalef
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | | | | | - Josep Comín-Colet
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Julia Roure
- Unidad de Insuficiencia Cardiaca, Servicio de Cardiología, Hospital Universitario Dr. Josep Trueta, Girona, Spain; Institut d'Investigació Biomèdica de Girona Dr. Josep Trueta (IDIBGI), Girona, Spain
| | - José González-Costello
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Nicolás Manito
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - José M García-Pinilla
- Unidad de Insuficiencia Cardiaca, Servicio de Cardiología, Hospital Virgen de la Victoria, Málaga, Spain; Instituto de Investigación Sanitaria (IDIMA), Málaga, Spain
| | - Yolanda Sánchez-Paule
- Unidad de Insuficiencia Cardiaca, Servicio de Cardiología, Hospital Virgen de la Victoria, Málaga, Spain; Instituto de Investigación Sanitaria (IDIMA), Málaga, Spain
| | - Alfonso Varela-Román
- Unidad de Insuficiencia Cardiaca, Servicio de Cardiología, Hospital Universitario de Santiago, Santiago de Compostela, La Coruña, Spain; Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), La Coruña, Spain
| | - María Moure
- Unidad de Insuficiencia Cardiaca, Servicio de Cardiología, Hospital Universitario de Santiago, Santiago de Compostela, La Coruña, Spain; Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), La Coruña, Spain
| | - Javier Segovia-Cubero
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Puerta de Hierro Majadahonda, Majadahonda, Madrid, Spain
| | - Teresa Soria
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Puerta de Hierro Majadahonda, Majadahonda, Madrid, Spain
| | | | - Iñaki Lekuona
- Servicio de Cardiología, Hospital Universitario Galdakao-Usansolo, OSI Barrualde-Galdakao-Osakidetza, Servicio Vasco de Salud, Galdakao, Bizkaia, Spain
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22
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Veenis JF, Brunner-La Rocca HP, Linssen GCM, Van Gent MWF, Hoes AW, Brugts JJ. Treatment Differences in Chronic Heart Failure Patients With Reduced Ejection Fraction According to Blood Pressure. Circ Heart Fail 2020; 13:e006667. [PMID: 32370547 DOI: 10.1161/circheartfailure.119.006667] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Prescribed dosages of heart failure (HF) therapy in patients with a reduced left ventricular ejection fraction remain lower than guideline recommended. It remains unclear whether systolic blood pressure (BP) influences prescription of HF drugs to HF patients with a reduced left ventricular ejection fraction in a European setting. This study aimed to investigate the role of systolic BP on the prescription rate and actual dose of guideline-recommended HF therapy. METHODS A total of 8246 patients with chronic HF with a reduced left ventricular ejection fraction from 34 Dutch outpatient HF clinics were included. Detailed information on prescription rates and dosages of HF drugs were assessed according to systolic BP categories (<95, 95-109, 110-129, and ≥130 mm Hg). RESULTS Patients with systolic BP <95 mm Hg receive more often triple therapy (β-blocker, renin-angiotensin system inhibitor, and mineralocorticoid receptor antagonist; 40.3% versus 30.4% respectively, P<0.001) compared with ≥130 mm Hg. Patients with systolic BP <95 mm Hg received significantly more often mineralocorticoid receptor antagonists (64.5% versus 43.8%), ivabradine (8.3% versus 3.6%), and diuretics (94.2% versus 78.6%) and less often renin-angiotensin system inhibitors (75.4% versus 82.8%) compared with ≥130 mm Hg (P for all trends, <0.001). The prescribed dosages of β-blockers and renin-angiotensin system inhibitors were significantly lower in patients with systolic BP <95 mm Hg compared with ≥130 mm Hg (P for all trends, <0.001). CONCLUSIONS In this large cross-sectional cohort of patients with reduced left ventricular ejection fraction, patients with lower systolic BP receive more HF drugs but at lower dose relative to the target dose recommended in HF guidelines. Discussion is warranted regarding what target BP is acceptable and what should be limiting factors in uptitration to adequate levels of HF medication.
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Affiliation(s)
- Jesse F Veenis
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Thorax Center, Rotterdam, the Netherlands (J.F.V., J.J.B.).,Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands (H.-P.B.-L.R.).,Hospital Group Twente, Department of Cardiology, Almelo and Hengelo, the Netherlands (G.C.M.L.).,Albert Schweitzer Ziekenhuis, Department of Cardiology, Dordrecht, the Netherlands (M.W.F.V.G.).,Department of Cardiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands (A.W.H.)
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Thorax Center, Rotterdam, the Netherlands (J.F.V., J.J.B.).,Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands (H.-P.B.-L.R.).,Hospital Group Twente, Department of Cardiology, Almelo and Hengelo, the Netherlands (G.C.M.L.).,Albert Schweitzer Ziekenhuis, Department of Cardiology, Dordrecht, the Netherlands (M.W.F.V.G.).,Department of Cardiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands (A.W.H.)
| | - Gerard C M Linssen
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Thorax Center, Rotterdam, the Netherlands (J.F.V., J.J.B.).,Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands (H.-P.B.-L.R.).,Hospital Group Twente, Department of Cardiology, Almelo and Hengelo, the Netherlands (G.C.M.L.).,Albert Schweitzer Ziekenhuis, Department of Cardiology, Dordrecht, the Netherlands (M.W.F.V.G.).,Department of Cardiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands (A.W.H.)
| | - Marco W F Van Gent
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Thorax Center, Rotterdam, the Netherlands (J.F.V., J.J.B.).,Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands (H.-P.B.-L.R.).,Hospital Group Twente, Department of Cardiology, Almelo and Hengelo, the Netherlands (G.C.M.L.).,Albert Schweitzer Ziekenhuis, Department of Cardiology, Dordrecht, the Netherlands (M.W.F.V.G.).,Department of Cardiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands (A.W.H.)
| | - Arno W Hoes
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Thorax Center, Rotterdam, the Netherlands (J.F.V., J.J.B.).,Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands (H.-P.B.-L.R.).,Hospital Group Twente, Department of Cardiology, Almelo and Hengelo, the Netherlands (G.C.M.L.).,Albert Schweitzer Ziekenhuis, Department of Cardiology, Dordrecht, the Netherlands (M.W.F.V.G.).,Department of Cardiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands (A.W.H.)
| | - Jasper J Brugts
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Thorax Center, Rotterdam, the Netherlands (J.F.V., J.J.B.).,Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands (H.-P.B.-L.R.).,Hospital Group Twente, Department of Cardiology, Almelo and Hengelo, the Netherlands (G.C.M.L.).,Albert Schweitzer Ziekenhuis, Department of Cardiology, Dordrecht, the Netherlands (M.W.F.V.G.).,Department of Cardiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands (A.W.H.)
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- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Thorax Center, Rotterdam, the Netherlands (J.F.V., J.J.B.).,Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands (H.-P.B.-L.R.).,Hospital Group Twente, Department of Cardiology, Almelo and Hengelo, the Netherlands (G.C.M.L.).,Albert Schweitzer Ziekenhuis, Department of Cardiology, Dordrecht, the Netherlands (M.W.F.V.G.).,Department of Cardiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands (A.W.H.)
