Review Highlights Interventions to Address Therapeutic Gaps in Heart Failure Management

A new review outlines strategies that may help close the large therapeutic gap between guideline-directed recommendations and real-world practice when it comes to managing patients with heart failure.

Writing in Current Treatment Options in Cardiovascular Medicine, researchers discussed several of these strategies that hold potential to reduce implementation gaps and improve outcomes for patients.

These include integrating multidisciplinary team–based approaches, auto-populating heart failure registries that can measure integrated health system performance, and electronic health record (EHR) embedded tools like clinical alerts. Additional pathways to improving care could include machine learning and multidisciplinary virtual care.

Accelerating the safe implementation guideline-directed medical therapy (GDMT) has also been shown to reduce heart failure–related morbidity and mortality, the study authors noted, underscoring the need for more integration into current care.

In recent years, newer therapies for patients with heart failure with reduced ejection fraction have been approved and integrated into care. However, “adoption and dose titration of these therapies remain poor in national registries representative of the contemporary implementation of GDMT,” the researchers explained.

This slow uptake can be attributed in part to low health care literacy, clinician competency, concerns for adverse events, and uneven insurance coverage, among other factors. The researchers assessed the benefits and drawbacks of several interventions that could improve GDMT for those with heart failure.

Although alerts or prompting may have limited effects, they are easily scalable, and several randomized trials have used EHR-embedded alerts or tools to improve medication prescription among patients with heart failure, the researchers said.

“Multiple recent trials with tailored clinical alerts and patient-centered education initiatives have increased GDMT prescription,” including the PROMPT-HF trial, they noted. The design structure of this trial allowed for cheap and rapid patient enrollment and participation, although it was only carried out at 1 health care system and may not be easily scalable.

Another trial found a patient education video delivered electronically to those with a scheduled cardiology visit resulted in an improvement in medication prescription after 30 days.

But overall, data supporting EHR-based alerts, patient messaging, and large-scale quality initiatives have been mixed, the authors wrote. However, because racial, socioeconomic, and sex-specific disparities continue in heart failure care, EHR-based registries could help address barriers to access to medical therapy by allowing for a better understanding of practice differences across systems and may help mitigate these disparities.

In addition, research shows intensive heart failure management with experts is effective but can be resource intensive. Studies have found care can improve with multidisciplinary teams of heart failure cardiologists, pharmacists, and clinical navigators. This intervention might also have a visit structure that could be difficult to replicate in health systems across the United States, the authors cautioned.

Furthermore, “who will receive, interpret, and act on growing amounts of patient data remains an unanswered question that will continue to limit the scalability of studies that do not incorporate and disseminate the appropriate resourcing to effectively deploy novel technologies or strategies of [heart failure] care,” they said.

When it comes to the expansion of remote monitoring and virtual care, progress will likely evolve based on legislative action and reimbursement structures, the researchers added.

They conclude more studies are needed to better refine patient populations who will benefit most from interventions.

“A multifaceted approach to improving [heart failure] therapy that incorporates iterative evidence generation to confirm effectiveness and efficacy is within reach for many contemporary health systems,” the authors wrote. “With time, we may prove that the multidisciplinary, technology-enabled whole is greater than the sum of its parts in modern [heart failure] care.”

Reference

Brooksbank JA, Faulkenberg KD, Tang WHW, and Martyn T. Novel strategies to improve prescription of guideline-directed medical therapy in heart failure. Curr Treat Options Cardiovasc Med. Published online April 5, 2023. doi:10.1007/s11936-023-00979-4