Key Points
- Despite an extensive body of evidence supporting the benefit and use of guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF), its implementation remains low
- The IMPLEMENT-HF study explored the efficacy of virtual optimization of GDMT for hospitalized patients, hypothesizing that a dedicated GDMT Team would improve GDMT optimization during admission compared to usual care
- A virtual care team-guided strategy improved GDMT in hospitalized HFrEF patients; this strategy was safe and was not associated with increased hospital length of stay.
Hospitalizations, readmission, and emergency department visits are unfortunately not uncommon for patients with heart failure with reduced ejection fraction (HFrEF). As providers seek opportunities for improving the quality of care provided to this patient group, investigators have turned to developing virtual medicine strategies, specifically the implementation of virtual care teams. Admissions pose a unique opportunity for patients with HFrEF to optimize available guideline-directed medical therapy (GDMT, i.e., evidence-based ß-blockers, ACEi/ARB/ARNI, MRA, & SGLT2i) under close supervision, yet this requires nuanced understanding of such medications in order for uptitration to be safe and effective. Recent advances in virtual medicine have positioned virtual consultation and outreach in a unique place to improve patient care. In the study titled, Safety And Efficacy Of Virtual Care Team Guided Therapeutic Optimization During Hospitalization In Patients With HFrEF, or the IMPLEMENT-HF Study, investigators used a virtual care team to aid inpatient providers in therapeutic changes during hospital admissions for any cause.
IMPLEMENT-HF was a prospective implementation trial in patients with HFrEF admitted to 3 hospitals within an integrated healthcare delivery system (Mass General Brigham, Boston, MA) from October 2021 through June 2022. The study evaluated inpatient therapeutic changes to GDMT for consecutive admissions in HFrEF patients hospitalized with and without implementation of a virtual care team-guided strategy. There were three sites included in the study, comprised of an academic medical center, a community teaching hospital, and a community hospital. The virtual care team was comprised of a pharmacist and physician who provided GDMT optimization suggestions to primary teams based on an evidence-based algorithm. Patients had to be ≥18 years of age, with an LVEF ≤40%, and admitted to a participating facility on a non-intensive care unit medical or surgical service to be included in the study. Importantly, patients with critical illness and systolic blood pressure less than 90 mmHg in the preceding 24 hours prior to study enrollment were excluded; other exclusion criteria included severe valvular disease, pulmonary hypertension, recent cardiac intervention, or admission for COVID-19 among others. A total of 252 patient encounters were selected after review by investigators (198 unique patients). After allocation and follow up, 143 encounters received usual care and 106 received the virtual care team-guided intervention. The primary outcome was GDMT optimization score, described as the sum of positive (+2 for new initiations, 1+ for dose up-titrations) and negative therapeutic changes (-2 for discontinuations, -1 for dose down-titrations) at hospital discharge compared to medication regimen on admission. Both patient groups were well-matched in terms of baseline characteristics. Important to note, 70% of patients were admitted for indications other than a heart failure exacerbation, 20% of patients had de novo heart failure presentations.
The use of a virtual care team to optimize GDMT during consecutive hospitalizations showed a statistically significant improvement in GDMT optimization score (+1.2, 95% confidence interval [CI] +0.7 to +1.8; per adjusted beta coefficient) with a p-value of <0.001. Secondary outcomes showed an increase in new initiations across all GDMT classes, with beta blockers and mineralocorticoid antagonists having statistically significant new initiations. A highlight of the results was the number needed to intervene of 5 encounters. In-hospital adverse events were examined as a marker of safety; there were no significant differences between the virtual care team strategy and usual care in terms of hypertension, hyperkalemia, acute kidney injury, bradycardia, and in-hospital death.
A virtual care team-guided strategy improved GDMT in hospitalized HFrEF patients. Importantly, investigators found that this strategy was safe, scalable, and was not associated with increased hospital length of stay. While presenting the results, Dr. Ankeet Bhatt remarked that “benefits were consistent across most subgroups, including hospitalizations for non-heart failure indications and de novo heart failure presentations.” This study adds to a mounting body of evidence supporting the use of virtual medicine resources across the spectrum of care for patients with HFrEF. Future studies externally validating these findings with a focus on medication durability and clinical outcomes stemming from the use of virtual care teams would add to the growing promise of virtual medicine.