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23
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Blood AJ, Fischer CM, Fera LE, MacLean TE, Smith KV, Dunning JR, Bosque-Hamilton JW, Aronson SJ, Gaziano TA, MacRae CA, Matta LS, Mercurio-Pinto AA, Murphy SN, Scirica BM, Wagholikar K, Desai AS. Rationale and design of a navigator-driven remote optimization of guideline-directed medical therapy in patients with heart failure with reduced ejection fraction. Clin Cardiol 2019; 43:4-13. [PMID: 31725920 PMCID: PMC6954374 DOI: 10.1002/clc.23291] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 10/31/2019] [Accepted: 11/01/2019] [Indexed: 12/11/2022] Open
Abstract
Although optimal pharmacological therapy for heart failure with reduced ejection fraction (HFrEF) is carefully scripted by treatment guidelines, many eligible patients are not treated with guideline‐directed medical therapy (GDMT) in clinical practice. We designed a strategy for remote optimization of GDMT on a population scale in patients with HFrEF leveraging nonphysician providers. An electronic health record‐based algorithm was used to identify a cohort of patients with a diagnosis of heart failure (HF) and ejection fraction (EF) ≤ 40% receiving longitudinal follow‐up at our center. Those with end‐stage HF requiring inotropic support, mechanical circulatory support, or transplantation and those enrolled in hospice or palliative care were excluded. Treating providers were approached for consent to adjust medical therapy according to a sequential, stepped titration algorithm modeled on the current American College of Cardiology (ACC)/American Heart Association (AHA) HF Guidelines within a collaborative care agreement. The program was approved by the institutional review board at Brigham and Women's Hospital with a waiver of written informed consent. All patients provided verbal consent to participate. A navigator then facilitated medication adjustments by telephone and conducted longitudinal surveillance of laboratories, blood pressure, and symptoms. Each titration step was reviewed by a pharmacist with supervision as needed from a nurse practitioner and HF cardiologist. Patients were discharged from the program to their primary cardiologist after achievement of an optimal or maximally tolerated regimen. A navigator‐led remote management strategy for optimization of GDMT may represent a scalable population‐level strategy for closing the gap between guidelines and clinical practice in patients with HFrEF.
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Affiliation(s)
- Alexander J Blood
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Christina M Fischer
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Liliana E Fera
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Taylor E MacLean
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Katelyn V Smith
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jacqueline R Dunning
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Samuel J Aronson
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts.,Research Information Science and Computing, Partners Healthcare, Somerville, Massachusetts
| | - Thomas A Gaziano
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Calum A MacRae
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lina S Matta
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ana A Mercurio-Pinto
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Shawn N Murphy
- Massachusetts General Hospital, Boston, Massachusetts.,Research Information Science and Computing, Partners Healthcare, Somerville, Massachusetts
| | - Benjamin M Scirica
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kavishwar Wagholikar
- Massachusetts General Hospital, Boston, Massachusetts.,Research Information Science and Computing, Partners Healthcare, Somerville, Massachusetts
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
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24
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DeVore AD, Hill CL, Thomas L, Sharma PP, Albert NM, Butler J, Patterson JH, Spertus JA, Williams FB, Duffy CI, McCague K, Hernandez AF, Fonarow GC. Patient, Provider, and Practice Characteristics Associated With Sacubitril/Valsartan Use in the United States. Circ Heart Fail 2019; 11:e005400. [PMID: 30354360 DOI: 10.1161/circheartfailure.118.005400] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Background Current guidelines recommend sacubitril/valsartan for patients with heart failure with reduced ejection fraction, but the rate of adoption in the United States has been slow. Methods and Results Using data from CHAMP-HF (Change the Management of Patients With Heart Failure), we described current sacubitril/valsartan use and identified patient, provider, and practice characteristics associated with its use. We considered patients to be on sacubitril/valsartan if they were prescribed it before enrollment or initiated on it at the baseline visit. We excluded patients with a contraindication to sacubitril/valsartan and practices with <10 patients enrolled. Of 4216 patients from 121 sites, 616 (15%) were prescribed sacubitril/valsartan, 2506 (59%) an angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB), and 1094 (26%) neither. Patients prescribed sacubitril/valsartan were younger (63 years versus 66 years ACE inhibitor/ARB versus 69 years neither, P<0.001), less likely to have chronic kidney disease (15% versus 17% ACE inhibitor/ARB versus 30% neither, P<0.001), more likely to have cardiac resynchronization therapy (12% versus 7% ACE inhibitor/ARB versus 7% neither, P<0.001), and had lower ejection fraction (27% versus 30% ACE inhibitor/ARB versus 30% neither, P<0.001). Larger practices, based on number of cardiologists and advanced practice providers, were associated with the highest sacubitril/valsartan use. After multivariable adjustment, the number of advanced practice providers was associated with sacubitril/valsartan use (adjusted odds ratio,1.08; 95% CI, 1.03-1.14). Conclusions Despite current guideline recommendations, adoption of sacubitril/valsartan remains low. Provider and practice characteristics associated with sacubitril/valsartan use were related to general practice size and were not associated with practice characteristics specific for heart failure. Further research is needed to identify strategies for effective quality improvement interventions in chronic heart failure with reduced ejection fraction.
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Affiliation(s)
- Adam D DeVore
- Duke Clinical Research Institute, Durham, NC (A.D.D., C.L.H., L.T., A.F.H.).,Department of Medicine, Duke University School of Medicine, Durham, NC (A.D.D., A.F.H.)
| | - C Larry Hill
- Duke Clinical Research Institute, Durham, NC (A.D.D., C.L.H., L.T., A.F.H.)
| | - Laine Thomas
- Duke Clinical Research Institute, Durham, NC (A.D.D., C.L.H., L.T., A.F.H.)
| | - Puza P Sharma
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.P.S., C.I.D., K.M.)
| | | | - Javed Butler
- University of Mississippi Medical Center, Jackson (J.B.)
| | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.)
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City (J.A.S.)
| | | | - Carol I Duffy
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.P.S., C.I.D., K.M.)
| | - Kevin McCague
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.P.S., C.I.D., K.M.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC (A.D.D., C.L.H., L.T., A.F.H.).,Department of Medicine, Duke University School of Medicine, Durham, NC (A.D.D., A.F.H.)
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center (G.C.F.)
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25
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Adherence to Treatment Guidelines in Heart Failure Patients in the Top End Region of Northern Territory. Heart Lung Circ 2019; 28:1042-1049. [PMID: 29980453 DOI: 10.1016/j.hlc.2018.06.1038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 04/10/2018] [Accepted: 06/03/2018] [Indexed: 11/24/2022]
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26
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Sivagnanam K, Mendes LA, Schlendorf KH, Damp JB, Stevenson LW, Ramu V, Walsh MN, Jessup M, Lindenfeld J. Bridge to Transplantation: Advanced Heart Failure and Transplant Cardiology Training for Cardiovascular Disease Fellows. J Am Coll Cardiol 2019; 70:1413-1416. [PMID: 28882239 DOI: 10.1016/j.jacc.2017.07.769] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | - Lisa A Mendes
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Julie B Damp
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Vijay Ramu
- East Tennessee State University, Johnson City, Tennessee
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Marti CN, Fonarow GC, Anker SD, Yancy C, Vaduganathan M, Greene SJ, Ahmed A, Januzzi JL, Gheorghiade M, Filippatos G, Butler J. Medication dosing for heart failure with reduced ejection fraction - opportunities and challenges. Eur J Heart Fail 2018; 21:286-296. [PMID: 30537163 DOI: 10.1002/ejhf.1351] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 03/18/2018] [Accepted: 08/23/2018] [Indexed: 12/11/2022] Open
Abstract
Multiple drug classes have shown incremental benefits in heart failure with reduced ejection fraction. Most of these trials were designed to achieve specific doses of the investigational agent. Clinical practice guidelines recommend using the same target dosing of therapies, as tolerated. However, with the increasing number of available therapies, clinicians face the challenge of simultaneously using several drugs, achieving target doses, and managing side effects that are often overlapping. Blood pressure, renal function, hyperkalaemia, and other factors may impede achieving target doses of all medications, leaving clinicians with dilemmas as to how to sequence and dose these various classes of drugs. The guideline-directed eligibility for certain drugs and devices requires stability on maximally tolerated doses of background therapies. However, significant variability exists in dosing achieved in clinical practice. We discuss the existing background data regarding the doses of heart failure medications in clinical trials and in practice, and provide recommendations on how to navigate this complex therapeutic decision-making.
