Cardiology Guidelines

HFrEF Treatment’s Guideline Barrier

Guideline-directed medical therapies (GDMT) for heart failure have proven to be “profoundly effective at reducing morbidity and mortality,” and yet prescription rates for many HFrEF therapies are far too low and inconsistent.

To unravel this challenge, a UCLA team analyzed VA data from 178k veterans in 306 Hospital Referral Regions (HRRs) across the US.

On a national level, the researchers observed low median nationwide prescription rates for many key HFrEF drug classes, but relatively high rates for others:

  • Beta-blockers – 80%
  • ACEI/ARB/ARNI – 69.3%
  • MRA – 29.2% (some seemed particularly concerned about this)
  • ARNI – 12.2%
  • SGLT2I – 10.3%

A deeper dive into these numbers reveals even greater regional variations, finding:

  • Wide variations across HRRs nationwide and within geographic regions
  • An inverse association between prescription rates and income inequality
  • A strong association between prescription rates and access to cardiology clinics
  • A strong association between prescription rates and VA telehealth use

Noting that drug costs are less of an issue with VA patients, the study and related editorial paid special attention to the role that cardiology clinic and telehealth access played in GDMT compliance. 

  • 60% of HRRs in the top 10% of cardiology clinic visits had above-median GDMT rates
  • 7 of the 10 HRRs with the lowest prescription scores didn’t have a VA cardiology clinic
  • 67% of HRRs in the top 5% of cardiology telehealth visits had above-median GDMT rates
  • 8 of the 10 HRRs with the lowest prescription scores didn’t have any VA cardiology telehealth visits

Given the significant variations within this single health system, and the importance of GDMT adherence, the study and editorial authors proposed a long list of targeted strategies to improve overall heart failure care:

  • Forming multidisciplinary heart failure management team
  • Making guidelines universally available and implementable
  • Seamlessly implementation GDMT into provider workflows, especially the EHR
  • Increased HF medication education, focused on prescription and uptitration 
  • Dedicating more resources to social determinants of HF health 
  • Expanding access to cardiology clinics and telehealth

The Takeaway

Heart failure treatments and diagnostics have come a long way in recent years, but this study illustrates the important role that GDMT compliance will play in order for those major scientific advancements to have a similarly major impact on patient care.

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