Virtual Care Team Guided Management of Patients With Heart Failure During Hospitalization.
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Bhatt Ankeet S, Varshney Anubodh S, Moscone Alea, Claggett Brian L, Miao Zi Michael, Chatur Safia, Lopes Mathew S, Ostrominski John W, Pabon Maria A, Unlu Ozan, Wang Xiaowen, Bernier Thomas D, Buckley Leo F, Cook Bryan, Eaton Rachael, Fiene Jillian, Kanaan Dareen, Kelly Julie, Knowles Danielle M, Lupi Kenneth, Matta Lina S, Pimentel Liriany Y, Rhoten Megan N, Malloy Rhynn, Ting Clara, Chhor Rosette, Guerin Joshua R, Schissel Scott L, Hoa Brenda, Lio Connie H, Milewski Kristina, Espinosa Michelle E, Liu Zhenzhen, McHatton Ralph, Cunningham Jonathan W, Jering Karola S, Bertot John H, Kaur Gurleen, Ahmad Adeel, Akash Muhammad, Davoudi Farideh, Hinrichsen Mona Z, Rabin David L, Gordan Patrick L, Roberts David J, Urma Daniela, McElrath Erin E, Hinchey Emily D, Choudhry Niteesh K, Nekoui Mahan, Solomon Scott D, Adler Dale S, Vaduganathan Muthiah
Аннотация
OBJECTIVES: The authors assessed the safety and effectiveness of a virtual care team guided strategy on GDMT optimization in hospitalized patients with heart failure with reduced ejection fraction (HFrEF).
METHODS: In a multicenter implementation trial, we allocated 252 hospital encounters in patients with left ventricular ejection fraction ≤40% to a virtual care team guided strategy (107 encounters among 83 patients) or usual care (145 encounters among 115 patients) across 3 centers in an integrated health system. In the virtual care team group, clinicians received up to 1 daily GDMT optimization suggestion from a physician-pharmacist team. The primary effectiveness outcome was in-hospital change in GDMT optimization score (+2 initiations, +1 dose up-titrations, -1 dose down-titrations, -2 discontinuations summed across classes). In-hospital safety outcomes were adjudicated by an independent clinical events committee.
RESULTS: Among 252 encounters, the mean age was 69 ± 14 years, 85 (34%) were women, 35 (14%) were Black, and 43 (17%) were Hispanic. The virtual care team strategy significantly improved GDMT optimization scores vs usual care (adjusted difference: +1.2; 95% CI: 0.7-1.8; P < 0.001). New initiations (44% vs 23%; absolute difference: +21%; P = 0.001) and net intensifications (44% vs 24%; absolute difference: +20%; P = 0.002) during hospitalization were higher in the virtual care team group, translating to a number needed to intervene of 5 encounters. Overall, 23 (21%) in the virtual care team group and 40 (28%) in usual care experienced 1 or more adverse events (P = 0.30). Acute kidney injury, bradycardia, hypotension, hyperkalemia, and hospital length of stay were similar between groups.
CONCLUSIONS: Among patients hospitalized with HFrEF, a virtual care team guided strategy for GDMT optimization was safe and improved GDMT across multiple hospitals in an integrated health system. Virtual teams represent a centralized and scalable approach to optimize GDMT.