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Affiliation(s)
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Stefan D Anker
- Division of Cardiology and Metabolism - Heart Failure, Cachexia & Sarcopenia, Department of Cardiology (CVK) and Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité University Medicine, Berlin, Germany
| | - Clyde Yancy
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Stephen J Greene
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Ali Ahmed
- Veterans Affairs Medical Center and George Washington University, Washington, DC, USA
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, and the Baim Institute for Clinical Research, Boston, MA, USA
| | - Mihai Gheorghiade
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
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Balakumaran K, Patil A, Marsh S, Ingrassia J, Kuo CL, Jacoby DL, Arora S, Soucier R. Evaluation of a guideline directed medical therapy titration program in patients with heart failure with reduced ejection fraction. IJC HEART & VASCULATURE 2018; 22:1-5. [PMID: 30480083 PMCID: PMC6240631 DOI: 10.1016/j.ijcha.2018.10.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/07/2018] [Accepted: 10/10/2018] [Indexed: 12/22/2022]
Abstract
Introduction Heart failure is associated with recurrent hospitalizations and high mortality. Guideline directed medical treatment (GDMT), including beta blockers (BBs), angiotensin converting enzyme inhibitors (ACE-Is), angiotensin receptor blockers (ARBs) and aldosterone antagonists (AAs) has shown to improve outcomes. Current guidelines recommend the use of these medication classes at maximally tolerated dosages. Despite the evidence, < 25% of patients with heart failure with reduced left ventricular ejection fraction (HFrEF) are on the appropriate medical regimen titrated to the target doses. As such, we sought to assess the utility of a focused GDMT clinic to reduce this gap. Methods We conducted a retrospective chart review through existing patient data in a single center teaching hospital of patients referred to a focused GDMT clinic primarily staffed with heart failure trained nurse specialists, physician assistants and cardiologists. Management guidelines were developed with protocols for the initiation and uptitration of all therapeutic agents considered as GDMT. Our primary objective was to determine whether enrollment into a dedicated nursing led guideline directed medical therapy clinic would increase the proportion of patients with heart failure with reduced ejection fraction on appropriate medications as well as medication dosages in patients, the percentage of patients on the following medications and percentage at target doses: Renin-Angiotensin-Aldosterone System Blockers, Evidence Based Beta Blockers, and Aldosterone Antagonists. Our secondary objective was to determine if there was any clinical benefit on objective measures including renal function, hospital admissions, mortality and implantable defibrillator shocks. Results Between October 2015 and March 2017, 63 patients were identified by requisition forms, in which 61 were able to be identified based on legibility of identifying information. Mean duration of follow up was 264.44 ± 162.68 days over 7 ± 3.94 days. Mean ejection fraction was 21.8 ± 7.3%. New onset cardiomyopathies (diagnosed within 30 days) compiled 21% of the patient population while those with demonstrated cardiomyopathies (> 90 days) compiled 48% of the patient population. Patients with NYHA class III heart failure compiled 65% of the patient population. There was a statistically significant increase in the mean number of GDMT at any dose (2.31 ± 0.76 to 2.74 ± 0.66; p < 0.001) and mean number of GDMT at target doses (0.54 ± 0.79 to 1.52 ± 1.1; p < 0.001). Percentage of the population that were on no target doses at initial visit was 62% which was reduced to 18% after intervention. Clinical improvement was reflected in significant improvement in ejection fraction from 21.8 ± 7.8% to 36.2 ± 14.3% (p < 0.001). Increases in sodium and chloride were statistically small but significant. There a significant reduction in heart failure hospitalizations in comparison to a year prior to after the initial encounter in the clinic (p < 0.001). Conclusion This pilot study showed that a nurse directed GDMT titration program successfully increased the number of GDMT that patients were able to tolerate in a timely fashion, all the while enhancing ejection fraction, sodium and chloride levels, with a reduction in rehospitalization rates.
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Affiliation(s)
- Kathir Balakumaran
- Department of Cardiology, University of Connecticut, Farmington, CT, United States of America
| | - Aadhar Patil
- Department of Internal Medicine, University of Connecticut, Farmington, CT, United States of America
| | - Shannon Marsh
- Department of Cardiology, St Francis Hospital and Medical Center, Hartford, CT, United States of America
| | - Joseph Ingrassia
- Department of Cardiology, University of Connecticut, Farmington, CT, United States of America
| | - Chia-Ling Kuo
- CT Institute for Clinical & Translational Science, University of Connecticut, Farmington, CT, United States of America
| | - Daniel Louis Jacoby
- Department of Cardiology, Yale New Haven Medical Center, New Haven, CT, United States of America
| | - Sabeena Arora
- Department of Cardiology, St Francis Hospital and Medical Center, Hartford, CT, United States of America
| | - Richard Soucier
- Department of Cardiology, St Francis Hospital and Medical Center, Hartford, CT, United States of America.,Department of Cardiology, Yale New Haven Medical Center, New Haven, CT, United States of America
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Albert NM, Kozinn MJ. In-Hospital Initiation of Guideline-Directed Heart Failure Pharmacotherapy to Improve Long-Term Patient Adherence and Outcomes. Crit Care Nurse 2018; 38:16-24. [DOI: 10.4037/ccn2018669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Heart failure is a burdensome cardiovascular condition associated with high rates of morbidity and mortality. The 3-month period after hospitalization is a vulnerable phase in which patients are at high risk for mortality and rehospitalization. To reduce risk during this period, patients with heart failure and reduced ejection fraction should receive guideline-directed pharmacological therapies—the right drugs at the right doses—before hospital discharge. Optimal pharmacotherapies for these patients include agents that suppress the renin-angiotensin-aldosterone system, suppress the sympathetic nervous system, enhance vasodilation, slow heart rate when needed, and reduce excess volume. Because optimal prescription and adherence are both necessary to ensure the best clinical outcomes, nurses need to participate in interventions that optimize prescription and drug use over time. Collaboration with pharmacists and advanced practice acute care nurses may help ensure that medication selection and dosing are consistent with national guidelines. Use of a predischarge order set and electronic medical records checklist can enhance collaborative care.
