Abstract 218: Improving Guideline-Directed Medical Therapy Utilization for Heart Failure With Reduced Ejection Fraction Within a Veteran's Affairs Health System
Authors: Slade Justin J , Lee Michelle , Park Jun , Liu Alexander , Heidenreich Paul A , Allaudeen Nazima 
Published: May 2020

Despite a robust evidence base and well-established clinical guidelines for patients with HFrEF, a significant number of patients with this disease are not currently prescribed ACEI/ARB/ARNI and beta-blocker therapies at or near target doses proven to reduce the risk of cardiovascular events and mortality in randomized clinical trials. Within the VA Palo Alto Health System we found that the minority of patients with HFrEF prescribed these therapies were receiving ACEI/ARB/ARNI (45.2%: 410 of 908) and beta-blockers (45.4%: 458 of 1008) at ≥50% of target doses.

Limited general medicine and cardiology appointment availability as well as clinical inertia were identified as root causes of suboptimal dosing of guideline-directed medical therapy (GDMT). We addressed these with implementation of a pharmacist driven Heart Failure Medication Titration Clinic through a shared practice agreement with general medicine physicians, initially at one clinical site with 190 total HFrEF patients. An academic detailing clinical dashboard including medication prescribing and LV ejection fraction data (obtained via natural language processing of imaging reports) is utilized by the on-site clinical pharmacist to identify actionable HFrEF patients on suboptimal GDMT. If felt appropriate for escalation of therapy, a patient’s primary care physician or cardiologist approves a referral to the clinic. The pharmacist then conducts regular clinic or telephone visits (typically every two weeks) with the patient to assess tolerance of therapy and eligibility for further dose escalation per an established titration algorithm that integrates recent symptoms, vital signs, and lab values.

In three months, patients referred to the Heart Failure Medication Titration Clinic have had their average ACE/ARB/ARNI dose escalated from 21.9% to 42.7% of target dose and their average beta-blocker dose escalated from 56.3% to 81.3% of target dose. No adverse medication events or hospitalizations have occurred. There has been a corresponding increase in the overall percentage of this clinical site’s HFrEF patients on ACEI/ARB/ARNI (36.4% to 43.7%: 55 of 126) and beta-blockers (39.4% to 43.0%: 55 of 128) that are receiving ≥50% of target dose therapy.

These results suggest that clinical pharmacists can play a vital role in identifying and treating patients that are on suboptimal treatment for HFrEF via utilization of an academic detailing dashboard and pharmacist led medication titration clinics. Limitations of this quality improvement initiative include short duration of follow-up to date and performance of these interventions within an integrated health care system, which may not be generalizable to other health care delivery models. Next steps include addition of mineralocorticoid antagonist therapy to our titration algorithm and scaling these interventions to additional clinical sites within our health system.