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Bhatt AS, Varshney AS, Nekoui M, Moscone A, Cunningham JW, Jering KS, Patel PN, Sinnenberg LE, Bernier TD, Buckley LF, Cook BM, Dempsey J, Kelly J, Knowles DM, Lupi K, Malloy R, Matta LS, Rhoten MN, Sharma K, Snyder CA, Ting C, McElrath EE, Amato MG, Alobaidly M, Ulbricht CE, Choudhry NK, Adler DS, Vaduganathan M. Virtual optimization of guideline-directed medical therapy in hospitalized patients with heart failure with reduced ejection fraction: the IMPLEMENT-HF pilot study. Eur J Heart Fail 2021; 23:1191-1201. [PMID: 33768599 DOI: 10.1002/ejhf.2163] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [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] [Received: 01/10/2021] [Revised: 03/18/2021] [Accepted: 03/21/2021] [Indexed: 11/10/2022] Open
Abstract
AIMS Implementation of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) remains incomplete. Non-cardiovascular hospitalization may present opportunities for GDMT optimization. We assessed the efficacy and durability of a virtual, multidisciplinary 'GDMT Team' on medical therapy prescription for HFrEF. METHODS AND RESULTS Consecutive hospitalizations in patients with HFrEF (ejection fraction ≤40%) were prospectively identified from 3 February to 1 March 2020 (usual care group) and 2 March to 28 August 2020 (intervention group). Patients with critical illness, de novo heart failure, and systolic blood pressure <90 mmHg in the preceeding 24 hs prior to enrollment were excluded. In the intervention group, a pharmacist-physician GDMT Team provided optimization suggestions to treating teams based on an evidence-based algorithm. The primary outcome was a GDMT optimization score, the sum of positive (+1 for new initiations or up-titrations) and negative therapeutic changes (-1 for discontinuations or down-titrations) at hospital discharge. Serious in-hospital safety events were assessed. Among 278 consecutive encounters with HFrEF, 118 met eligibility criteria; 29 (25%) received usual care and 89 (75%) received the GDMT Team intervention. Among usual care encounters, there were no changes in GDMT prescription during hospitalization. In the intervention group, β-blocker (72% to 88%; P = 0.01), angiotensin receptor-neprilysin inhibitor (6% to 17%; P = 0.03), mineralocorticoid receptor antagonist (16% to 29%; P = 0.05), and triple therapy (9% to 26%; P < 0.01) prescriptions increased during hospitalization. After adjustment for clinically relevant covariates, the GDMT Team was associated with an increase in GDMT optimization score (+0.58; 95% confidence interval +0.09 to +1.07; P = 0.02). There were no serious in-hospital adverse events. CONCLUSIONS Non-cardiovascular hospitalizations are a potentially safe and effective setting for GDMT optimization. A virtual GDMT Team was associated with improved heart failure therapeutic optimization. This implementation strategy warrants testing in a prospective randomized controlled trial.
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Affiliation(s)
- Ankeet S Bhatt
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Anubodh S Varshney
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Alea Moscone
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jonathan W Cunningham
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Karola S Jering
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Parth N Patel
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Thomas D Bernier
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Leo F Buckley
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Bryan M Cook
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Jillian Dempsey
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Julie Kelly
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Kenneth Lupi
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Rhynn Malloy
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Lina S Matta
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Megan N Rhoten
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Krishan Sharma
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Clara Ting
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Erin E McElrath
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Mary G Amato
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Massachusetts College of Pharmacy and Health Sciences, Boston, MA, USA
| | - Maryam Alobaidly
- Department of Quality and Safety, Brigham and Women's Hospital, Boston, MA, USA
| | - Catherine E Ulbricht
- Massachusetts College of Pharmacy and Health Sciences, Boston, MA, USA.,Department of Quality and Safety, Brigham and Women's Hospital, Boston, MA, USA
| | - Niteesh K Choudhry
- Center for Healthcare Delivery Sciences, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Dale S Adler
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Muthiah Vaduganathan
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Sinnenberg LE, Wanner KJ, Perrone J, Barg FK, Rhodes KV, Meisel ZF. What Factors Affect Physicians' Decisions to Prescribe Opioids in Emergency Departments? MDM Policy Pract 2017; 2:2381468316681006. [PMID: 30288413 PMCID: PMC6124837 DOI: 10.1177/2381468316681006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 10/31/2016] [Indexed: 11/28/2022] Open
Abstract
Objective: With 42% of all emergency department visits in the United
States related to pain, physicians who work in this setting are tasked with
providing adequate pain management to patients with varying primary complaints
and medical histories. Complicating this, the United States is in the midst of
an opioid overdose epidemic. State governments and national organizations have
developed guidelines and legislation to curtail opioid prescriptions in acute
care settings, while also incentivizing providers for patient satisfaction and
completeness of pain control. In order to inform future policies that focus on
provider pain medication prescribing, we sought to characterize the factors
physicians weigh when considering treating pain with opioids in the emergency
department. Methods: We conducted and transcribed open-ended,
semistructured qualitative interviews with 52 physicians at a national emergency
medicine conference. Results: Participants reported a wide range of
factors contributing to their opioid prescribing patterns related to three
domains: 1) provider assessment of pain characteristics, 2) patient-based
considerations, and 3) practice environment. Pain characteristics include the
characteristics of various acute and chronic pain syndromes, including
physicians’ empathy due to their own experiences with pain. Patient
characteristics include “trustworthiness,” race and ethnicity, and the concern
for risk of misuse. Factors related to the practice environment include hospital
policy, legislation/regulation, and guidelines. Conclusion: The
decision to prescribe opioids to patients in the emergency department is complex
and nuanced. Physicians are interested in guidance and are concerned about the
competing pressures placed on their opioid prescribing due to incentives related
to patient satisfaction scores on one hand and inflexible policies that do not
allow for individualized, patient-centered decisions on the other.