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Affiliation(s)
- Nancy M. Albert
- Nancy M. Albert is associate chief nursing officer, Office of Nursing Research and Innovation, and a clinical nurse specialist, Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marc J. Kozinn
- Marc J. Kozinn is US cardiovascular medical director, heart failure, Amgen, Inc, Thousand Oaks, California
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Fønhus MS, Dalsbø TK, Johansen M, Fretheim A, Skirbekk H, Flottorp SA. Patient-mediated interventions to improve professional practice. Cochrane Database Syst Rev 2018; 9:CD012472. [PMID: 30204235 PMCID: PMC6513263 DOI: 10.1002/14651858.cd012472.pub2] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Healthcare professionals are important contributors to healthcare quality and patient safety, but their performance does not always follow recommended clinical practice. There are many approaches to influencing practice among healthcare professionals. These approaches include audit and feedback, reminders, educational materials, educational outreach visits, educational meetings or conferences, use of local opinion leaders, financial incentives, and organisational interventions. In this review, we evaluated the effectiveness of patient-mediated interventions. These interventions are aimed at changing the performance of healthcare professionals through interactions with patients, or through information provided by or to patients. Examples of patient-mediated interventions include 1) patient-reported health information, 2) patient information, 3) patient education, 4) patient feedback about clinical practice, 5) patient decision aids, 6) patients, or patient representatives, being members of a committee or board, and 7) patient-led training or education of healthcare professionals. OBJECTIVES To assess the effectiveness of patient-mediated interventions on healthcare professionals' performance (adherence to clinical practice guidelines or recommendations for clinical practice). SEARCH METHODS We searched MEDLINE, Ovid in March 2018, Cochrane Central Register of Controlled Trials (CENTRAL) in March 2017, and ClinicalTrials.gov and the International Clinical Trials Registry (ICTRP) in September 2017, and OpenGrey, the Grey Literature Report and Google Scholar in October 2017. We also screened the reference lists of included studies and conducted cited reference searches for all included studies in October 2017. SELECTION CRITERIA Randomised studies comparing patient-mediated interventions to either usual care or other interventions to improve professional practice. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data and assessed risk of bias. We calculated the risk ratio (RR) for dichotomous outcomes using Mantel-Haenszel statistics and the random-effects model. For continuous outcomes, we calculated the mean difference (MD) using inverse variance statistics. Two review authors independently assessed the certainty of the evidence (GRADE). MAIN RESULTS We included 25 studies with a total of 12,268 patients. The number of healthcare professionals included in the studies ranged from 12 to 167 where this was reported. The included studies evaluated four types of patient-mediated interventions: 1) patient-reported health information interventions (for instance information obtained from patients about patients' own health, concerns or needs before a clinical encounter), 2) patient information interventions (for instance, where patients are informed about, or reminded to attend recommended care), 3) patient education interventions (intended to increase patients' knowledge about their condition and options of care, for instance), and 4) patient decision aids (where the patient is provided with information about treatment options including risks and benefits). For each type of patient-mediated intervention a separate meta-analysis was produced.Patient-reported health information interventions probably improve healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We found that for every 100 patients consulted or treated, 26 (95% CI 23 to 30) are in accordance with recommended clinical practice compared to 17 per 100 in the comparison group (no intervention or usual care). We are uncertain about the effect of patient-reported health information interventions on desirable patient health outcomes and patient satisfaction (very low-certainty evidence). Undesirable patient health outcomes and adverse events were not reported in the included studies and resource use was poorly reported.Patient information interventions may improve healthcare professionals' adherence to recommended clinical practice (low-certainty evidence). We found that for every 100 patients consulted or treated, 32 (95% CI 24 to 42) are in accordance with recommended clinical practice compared to 20 per 100 in the comparison group (no intervention or usual care). Patient information interventions may have little or no effect on desirable patient health outcomes and patient satisfaction (low-certainty evidence). We are uncertain about the effect of patient information interventions on undesirable patient health outcomes because the certainty of the evidence is very low. Adverse events and resource use were not reported in the included studies.Patient education interventions probably improve healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We found that for every 100 patients consulted or treated, 46 (95% CI 39 to 54) are in accordance with recommended clinical practice compared to 35 per 100 in the comparison group (no intervention or usual care). Patient education interventions may slightly increase the number of patients with desirable health outcomes (low-certainty evidence). Undesirable patient health outcomes, patient satisfaction, adverse events and resource use were not reported in the included studies.Patient decision aid interventions may have little or no effect on healthcare professionals' adherence to recommended clinical practice (low-certainty evidence). We found that for every 100 patients consulted or treated, 32 (95% CI 24 to 43) are in accordance with recommended clinical practice compared to 37 per 100 in the comparison group (usual care). Patient health outcomes, patient satisfaction, adverse events and resource use were not reported in the included studies. AUTHORS' CONCLUSIONS We found that two types of patient-mediated interventions, patient-reported health information and patient education, probably improve professional practice by increasing healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We consider the effect to be small to moderate. Other patient-mediated interventions, such as patient information may also improve professional practice (low-certainty evidence). Patient decision aids may make little or no difference to the number of healthcare professionals' adhering to recommended clinical practice (low-certainty evidence).The impact of these interventions on patient health and satisfaction, adverse events and resource use, is more uncertain mostly due to very low certainty evidence or lack of evidence.
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Affiliation(s)
- Marita S Fønhus
- Norwegian Institute of Public HealthPO Box 4404, NydalenOsloNorwayN‐0403
| | - Therese K Dalsbø
- Norwegian Institute of Public HealthPO Box 4404, NydalenOsloNorwayN‐0403
| | - Marit Johansen
- Norwegian Institute of Public HealthPO Box 4404, NydalenOsloNorwayN‐0403
| | - Atle Fretheim
- Norwegian Institute of Public HealthPO Box 4404, NydalenOsloNorwayN‐0403
| | - Helge Skirbekk
- Norwegian National Advisory Unit on Learning and Mastery in Health, Oslo University HospitalOsloNorway0586
- Institute of Health and Society, Medical Faculty, University of OsloDepartment of Health Management and Health EconomicsOsloNorway
| | - Signe A. Flottorp
- Norwegian Institute of Public HealthPO Box 4404, NydalenOsloNorwayN‐0403
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Smith MW, Brown C, Virani SS, Weir CR, Petersen LA, Kelly N, Akeroyd J, Garvin JH. Incorporating Guideline Adherence and Practice Implementation Issues into the Design of Decision Support for Beta-Blocker Titration for Heart Failure. Appl Clin Inform 2018; 9:478-489. [PMID: 29949816 DOI: 10.1055/s-0038-1660849] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The recognition of and response to undertreatment of heart failure (HF) patients can be complicated. A clinical reminder can facilitate use of guideline-concordant β-blocker titration for HF patients with depressed ejection fraction. However, the design must consider the cognitive demands on the providers and the context of the work. OBJECTIVE This study's purpose is to develop requirements for a clinical decision support tool (a clinical reminder) by analyzing the cognitive demands of the task along with the factors in the Cabana framework of physician adherence to guidelines, the health information technology (HIT) sociotechnical framework, and the Promoting Action on Research Implementation in Health Services (PARIHS) framework of health services implementation. It utilizes a tool that extracts information from medical records (including ejection fraction in free text reports) to identify qualifying patients at risk of undertreatment. METHODS We conducted interviews with 17 primary care providers, 5 PharmDs, and 5 Registered Nurses across three Veterans Health Administration outpatient clinics. The interviews were based on cognitive task analysis (CTA) methods and enhanced through the inclusion of the Cabana, HIT sociotechnical, and PARIHS frameworks. The analysis of the interview data led to the development of requirements and a prototype design for a clinical reminder. We conducted a small pilot usability assessment of the clinical reminder using realistic clinical scenarios. RESULTS We identified organizational challenges (such as time pressures and underuse of pharmacists), knowledge issues regarding the guideline, and information needs regarding patient history and treatment status. We based the design of the clinical reminder on how to best address these challenges. The usability assessment indicated the tool could help the decision and titration processes. CONCLUSION Through the use of CTA methods enhanced with adherence, sociotechnical, and implementation frameworks, we designed a decision support tool that considers important challenges in the decision and execution of β-blocker titration for qualifying HF patients at risk of undertreatment.
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Affiliation(s)
- Michael W Smith
- Department of Industrial & Mechanical Engineering, Universidad de las Americas Puebla, Cholula, PUE, Mexico
| | - Charnetta Brown
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, United States
| | - Salim S Virani
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, United States.,Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States
| | - Charlene R Weir
- Salt Lake City VA Health Care System HSR&D Informatics, Decision-Enhancement and Analytic Sciences Center, Salt Lake City, Utah, United States.,Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States
| | - Laura A Petersen
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, United States.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States
| | - Natalie Kelly
- Salt Lake City VA Health Care System HSR&D Informatics, Decision-Enhancement and Analytic Sciences Center, Salt Lake City, Utah, United States
| | - Julia Akeroyd
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, United States
| | - Jennifer H Garvin
- Salt Lake City VA Health Care System HSR&D Informatics, Decision-Enhancement and Analytic Sciences Center, Salt Lake City, Utah, United States.,Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States.,Division of Health Information Management and Systems, The Ohio State University, Columbus, Ohio, United States.,Indianapolis VA Medical Center HSR&D Center for Health Information and Communication, Indianapolis, Indiana, United States
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Shanbhag D, Graham ID, Harlos K, Haynes RB, Gabizon I, Connolly SJ, Van Spall HGC. Effectiveness of implementation interventions in improving physician adherence to guideline recommendations in heart failure: a systematic review. BMJ Open 2018; 8:e017765. [PMID: 29511005 PMCID: PMC5855256 DOI: 10.1136/bmjopen-2017-017765] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The uptake of guideline recommendations that improve heart failure (HF) outcomes remains suboptimal. We reviewed implementation interventions that improve physician adherence to these recommendations, and identified contextual factors associated with implementation success. METHODS We searched databases from January 1990 to November 2017 for studies testing interventions to improve uptake of class I HF guidelines. We used the Cochrane Effective Practice and Organisation of Care and Process Redesign frameworks for data extraction. Primary outcomes included: proportion of eligible patients offered guideline-recommended pharmacotherapy, self-care education, left ventricular function assessment and/or intracardiac devices. We reported clinical outcomes when available. RESULTS We included 38 studies. Provider-level interventions (n=13 studies) included audit and feedback, reminders and education. Organisation-level interventions (n=18) included medical records system changes, multidisciplinary teams, clinical pathways and continuity of care. System-level interventions (n=3) included provider/institutional incentives. Four studies assessed multi-level interventions. We could not perform meta-analyses due to statistical/conceptual heterogeneity. Thirty-two studies reported significant improvements in at least one primary outcome. Clinical pathways, multidisciplinary teams and multifaceted interventions were most consistently successful in increasing physician uptake of guidelines. Among randomised controlled trials (RCT) (n=10), pharmacist and nurse-led interventions improved target dose prescriptions. Eleven studies reported clinical outcomes; significant improvements were reported in three, including a clinical pathway, a multidisciplinary team and a multifaceted intervention. Baseline assessment of barriers, staff training, iterative intervention development, leadership commitment and policy/financial incentives were associated with intervention effectiveness. Most studies (n=20) had medium risk of bias; nine RCTs had low risk of bias. CONCLUSION Our study is limited by the quality and heterogeneity of the primary studies. Clinical pathways, multidisciplinary teams and multifaceted interventions appear to be most consistent in increasing guideline uptake. However, improvements in process outcomes were rarely accompanied by improvements in clinical outcomes. Our work highlights the need for improved research methodology to reliably assess the effectiveness of implementation interventions.
