The prevalence of heart failure continues to rise with the aging population in the United States, as do the costs associated.1 It is estimated that by year 2035, more than 130 million adults in the United States (45.1 percent) are expected to have some form of cardiovascular disease and the costs associated are expected to reach 1.1 trillion dollars.1 It is also important to note that more than 20 percent of patients with heart failure are readmitted to the hospital within 30 days and up to 50 percent within months.2 Although heart failure cannot be cured, the burdens associated with the disease can be reduced with appropriate pharmacotherapy. By targeting this population with guideline recommended pharmacotherapy we can slow heart failure progression, reduce mortality and morbidity and improve symptoms to prevent hospitalizations.
The primary purpose of this study, the Physician Adherence to 2017 ACC/AHA/HFSA Clinical Practice Guidelines in Patients with Heart Failure with Reduced Ejection Fraction (HGrEF) in a Community Teaching Hospital study, was to evaluate physician adherence to guideline recommended medications that have shown morbidity and mortality benefit as well as reduce heart failure related hospitalizations in patients with HFrEF at Mercy Health Saint Mary's. Physician adherence was based on the adherence score for prescribed medications at discharge for patients within the cardiology consult group and the primary care services group.
There are multiple studies that utilize an adherence score to evaluate the appropriateness of medications prescribed to patients with HFrEF. The adherence score was originally developed and used in the QUALIFY study which aimed to understand the impact of physician adherence to guidelines from the European Society of Cardiology.3 The adherence score provides an objective assessment and is calculated by obtaining the ratio of the evidenced-based medications prescribed to the evidenced-based medications that theoretically should have been prescribed. The medications that theoretically should have been prescribed are chosen based on their significant improvement in morbidity and mortality as well as reduction in heart failure hospitalizations as supported by the current guidelines. Each medication is reviewed for appropriateness based on the current guidelines4 and then given a score of either zero points for the lack of prescribing of an evidenced-based medication in the absence of contraindications, 0.5 points for the use of evidenced-based medication at < 50 percent target dosage or one point for the use of evidenced-based medication > 50 percent target dosage or for not prescribing in the presence of contraindications, intolerances or allergies.
This was a retrospective chart review that included adult patients admitted between June 1, 2017 and June 1, 2018 with a discharge diagnosis of heart failure with reduced ejection fraction (ejection fraction < 40% measured on echocardiogram) confirmed by documentation within the past one year from date of admission. Two cohorts of patients were identified for comparison: patients with a cardiology consult and patients managed by a primary care service. The primary care services group comprised of patients admitted to one of the following three services: the family medicine resident service, internal medicine resident service or the hospitalist service. The primary outcome was to compare the average physician adherence score between the cardiology consult group and the primary care services group. The secondary outcome was to compare the average physician adherence score between the internal medicine resident service, family medicine resident service and the hospitalist service. The reasons for not prescribing guideline recommended medications was also explored.
The mean physician adherence score was significantly higher for the cardiology consult group versus the primary care services group, which was 0.59 and 0.47 respectively (p = 0.0279). Contraindications was the most commonly inferred reason for not prescribing guideline recommended medications as it was present in 67 percent of patients in the cardiology consult group and 87 percent of patients in the primary care services group (p = 0.008). However, contraindications were accounted for when calculating the adherence score.
This study showed a statistically significant difference in the mean physician adherence scores between the cardiology consult group and the primary care services group. Based on our evaluation, this indicates that if a cardiology consult was obtained, patients were more likely to be discharged on guideline recommended medications at appropriate target doses based on our evaluation. However, there were multiple patient baseline characteristics that were different among the two cohorts which might have contributed to the difference seen in the mean physician adherence score. There was no difference in the mean physician adherence scores between the primary care services. A larger patient population may be needed to further assess the clinical significance of physician adherence scores between the cardiology consult group and primary care services group.
There is potentially room for improvement in physician adherence to evidenced-based medications for HFrEF. The unique skillset of a pharmacist readily optimizes medication regimens and identifies gaps in adherence. We can assess for true allergies and recommend alternative medications when appropriate, assess for physician and patient hesitancy to the prescribed medications and provide education to reduce hesitancy. We can also provide close follow up and assist in medication titration. A prospective study would be valuable to provide further insight to reasons for not prescribing evidenced-based medications in the absence of allergies, contraindications or adverse events.
References
1. Benjamin EJ, Virani SS, Callaway CW, et al. Heart disease and stroke statistics-2018 update: a report from the American Heart Association. Circulation [Internet]. 2018 Jan 31 [cited 2018 Mar 31];137(13): e67-e493. Available from: http://circ.ahajournals.org/content/early/2018/01/30/CIR.0000000000000558
2. O'Conner CM. High heart failure readmission rates: is it the health system's fault? JACC Heart Fail [Internet]. 2017 May [cited 2018 Mar 31];5(5):393. Available from: http://heartfailure.onlinejacc.org/content/5/5/393
3. Komajda M, Cowie MR, Tavazzi L et al. Physicians' guideline adherence is associated with better prognosis in outpatients with heart failure with reduced ejection fraction: the QUALIFY international registry. Eur J Heart Fail [Internet]. 2017 Nov [cited 2018 Feb 22];19(11):1414-23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28463464
4. Yancy CW, Jessup M, Bozkurt B et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines and the Heart Failure Society of America. J Am Coll Cardiol [Internet]. 2017 Aug 8 [cited 2018 Mar 4];70(6):776-803. Available from: https://www.ahajournals.org/doi/10.1161/cir.0000000000000509