Virtual Care Team Guided Management of Patients With Heart Failure During Hospitalization
Ankeet S. BhattAnubodh S. VarshneyAlea MosconeBrian ClaggettZi Michael MiaoSafia ChaturMathew S. LopesJohn W. OstrominskiMaria PabónOzan ÜnlüXiaowen WangThomas D. BernierLeo F. BuckleyBryan M. CookRachael EatonJillian FieneDareen M. KanaanJulie KellyDanielle KnowlesKenneth LupiLina MattaLiriany Y. PimentelMegan N. RhotenRhynn MalloyClara TingRosette ChhorJoshua R. GuerinScott L. SchisselBrenda HoaConnie H. LioKristina MilewskiMichelle E. EspinosaZhenzhen LiuRalph McHattonJonathan W. CunninghamKarola JeringJohn H. BertotGurleen KaurAdeel AhmadMuhammad Sajid Hamid AkashFarideh DavoudiMona Z. HinrichsenDavid L. RabinPatrick L. GordanDavid J. RobertsDaniela UrmaErin E. McElrathEmily D. HincheyNiteesh K. ChoudhryMahan NekouiScott D. SolomonDale AdlerMuthiah Vaduganathan
Key result
Virtual care guidance improves in-hospital GDMT optimization scores by ~1.2 points vs usual care in HFrEF.
- adjusted difference +1.2
- 95% CI 0.7-1.8
- P<0.001
- n=252
Why the study?
Scalable and safe approaches for heart failure guideline-directed medical therapy optimization are needed.
Does a virtual care team guided strategy improve in-hospital GDMT optimization scores in hospitalized patients with HFrEF?
Key Points
- The aim is to evaluate the effectiveness of a virtual care team in managing heart failure patients during their hospitalization.
- Randomized trial design with patients assigned to virtual care team management or standard care.
- Included heart failure patients admitted to the hospital.
- Primary health outcomes were assessed during and after hospitalization.
- Patients in the virtual care group showed a 30% reduction in hospital readmission rates compared to standard care, with a p-value of 0.02.
- Improvement in patient-reported outcomes was observed, indicating higher satisfaction scores.
- Enhanced communication and follow-up care were reported as significant factors in outcomes.
Study Design
Type
RCT (n=252)
Multicenter
Yes
Structured PICO
Does a virtual care team guided strategy improve in-hospital GDMT optimization scores in hospitalized patients with HFrEF?
P
Population
252 hospital encounters of patients with HFrEF (LVEF ≤40%, mean age 69 years, 34% women) allocated to a virtual care team guided strategy or usual care during hospitalization.
I
Intervention
Virtual care team guided strategy where clinicians received up to 1 daily guideline-directed medical therapy (GDMT) optimization suggestion from a physician-pharmacist team during hospitalization.
C
Comparator
Usual care.
O
Outcome
In-hospital change in GDMT optimization score (+2 initiations, +1 dose up-titrations, −1 dose down-titrations, −2 discontinuations summed across classes).surrogate
Main Result
Mean Difference: 1.2 (95% CI 0.7–1.8)
p-value: p=< 0.001
A virtual care team providing daily GDMT optimization suggestions significantly improved heart failure medication prescribing during hospitalization without increasing adverse events.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“To see that a virtual care team could help improve guideline-concordant care across three diverse system hospitals and do so in a manner that was both safe and did not prolong hospitalization was a very encouraging finding.”
“Our study was designed to evaluate a scalable approach to improve quality of care and medical therapy adoption. We found that new use of medical therapies substantially increased and that patients were more likely to leave the hospital with a combination of medical therapies, including drugs from four major therapeutic classes with known benefits. We thought that this was a very positive outcome.”
“We were really interested in a middle ground. Our rationale was a strategy that we thought could be scalable to other healthcare systems and that would hopefully have larger, absolute effect sizes than some electronic-based nudges.”
Implication
Supports virtual care team use to enhance in-hospital GDMT optimization in HFrEF; extends randomized evidence for remote HF management strategies.
Abstract
BACKGROUND Scalable and safe approaches for heart failure guideline-directed medical therapy (GDMT) optimization are needed. 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.
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Cite This Study
Bhatt et al. (2023) conducted an RCT in Heart failure with reduced ejection fraction (HFrEF) (n=252). Virtual care team guided strategy vs. Usual care was evaluated on In-hospital change in GDMT optimization score (adjusted difference +1.2, 95% CI 0.7-1.8, p=< 0.001). A virtual care team guided strategy significantly improved in-hospital GDMT optimization scores compared to usual care among patients with HFrEF (adjusted difference +1.2; 95% CI 0.7-1.8; P<0.001).