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Affiliation(s)
- Deepti Shanbhag
- Bachelor of Health Sciences Program, McMaster University, Hamilton, Ontario, Canada
| | - Ian D Graham
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Karen Harlos
- Department of Business and Administration, University of Winnipeg, Winnipeg, Manitoba, Canada
| | - R Brian Haynes
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Itzhak Gabizon
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Harriette Gillian Christine Van Spall
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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Oyanguren J, García-Garrido LL, Nebot Margalef M, Lekuona I, Comin-Colet J, Manito N, Roure J, Ruiz Rodriguez P, Enjuanes C, Latorre P, Torcal Laguna J, García-Gutiérrez S. Design of a multicentre randomized controlled trial to assess the safety and efficacy of dose titration by specialized nurses in patients with heart failure. ETIFIC study protocol. ESC Heart Fail 2017; 4:507-519. [PMID: 29154427 PMCID: PMC5695164 DOI: 10.1002/ehf2.12152] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 01/25/2017] [Accepted: 02/17/2017] [Indexed: 01/06/2023] Open
Abstract
Aims Heart failure (HF) is associated with many hospital admissions and relatively high mortality, rates decreasing with administration of beta‐blockers (BBs), angiotensin‐converting‐enzyme inhibitors, angiotensin II receptor blockers, and mineralocorticoid receptor antagonists. The effect is dose dependent, suboptimal doses being common in clinical practice. The 2012 European guidelines recommend close monitoring and dose titration by HF nurses. Our main aim is to compare BB doses achieved by patients after 4 months in intervention (HF nurse‐managed) and control (cardiologist‐managed) groups. Secondary aims include comparing doses of the other aforementioned drugs achieved after 4 months, adverse events, and outcomes at 6 months in the two groups. Methods We have designed a multicentre (20 hospitals) non‐inferiority randomized controlled trial, including patients with new‐onset HF, left ventricular ejection fraction ≤40%, and New York Heart Association class II–III, with no contraindications to BBs. We will also conduct qualitative analysis to explore potential barriers to and facilitators of dose titration by HF nurses. In the intervention group, HF nurses will implement titration as prescribed by cardiologists, following a protocol. In controls, cardiologists will both prescribe and titrate doses. The study variables are doses of each of the drugs after 4 months relative to the target dose (%), New York Heart Association class, left ventricular ejection fraction, N‐terminal pro B‐type natriuretic peptide levels, 6 min walk distance, comorbidities, renal function, readmissions, mortality, quality of life, and psychosocial characteristics. Conclusions The trial seeks to assess whether titration by HF nurses of drugs recommended in practice guidelines is safe and not inferior to direct management by cardiologists. The results could have an impact on clinical practice.
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Affiliation(s)
- Juana Oyanguren
- Department of Cardiology, Galdakao Hospital-Barrualde, Osakidetza-Basque Health Service, Bilbao, Spain
| | - LLuisa García-Garrido
- Department of Cardiology, Girona University Hospital Dr. Josep Trueta, Girona, Spain
| | - Magdalena Nebot Margalef
- Department Cardiology, Catalan Institute of Health, Bellvitge University Hospital, IDIBELL, Institute of Biomedical Research, Barcelona, Spain
| | - Iñaki Lekuona
- Department of Cardiology, Galdakao Hospital-Barrualde, Osakidetza-Basque Health Service, Bilbao, Spain
| | - Josep Comin-Colet
- Department of Cardiology, Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain
| | - Nicolás Manito
- Department Cardiology, Catalan Institute of Health, Bellvitge University Hospital, IDIBELL, Institute of Biomedical Research, Barcelona, Spain
| | - Julia Roure
- Department of Cardiology, Girona University Hospital Dr. Josep Trueta, Girona, Spain
| | - Pilar Ruiz Rodriguez
- Department of Cardiology, Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain
| | - Cristina Enjuanes
- Department of Cardiology, Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain
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DeFilippis EM, Butler J, Vaduganathan M. Waiting Period Before Implantable Cardioverter-Defibrillator Implantation in Newly Diagnosed Heart Failure With Reduced Ejection Fraction: A Window of Opportunity. Circ Heart Fail 2017; 10:e004478. [PMID: 29138249 PMCID: PMC5777623 DOI: 10.1161/circheartfailure.117.004478] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Ersilia M DeFilippis
- From the Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (E.M.D., M.V.); and Division of Cardiology, Stony Brook University, NY (J.B.)
| | - Javed Butler
- From the Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (E.M.D., M.V.); and Division of Cardiology, Stony Brook University, NY (J.B.)
| | - Muthiah Vaduganathan
- From the Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (E.M.D., M.V.); and Division of Cardiology, Stony Brook University, NY (J.B.).
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Cranley LA, Cummings GG, Profetto-McGrath J, Toth F, Estabrooks CA. Facilitation roles and characteristics associated with research use by healthcare professionals: a scoping review. BMJ Open 2017; 7:e014384. [PMID: 28801388 PMCID: PMC5724142 DOI: 10.1136/bmjopen-2016-014384] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 12/30/2016] [Accepted: 02/21/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Implementing research findings into practice is a complex process that is not well understood. Facilitation has been described as a key component of getting research findings into practice. The literature on facilitation as a practice innovation is growing. This review aimed to identify facilitator roles and to describe characteristics of facilitation that may be associated with successful research use by healthcare professionals. METHODS We searched 10 electronic databases up to December 2016 and used predefined criteria to select articles. We included conceptual papers and empirical studies that described facilitator roles, facilitation processes or interventions, and that focused on healthcare professionals and research use. We used content and thematic analysis to summarise data. Rogers' five main attributes of an innovation guided our synthesis of facilitation characteristics. RESULTS Of the 38 488 articles identified from our online and manual search, we included 195 predominantly research studies. We identified nine facilitator roles: opinion leaders, coaches, champions, research facilitators, clinical/practice facilitators, outreach facilitators, linking agents, knowledge brokers and external-internal facilitators. Fifteen facilitation characteristics were associated with research use, which we grouped into five categories using Rogers' innovation attributes: relative advantage, compatibility, complexity, trialability and observability. CONCLUSIONS We found a diverse and broad literature on the concept of facilitation that can expand our current thinking about facilitation as an innovation and its potential to support an integrated, collaborative approach to improving healthcare delivery.
