In-hospital peer-to-peer consult may improve guideline-directed therapy in HFrEF
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CHICAGO — A clinician level peer-to-peer consultation may increase use of and optimize guideline-directed medical therapy in patients with HFrEF hospitalized for any cause compared with usual care, a speaker reported.
The virtual peer-to-peer consultation was associated with greater guideline-directed medical therapy (GDMT) initiation and dose optimization at discharge compared with usual care, according to data presented at the American Heart Association Scientific Sessions.
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“This single-center pilot randomized control trial showed that, when compared with usual care, admitting non-cardiology medical teams randomized to a virtual consultation intervention with recommendations to optimize GDMT and out-of-pocket cost estimates/prior authorization completion had increased comprehensive optimization of GDMT primarily through initiation, continuation, and dose increase of [ACE inhibitor, angiotensin receptor blockers, angiotensin receptor/neprilysin inhibition, mineralocorticoid receptor antagonists and SGLT2 inhibitor] therapies for eligible patients with HFrEF admitted for any cause,” Vishal Rao, MD, MPH, fellow in advanced heart failure and transplant cardiology at Duke University School of Medicine and Duke Clinical Research Institute, told Healio.
Between May and September 2021, researchers identified patients with HFrEF admitted at Duke University Medical Center to non-cardiology units for any cause and randomly assigned them to a clinician-level virtual peer-to-peer consult intervention or usual care.
Patients who had end-stage renal disease, who had hemodynamic instability or who were receiving hospice care were excluded. The study was simultaneously published in Circulation: Heart Failure.
Rao said that after an initial screening by a HF clinician, eligible patients’ medical history and clinical characteristics were reviewed daily, and teams randomly assigned to the intervention received a virtual consultation note and clinical page and/or call.
“The overall process took 20 to 30 minutes, sometimes longer while waiting for out-of-pocket cost estimates or prior authorization completion,” Rao told Healio. “These tasks occurred alongside routine clinical care duties.”
The primary endpoints included proportion of patients with new GDMT initiation or use and changes to HF optimal medical therapy scores which included target dosing.
GDMT at hospital admission was similar between the intervention and usual care groups.
Researchers observed a greater proportion of patients with GDMT initiation and/or continuation among those in the intervention arm compared with usual care for ACE inhibitors/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitors (71% vs. 49%; P = .04), and nominally higher initiation and/or continuation for therapies including mineralocorticoid receptor antagonists (41% vs. 21%; P = .05) and SGLT2 inhibitors (26% vs. 14%; P = .19).
GDMT discontinuation or dose reduction was similar between groups, although nominally with less in the intervention arm, according to the presentation.
After researchers adjusted for optimal medical therapy scores at hospital admission, score changes at discharge were higher in the intervention arm compared with usual care (+0.44 vs. –0.31, absolute difference, +0.75; P = .041).
“It is abundantly clear that we have a lot of work to improve GDMT use for HF. Any medical contact are key points to change the clinical trajectory for patients with HFrEF. We have increasing data showing that if patients are not prescribed GDMT for HF during a HF hospitalization, there is as much as a 90% chance they will never be prescribed these therapies during 1-year follow-up,” Rao told Healio. “Most patients treated for their primary admitting diagnosis and nearing discharge are still eligible for GDMT changes based on symptoms, BP and end-organ function. Thus, for stabilized and eligible patients nearing discharge, the non-HF reason for hospitalization alone are not contraindications to optimizing HF therapies.
“We hope studies like this may open doors to future investigations in optimal communication between multispecialty providers as we continue to explore treatment gaps to overcome barriers in GDMT optimization for HFrEF across varying health systems,” he said.
Reference:
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Shah A, et al. Abstract SA2203. Presented at: American Heart Association Scientific Sessions; Nov. 5-7, 2022; Chicago (hybrid meeting).
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