From the 2024 HVPA National Conference
Toluwalase Awoyemi MD (Northwestern University), Hani Hazani MD, Chrystina Gunnare PA-C, Tamy Le PharmD, Alex Trevino MD, Ahmad Faraz MD
Background:
Heart failure (HF) stands as the predominant cause of hospitalization in the United States. Guideline-directed medical therapy (GDMT) has been shown to significantly decrease mortality and 30-day readmission rates at the time of hospital discharge. Despite this, national and local data from Northwestern Memorial Hospital (NMH) indicates low prescription rates of GDMT.
Objective:
The primary objective of this study is to increase the prescription rate of mineralocorticoid receptor antagonists (MRAs) and one of the four pillars of GDMT, by 20% in hospitalized patients diagnosed with HFrEF admitted to an inpatient medicine floor at NMH through the implementation of pharmacy-driven interventions. This study is anticipated to be conducted over a 12-month period, commencing around February 2025.
Methods:
Data collection proceeded in multiple phases. The initial phase involved compiling baseline data utilizing Slicer Dicer and the enterprise data warehouse. Subsequently, a provider survey done via Microsoft Forms was utilized to learn more about clinician behavior and barriers to prescribing GDMTs and was disseminated via strategically timed interval emails to all healthcare providers encompassing residents, hospitalists, advanced practice providers, and attending RNs on January 8, 2024. This provider survey aimed to discern barriers to GDMT prescription and identify potential solutions that have demonstrated use. The results of this GDMT provider survey were used to inform our MRA-focused intervention.
Results:
In 2022, our institution admitted 1440 patients with HF. Within the institution, the prescribing patterns for GDMTs were as follows: 62.3% of HF patients received ACE inhibitors or ARBs, 54% received mineralocorticoid receptor antagonists (MRA), and approximately 30-40% received either SGLT2 inhibitors or ARNis. The survey received responses from 106 individuals, predominantly internal medicine residents (51.9%) and hospitalists (39.4%). Key barriers to prescribing identified in the survey included the need for price checks and prior authorization (15%), deferring GDMT initiation to primary care physicians (PCPs) or outpatient cardiologists (14.7%), and patients being hospitalized for reasons other than heart failure (11.79%). Furthermore, 23% of respondents expressed neutrality or discomfort with escalating GDMTs in the hospital setting, but 83% agreed that education focused on GDMTs could enhance prescription rates. Respondents indicated openness to receiving GDMT recommendations from pharmacists via face-to-face interaction (20%), paging (18.2%), or allowing pharmacists to pend orders for subsequent provider approval (18.2%).
Based on survey responses, spironolactone, an MRA, emerged as the preferred candidate for a quality improvement (QI) project due to its favorable side effect and accessibility profile. In comparison to other GDMT agents, spironolactone is less likely to significantly decrease blood pressure or worsen renal function, and it is available at most pharmacies, covered by the majority of prescription insurances, and highly affordable. The results in this abstract are the first phase of a larger QI project, implementation of the solutions identified from the survey are ongoing and results will soon be available.
Conclusions:
This initiative effectively identified barriers to GDMT prescription within our institution and identified actionable areas for improvement.
Clinical Implications:
This intervention, targeting barriers like price checks, prior authorizations, and provider reluctance identified through the survey, enhances the success potential of our guideline-directed medical therapy (GDMT) tailored quality improvement (QI) project.