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Affiliation(s)
- Lisa A Cranley
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | | | | | - Ferenc Toth
- Faculty of Nursing, University of Alberta, Edmonton, Canada
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Achieving a Maximally Tolerated β-Blocker Dose in Heart Failure Patients: Is There Room for Improvement? J Am Coll Cardiol 2017; 69:2542-2550. [PMID: 28521892 DOI: 10.1016/j.jacc.2017.03.563] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 03/07/2017] [Accepted: 03/10/2017] [Indexed: 02/07/2023]
Abstract
Heart failure (HF) is associated with significant morbidity and mortality. Although initially thought to be harmful in HF, beta-adrenergic blockers (β-blockers) have consistently been shown to reduce mortality and HF hospitalization in chronic HF with reduced ejection fraction. Proposed mechanisms include neurohormonal blockade and heart rate reduction. A new therapeutic agent now exists to target further heart rate lowering in patients who have been stable on a "maximally tolerated β-blocker dose," but this definition and how to achieve it are incompletely understood. In this review, the authors summarize published reports on the mechanisms by which β-blockers improve clinical outcomes. The authors describe differences in doses achieved in landmark clinical trials and those observed in routine clinical practice. They further discuss reasons for intolerance and the evidence behind using β-blocker dose and heart rate as therapeutic targets. Finally, the authors offer recommendations for clinicians actively initiating and up-titrating β-blockers that may aid in achieving maximally tolerated doses.
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D'Onofrio A, Palmisano P, Rapacciuolo A, Ammendola E, Calò L, Ruocco A, Bianchi V, Maresca F, Del Giorno G, Martino A, Mauro C, Campari M, Valsecchi S, Accogli M. Effectiveness of a management program for outpatient clinic or remote titration of beta-blockers in CRT patients: The RESTORE study. Int J Cardiol 2017; 236:290-295. [DOI: 10.1016/j.ijcard.2017.02.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 02/03/2017] [Indexed: 10/20/2022]
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Abstract
Large-scale randomised controlled trials (RCTs) have demonstrated that angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and beta-blockers decrease mortality and hospitalisation in patients with heart failure (HF) associated with a reduced left ventricular ejection fraction. This has led to high prescription rates; however, these drugs are generally prescribed at much lower doses than the doses achieved in the RCTs. A number of strategies have been evaluated to improve medication titration in HF, including forced medication up-titration protocols, point-of-care decision support and extended scope of clinical practice for nurses and pharmacists. Most successful strategies have been multifaceted and have adapted existing multidisciplinary models of care. Furthermore, given the central role of general practitioners in long-term monitoring and care coordination in HF patients, these strategies should engage with primary care to facilitate the transition between the acute and primary healthcare sectors.
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Affiliation(s)
- John J Atherton
- Department of Cardiology, Royal Brisbane and Women's Hospital,Brisbane, Queensland, Australia.,School of Medicine, University of Queensland,Brisbane, Queensland, Australia
| | - Annabel Hickey
- Advanced Heart Failure and Cardiac Transplant Unit, The Prince Charles Hospital,Brisbane, Queensland, Australia
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Hickey A, Suna J, Marquart L, Denaro C, Javorsky G, Munns A, Mudge A, Atherton JJ. Improving medication titration in heart failure by embedding a structured medication titration plan. Int J Cardiol 2016; 224:99-106. [DOI: 10.1016/j.ijcard.2016.09.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 08/19/2016] [Accepted: 09/01/2016] [Indexed: 11/28/2022]
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Weeks G, George J, Maclure K, Stewart D. Non-medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care. Cochrane Database Syst Rev 2016; 11:CD011227. [PMID: 27873322 PMCID: PMC6464275 DOI: 10.1002/14651858.cd011227.pub2] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND A range of health workforce strategies are needed to address health service demands in low-, middle- and high-income countries. Non-medical prescribing involves nurses, pharmacists, allied health professionals, and physician assistants substituting for doctors in a prescribing role, and this is one approach to improve access to medicines. OBJECTIVES To assess clinical, patient-reported, and resource use outcomes of non-medical prescribing for managing acute and chronic health conditions in primary and secondary care settings compared with medical prescribing (usual care). SEARCH METHODS We searched databases including CENTRAL, MEDLINE, Embase, and five other databases on 19 July 2016. We also searched the grey literature and handsearched bibliographies of relevant papers and publications. SELECTION CRITERIA Randomised controlled trials (RCTs), cluster-RCTs, controlled before-and-after (CBA) studies (with at least two intervention and two control sites) and interrupted time series analysis (with at least three observations before and after the intervention) comparing: 1. non-medical prescribing versus medical prescribing in acute care; 2. non-medical prescribing versus medical prescribing in chronic care; 3. non-medical prescribing versus medical prescribing in secondary care; 4 non-medical prescribing versus medical prescribing in primary care; 5. comparisons between different non-medical prescriber groups; and 6. non-medical healthcare providers with formal prescribing training versus those without formal prescribing training. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently reviewed studies for inclusion, extracted data, and assessed study quality with discrepancies resolved by discussion. Two review authors independently assessed risk of bias for the included studies according to EPOC criteria. We undertook meta-analyses using the fixed-effect model where studies were examining the same treatment effect and to account for small sample sizes. We compared outcomes to a random-effects model where clinical or statistical heterogeneity existed. MAIN RESULTS We included 46 studies (37,337 participants); non-medical prescribing was undertaken by nurses in 26 studies and pharmacists in 20 studies. In 45 studies non-medical prescribing as a component of care was compared with usual care medical prescribing. A further study compared nurse prescribing supported by guidelines with usual nurse prescribing care. No studies were found with non-medical prescribing being undertaken by other health professionals. The education requirement for non-medical prescribing varied with country and location.A meta-analysis of surrogate markers of chronic disease (systolic blood pressure, glycated haemoglobin, and low-density lipoprotein) showed positive intervention group effects. There was a moderate-certainty of evidence for studies of blood pressure at 12 months (mean difference (MD) -5.31 mmHg, 95% confidence interval (CI) -6.46 to -4.16; 12 studies, 4229 participants) and low-density lipoprotein (MD -0.21, 95% CI -0.29 to -0.14; 7 studies, 1469 participants); we downgraded the certainty of evidence from high due to considerations of serious inconsistency (considerable heterogeneity), multifaceted interventions, and variable prescribing autonomy. A high-certainty of evidence existed for comparative studies of glycated haemoglobin management at 12 months (MD -0.62, 95% CI -0.85 to -0.38; 6 studies, 775 participants). While there appeared little difference in medication adherence across studies, a meta-analysis of continuous outcome data from four studies showed an effect favouring patient adherence in the non-medical prescribing group (MD 0.15, 95% CI 0.00 to 0.30; 4 studies, 700 participants). We downgraded the certainty of evidence for adherence to moderate due to the serious risk of performance bias. While little difference was seen in patient-related adverse events between treatment groups, we downgraded the certainty of evidence to low due to indirectness, as the range of adverse events may not be related to the intervention and selective reporting failed to adequately report adverse events in many studies.Patients were generally satisfied with non-medical prescriber care (14 studies, 7514 participants). We downgraded the certainty of evidence from high to moderate due to indirectness, in that satisfaction with the prescribing component of care was only addressed in one study, and there was variability of satisfaction measures with little use of validated tools. A meta-analysis of health-related quality of life scores (SF-12 and SF-36) found a difference favouring usual care for the physical component score (MD 1.17, 95% CI 0.16 to 2.17), but not the mental component score (MD 0.58, 95% CI -0.40 to 1.55). However, the quality of life measurement may more appropriately reflect composite care rather than the prescribing component of care, and for this reason we downgraded the certainty of evidence to moderate due to indirectness of the measure of effect. A wide variety of resource use measures were reported across studies with little difference between groups for hospitalisations, emergency department visits, and outpatient visits. In the majority of studies reporting medication use, non-medical prescribers prescribed more drugs, intensified drug doses, and used a greater variety of drugs compared to usual care medical prescribers.The risk of bias across studies was generally low for selection bias (random sequence generation), detection bias (blinding of outcome assessment), attrition bias (incomplete outcome data), and reporting bias (selective reporting). There was an unclear risk of selection bias (allocation concealment) and for other biases. A high risk of performance bias (blinding of participants and personnel) existed. AUTHORS' CONCLUSIONS The findings suggest that non-medical prescribers, practising with varying but high levels of prescribing autonomy, in a range of settings, were as effective as usual care medical prescribers. Non-medical prescribers can deliver comparable outcomes for systolic blood pressure, glycated haemoglobin, low-density lipoprotein, medication adherence, patient satisfaction, and health-related quality of life. It was difficult to determine the impact of non-medical prescribing compared to medical prescribing for adverse events and resource use outcomes due to the inconsistency and variability in reporting across studies. Future efforts should be directed towards more rigorous studies that can clearly identify the clinical, patient-reported, resource use, and economic outcomes of non-medical prescribing, in both high-income and low-income countries.