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Affiliation(s)
- Lauren E Sinnenberg
- Department of Emergency Medicine (LES, JP, ZFM), Perelman School of Medicine.,Department of Family Medicine and Community Health (FKB), Perelman School of Medicine.,Center for Clinical Epidemiology and Biostatistics (FKB), Perelman School of Medicine.,Center for Emergency Care Policy and Research (LES, KJW, ZFM), University of Pennsylvania, Philadelphia, Pennsylvania.,Office of Population Health Management, Hofstra Northwell School of Medicine, Hempstead, New York (KVR)
| | - Kathryn J Wanner
- Department of Emergency Medicine (LES, JP, ZFM), Perelman School of Medicine.,Department of Family Medicine and Community Health (FKB), Perelman School of Medicine.,Center for Clinical Epidemiology and Biostatistics (FKB), Perelman School of Medicine.,Center for Emergency Care Policy and Research (LES, KJW, ZFM), University of Pennsylvania, Philadelphia, Pennsylvania.,Office of Population Health Management, Hofstra Northwell School of Medicine, Hempstead, New York (KVR)
| | - Jeanmarie Perrone
- Department of Emergency Medicine (LES, JP, ZFM), Perelman School of Medicine.,Department of Family Medicine and Community Health (FKB), Perelman School of Medicine.,Center for Clinical Epidemiology and Biostatistics (FKB), Perelman School of Medicine.,Center for Emergency Care Policy and Research (LES, KJW, ZFM), University of Pennsylvania, Philadelphia, Pennsylvania.,Office of Population Health Management, Hofstra Northwell School of Medicine, Hempstead, New York (KVR)
| | - Frances K Barg
- Department of Emergency Medicine (LES, JP, ZFM), Perelman School of Medicine.,Department of Family Medicine and Community Health (FKB), Perelman School of Medicine.,Center for Clinical Epidemiology and Biostatistics (FKB), Perelman School of Medicine.,Center for Emergency Care Policy and Research (LES, KJW, ZFM), University of Pennsylvania, Philadelphia, Pennsylvania.,Office of Population Health Management, Hofstra Northwell School of Medicine, Hempstead, New York (KVR)
| | - Karin V Rhodes
- Department of Emergency Medicine (LES, JP, ZFM), Perelman School of Medicine.,Department of Family Medicine and Community Health (FKB), Perelman School of Medicine.,Center for Clinical Epidemiology and Biostatistics (FKB), Perelman School of Medicine.,Center for Emergency Care Policy and Research (LES, KJW, ZFM), University of Pennsylvania, Philadelphia, Pennsylvania.,Office of Population Health Management, Hofstra Northwell School of Medicine, Hempstead, New York (KVR)
| | - Zachary F Meisel
- Department of Emergency Medicine (LES, JP, ZFM), Perelman School of Medicine.,Department of Family Medicine and Community Health (FKB), Perelman School of Medicine.,Center for Clinical Epidemiology and Biostatistics (FKB), Perelman School of Medicine.,Center for Emergency Care Policy and Research (LES, KJW, ZFM), University of Pennsylvania, Philadelphia, Pennsylvania.,Office of Population Health Management, Hofstra Northwell School of Medicine, Hempstead, New York (KVR)
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