1
|
Swat SA, Helmkamp LJ, Tietbohl C, Thompson JS, Fitzgerald M, McIlvennan CK, Harger G, Ho PM, Ahmad FS, Ahmad T, Buttrick P, Allen LA. Clinical Inertia Among Outpatients With Heart Failure: Application of Treatment Nonintensification Taxonomy to EPIC-HF Trial. JACC Heart Fail 2023; 11:1579-1591. [PMID: 37589610 DOI: 10.1016/j.jchf.2023.06.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND The contribution of clinical inertia to suboptimal guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF) remains unclear. OBJECTIVES This study examined reasons for GDMT nonintensification and characterized clinical inertia. METHODS In this secondary analysis of EPIC-HF (Electronically Delivered, Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure with Reduced Ejection Fraction), a randomized clinical trial evaluating a patient-activation tool on GDMT utilization, we performed a sequential, explanatory mixed-methods study. Reasons for nonintensification among 4 medication classes were assigned according to an expanded published taxonomy using structured chart reviews. Audio transcripts of clinic encounters were analyzed to further characterize nonintensification reasons. Integration occurred during the interpretation phase. RESULTS Among 292 HFrEF patients who completed a cardiology visit, 185 (63.4%) experienced no treatment intensification, of whom 90 (48.6%) had at least 1 opportunity for intensification of a medication class with no documented contraindication or barriers (ie, clinical inertia). Nonintensification reasons varied by medication class, and included heightened risk of adverse effects (range 18.2%-31.6%), patient nonadherence (range 0.8%-1.1%), patient preferences and beliefs (range 0.6%-0.9%), comanagement with other providers (range 4.6%-5.6%), prioritization of other issues (range 15.6%-31.8%), multiple categories (range 16.5%-22.7%), and clinical inertia (range 22.7%-31.6%). A qualitative analysis of 32 clinic audio recordings demonstrated common characteristics of clinical inertia: 1) clinician review of medication regimens without education or intensification discussions; 2) patient stability as justification for nonintensification; and 3) shorter encounters for nonintensification vs intensification. CONCLUSIONS In this comprehensive study exploring HFrEF prescribing, clinical inertia is a main contributor to nonintensification within an updated taxonomy classification for suboptimal GDMT prescribing. This approach should help target strategies overcoming GDMT underuse.
Collapse
Affiliation(s)
- Stanley A Swat
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Laura J Helmkamp
- Adult and Child Center for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Caroline Tietbohl
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Adult and Child Center for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Jocelyn S Thompson
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Adult and Child Center for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Monica Fitzgerald
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Colleen K McIlvennan
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Adult and Child Center for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Geoffrey Harger
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - P Michael Ho
- Rocky Mountain VA Regional Medical Center, Aurora, Colorado, USA
| | - Faraz S Ahmad
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Tariq Ahmad
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Peter Buttrick
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Larry A Allen
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Adult and Child Center for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, USA.
| |
Collapse
|
2
|
Brereton E, Harger G, Matlock DD, Dorsey Holliman B, Tate CE. How Do Patients Describe Hospice Care? A Qualitative Analysis of the Language Used by Older Adults to Describe Hospice Care. J Palliat Med 2022; 25:1692-1696. [PMID: 35944273 PMCID: PMC9836666 DOI: 10.1089/jpm.2022.0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 01/22/2023] Open
Abstract
Background: Misconceptions about hospice are prevalent and create barriers to hospice enrollment. These misconceptions may be a result of the confusing language around hospice care. Objective: To conduct a content analysis exploring the language used and accuracy in which older adults describe hospice. Design: Participants in two prior studies were asked to describe hospice in their own words. Responses were coded inductively to explore the language used, and deductively to evaluate accuracy in describing hospice. Subjects: Two hundred sixty-six adults, aged at least 65 years or older. Results: The most common language used to describe hospice care related to "comfort," "care," and "family." Most participants accurately describe hospice eligibility, services, and goals of care but inaccurately described location of hospices services. Conclusions: Participants accurately described most of the logistical aspects of hospice care and words such as comfort, care, and family are commonly used to describe services suggesting preferred language for communication interventions. Clinicaltrials.gov (Cohort #1 NCT03794700 and Cohort #2 NCT04458090).
Collapse
Affiliation(s)
- Elinor Brereton
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Geoffrey Harger
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Daniel D. Matlock
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
- Division of Geriatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, Colorado, USA
| | - Brooke Dorsey Holliman
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Channing E. Tate
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| |
Collapse
|
4
|
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: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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.)
| |
Collapse
|