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Affiliation(s)
- Greg Weeks
- Monash UniversityCentre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical SciencesParkvilleVICAustralia3052
- Barwon HealthPharmacy DepartmentGeelongVictoriaAustralia
| | - Johnson George
- Monash UniversityCentre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical SciencesParkvilleVICAustralia3052
| | - Katie Maclure
- Robert Gordon UniversitySchool of PharmacyRiverside EastGarthdee RoadAberdeenUKAB10 7GJ
| | - Derek Stewart
- Robert Gordon UniversitySchool of PharmacyRiverside EastGarthdee RoadAberdeenUKAB10 7GJ
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Tipología y estándares de calidad de las unidades de insuficiencia cardiaca: consenso científico de la Sociedad Española de Cardiología. Rev Esp Cardiol 2016. [DOI: 10.1016/j.recesp.2016.06.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Classification and Quality Standards of Heart Failure Units: Scientific Consensus of the Spanish Society of Cardiology. ACTA ACUST UNITED AC 2016; 69:940-950. [PMID: 27576081 DOI: 10.1016/j.rec.2016.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 06/02/2016] [Indexed: 12/15/2022]
Abstract
The prevalence of heart failure remains high and represents the highest disease burden in Spain. Heart failure units have been developed to systematize the diagnosis, treatment, and clinical follow-up of heart failure patients, provide a structure to coordinate the actions of various entities and personnel involved in patient care, and improve prognosis and quality of life. There is ample evidence on the benefits of heart failure units or programs, which have become widespread in Spain. One of the challenges to the analysis of heart failure units is standardization of their classification, by determining which "programs" can be identified as heart failure "units" and by characterizing their complexity level. The aim of this article was to present the standards developed by the Spanish Society of Cardiology to classify and establish the requirements for heart failure units within the SEC-Excellence project.
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Lack of Left Ventricular Ejection Fraction Measurement Following a High B-type Natriuretic Peptide Value. Crit Pathw Cardiol 2016; 15:112-3. [PMID: 27465007 DOI: 10.1097/hpc.0000000000000077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The objective of this study was to determine how often providers did not obtain a recommended measure of left ventricular ejection fraction (LVEF) following a high B-type natriuretic peptide (BNP) value when the LVEF was not known to be low (<40%). Such patients may benefit from life-prolonging treatment. METHODS We identified consecutive patients (inpatient or outpatient) with a BNP value of at least 200 pg/mL within a single VA health care system (3 inpatient facilities and 8 community clinics) during a 10-month period (September 2008-June 2009). We performed chart review to determine results of any imaging study performed (inside or outside the health system) prior to or after the high BNP value. RESULTS Of the 296 patients with a high BNP, 212 were not known to have a low LVEF. Of these, 99 (47%) did not have the guideline recommended follow-up LVEF study. Among those that survived at least 6 months following BNP and a follow-up echocardiogram was indicated (no prior LVEF or prior LVEF was > 40%), mortality was 20% if an echocardiogram was performed within 6 months of the BNP and 27% if it was not performed within 6 months of BNP testing (P = 0.21). CONCLUSION Approximately half of patients with a high BNP and an LVEF not known to be low did not have a follow-up guideline recommended LVEF study and may have unrecognized heart failure. Our findings suggest that a trial is warranted of a clinical pathway where those patients with a high BNP and without appropriate follow-up are randomized to have their physician receive a notification of the high BNP value.
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D’Onofrio A, Stabile G, Capucci A, Amellone C, De Simone A, Leoni L, Morani G, Bianchi V, Campari M, Valsecchi S, Buja G. Association between remote implantable cardioverter defibrillator monitoring and beta-blocker utilization: An analysis from the EFFECT study. J Telemed Telecare 2016; 22:383-90. [DOI: 10.1177/1357633x15613701] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 10/02/2015] [Indexed: 01/21/2023]
Abstract
Introduction A substantial number of heart failure patients undergoing implantation of implantable cardioverter defibrillators (ICDs) fail to receive beta-blockers, or receive them at a suboptimal dose. Remote monitoring (RM) is becoming the standard means of following up recipients of ICDs. However, the impact of this shift toward remote ICD follow-up on the quality of drug therapy management in current clinical practice is unknown. The present analysis was aimed at investigating the impact of RM on the dose of beta-blockers achieved, and its association with clinical outcome at 12 months. Methods Altogether 987 consecutive patients were enrolled and followed up for at least 12 months in 25 Italian centres. RM was adopted by 499 patients. Results The number of patients receiving beta-blockers at any dose decreased after 12 months (from 403 (81%) to 370 (74%) for the remote arm and from 389 (80%) to 342 (70%) for the standard arm, both p < 0.02). Nonetheless, the number of patients on beta-blockers at the effective dose increased in both arms (from 60 (12%) to 82 (16%) for remote and from 63 (13%) to 98 (20%) for standard arms respectively, both p < 0.05). At multivariate analysis, RM was not associated with an effective dose of beta-blockers at the follow-up evaluation. However, the adoption of RM ( p = 0.003) and the achievement of the effective dose of beta-blockers ( p = 0.006) were independently and positively associated with an improved outcome. Discussion In a ‘real-world’ setting, we did not find an association between RM and the achieved dose of beta-blockers. However, we reported outcome benefits in achieving the effective dose of beta-blockers during follow-up and in adopting RM.
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McGinn T. Putting Meaning into Meaningful Use: A Roadmap to Successful Integration of Evidence at the Point of Care. JMIR Med Inform 2016; 4:e16. [PMID: 27199223 PMCID: PMC4891572 DOI: 10.2196/medinform.4553] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 08/26/2015] [Accepted: 09/22/2015] [Indexed: 11/13/2022] Open
Abstract
Pressures to contain health care costs, personalize patient care, use big data, and to enhance health care quality have highlighted the need for integration of evidence at the point of care. The application of evidence-based medicine (EBM) has great promise in the era of electronic health records (EHRs) and health technology. The most successful integration of evidence into EHRs has been complex decision tools that trigger at a critical point of the clinical visit and include patient specific recommendations.
The objective of this viewpoint paper is to investigate why the incorporation of complex CDS tools into the EMR is equally complex and continues to challenge health service researchers and implementation scientists. Poor adoption and sustainability of EBM guidelines and CDS tools at the point of care have persisted and continue to document low rates of usage. The barriers cited by physicians include efficiency, perception of usefulness, information content, user interface, and over-triggering.
Building on the traditional EHR implementation frameworks, we review keys strategies for successful CDSs: (1) the quality of the evidence, (2) the potential to reduce unnecessary care, (3) ease of integrating evidence at the point of care, (4) the evidence’s consistency with clinician perceptions and preferences, (5) incorporating bundled sets or automated documentation, and (6) shared decision making tools.
As EHRs become commonplace and insurers demand higher quality and evidence-based care, better methods for integrating evidence into everyday care are warranted. We have outlined basic criteria that should be considered before attempting to integrate evidenced-based decision support tools into the EHR.
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Affiliation(s)
- Thomas McGinn
- Hofstra North Shore LII School of Medicine, Manhasset, NY, United States.
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Carroll R, Mudge A, Suna J, Denaro C, Atherton J. Prescribing and up-titration in recently hospitalized heart failure patients attending a disease management program. Int J Cardiol 2016; 216:121-7. [PMID: 27153136 DOI: 10.1016/j.ijcard.2016.04.084] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 04/11/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND Heart failure (HF) medications improve clinical outcomes, with optimal doses defined in clinical trials. Patient, provider and system barriers may limit achievement of optimal doses in real life settings, although disease management programs (HF-DMPs) can facilitate up-titration. METHODS AND RESULTS Secondary analysis of a prospective cohort of 216 participants recently hospitalized with systolic HF, attending 5 HF-DMPs in Queensland, Australia. Medication history at baseline (6weeks after discharge) and 6months provided data to describe prescription rates, dosage and optimal titration of HF medications, and associations with patient and system factors were explored. At baseline, 94% were on an angiotensin converting enzyme inhibitor/angiotensin II receptor blocker (ACEI/ARB), 94% on a beta-blocker (BB) and 42% on a mineralocorticoid receptor antagonist (MRA). The proportion of participants on optimal doses of ACEI/ARB increased from 38% (baseline) to 52% (6months, p=0.001) and on optimal BB dose from 23% to 49% (p<0.001). Significant barriers to ACEI/ARB up-titration were body mass index (BMI)<25, female gender, polypharmacy, previously diagnosed HF, and tertiary hospital. Significant barriers for BB up-titration were BMI<25, previously diagnosed HF and non-cardiologist care. CONCLUSIONS Effective up-titration in HF DMPs is influenced by patient, disease and service factors. Better understanding of barriers to effective up-titration in women, normal weight, and established HF patients may help provide targeted strategies for improving outcomes in these groups.
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Affiliation(s)
- Robert Carroll
- Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Butterfield St., Herston, Qld 4006, Australia; University of Queensland School of Medicine, 288 Herston Road, Qld 4006, Australia.
| | - Alison Mudge
- Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Butterfield St., Herston, Qld 4006, Australia; University of Queensland School of Medicine, 288 Herston Road, Qld 4006, Australia
| | - Jessica Suna
- Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Butterfield St., Herston, Qld 4006, Australia
| | - Charles Denaro
- Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Butterfield St., Herston, Qld 4006, Australia; University of Queensland School of Medicine, 288 Herston Road, Qld 4006, Australia
| | - John Atherton
- University of Queensland School of Medicine, 288 Herston Road, Qld 4006, Australia; Department of Cardiology, Royal Brisbane and Women's Hospital, Butterfield St., Herston, Qld 4006, Australia
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Van Spall HGC, Shanbhag D, Gabizon I, Ibrahim Q, Graham ID, Harlos K, Haynes RB, Connolly SJ. Effectiveness of implementation strategies in improving physician adherence to guideline recommendations in heart failure: a systematic review protocol. BMJ Open 2016; 6:e009364. [PMID: 27033956 PMCID: PMC4823399 DOI: 10.1136/bmjopen-2015-009364] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION The uptake of Clinical Practice Guideline (CPG) recommendations that improve outcomes in heart failure (HF) remains suboptimal. We will conduct a systematic review to identify implementation strategies that improve physician adherence to class I recommendations, those with clear evidence that benefits outweigh the risks. We will use American, Canadian and European HF guidelines as our reference. METHODS AND ANALYSIS We will conduct a literature search in the databases of MEDLINE, EMBASE, HEALTHSTAR, CINAHL, Cochrane Library, Campbell Collaboration, Joanna Briggs Institute Evidence Based Practice, Centre for Reviews and Dissemination and Evidence Based Practice Centres. We will include prospective studies evaluating implementation interventions aimed at improving uptake of class I CPG recommendations in HF. We will extract data in duplicate. We will classify interventions according to their level of application (ie, provider, organisation, systems level) and common underlying characteristics (eg, education, decision-support, financial incentives) using the Cochrane Effective Practice and Organisation of Care Taxonomy. We will assess the impact of the intervention on adherence to the CPGs. Outcomes will include proportion of eligible patients who were: prescribed a CPG-recommended pharmacological treatment; referred for device consideration; provided self-care education at discharge; and provided left ventricular function assessment. We will include clinical outcomes such as hospitalisations, readmissions and mortality, if data is available. We will identify the common elements of successful and failing interventions, and examine the context in which they were applied, using the Process Redesign contextual framework. We will synthesise the results narratively and, if appropriate, will pool results for meta-analysis. DISCUSSION AND DISSEMINATION In this review, we will assess the impact of implementation strategies and contextual factors on physician adherence to HF CPGs. We will explore why some interventions may succeed in one setting and fail in another. We will disseminate our findings through briefing reports, publications and presentations. TRIAL REGISTRATION NUMBER CRD42015017155.
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Affiliation(s)
- Harriette G C Van Spall
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada Population Health Research Institute, Hamilton, Ontario, Canada Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Deepti Shanbhag
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Itzhak Gabizon
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Quazi Ibrahim
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Ian D Graham
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Karen Harlos
- Department of Business and Administration, University of Winnipeg, Winnipeg, Manitoba, Canada
| | - R Brian Haynes
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada Population Health Research Institute, Hamilton, Ontario, Canada Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Jun J, Kovner CT, Stimpfel AW. Barriers and facilitators of nurses' use of clinical practice guidelines: An integrative review. Int J Nurs Stud 2016; 60:54-68. [PMID: 27297368 DOI: 10.1016/j.ijnurstu.2016.03.006] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 03/06/2016] [Accepted: 03/08/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Preventable harm continues to be one of the leading causes of patient death. Each year about 400,000 patients die from sepsis, hospital acquired infections, venous thromboembolism, and pulmonary embolism. However, as shown in the recent reduction in hospital acquired infections, the number of deaths could be reduced if healthcare providers used evidence-based therapies, which are often included in clinical practice guidelines (CPGs). PURPOSE The purpose of this integrative review is to appraise and synthesize the current literature on barriers to and facilitators in the use of clinical practice guidelines (CPGs) by registered nurses. DESIGN Whittemore and Knafl integrative review methodology was used. Primary quantitative and qualitative studies about the nurses' use of CPGs and published in peer-reviewed journals between January 2000 and August 2015 were included. METHODS The Critical Skills Appraisal Program (CASP) was used to critically appraise the quality of sixteen selected quantitative and qualitative studies. RESULTS Internal factors were attitudes, perceptions, and knowledge whereas format and usability of CPGs, resources, leadership, and organizational culture were external factors influencing CPG use. CONCLUSION Given each barrier and facilitator, interventions and policies can be designed to increase nurses' use of CPGs to deliver more evidence based therapy. In order to improve the use of CPGs and to ensure high quality care for all patients, nurses must actively participate in development, implementation, and maintenance of CPGs.
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Affiliation(s)
- Jin Jun
- New York University, College of Nursing, United States.
| | - Christine T Kovner
- Mathy Mezey Professor of Geriatric Nursing, New York University, College of Nursing, United States.
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McGoldrick C, Ulahannan T, Krebs KL. Review of antibiotic use in respiratory disorders at a regional hospital in Queensland. Collegian 2016; 23:391-5. [PMID: 29116722 DOI: 10.1016/j.colegn.2016.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
tAdherence to antibiotic guidelines has been shown to improve outcomes in several clinical situations.Respiratory conditions are a major cause of mortality and morbidity in Queensland. A recent study showedlow levels of compliance with antibiotic guidelines in a Queensland metropolitan hospital. We undertookan audit of antibiotic use in a regional Queensland hospital against Therapeutic Guideline recommenda-tions. Therapeutic Guideline recommendations were followed in 16% of cases with ceftriaxone the mostcommonly prescribed. Re-admission rate within 28 days was for 53%, 26%, 11% and 5% respectively forceftriaxone, benzylpenicillin, amoxicillin/clavulanate and ceftriaxone combined doxycycline. Less thanhalf of patients treated for pneumonia had concordant radiographic changes. Admission via the emer-gency department may be a factor in the preference for intravenous injection of ceftriaxone and presenceof non-infective co-morbidities may also contribute to re-admissions. Considerable challenges exist inimproving compliance with antibiotic guidelines which can improve patient outcomes and antibioticstewardship.
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