Improving Provider Compliance with Outpatient Heart Failure Prescribing
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Abstract
Guidelines recommend prescribing four classifications of medications for individuals with heart failure with reduced ejection fraction (HFrEF). Individuals on guideline directed medical therapy (GDMT) have been shown to have reduced mortality and morbidity. If all eligible individuals were on GDMT, lives saved could be improved by 60% annually. The largest impact comes from prescribing GDMT with the lowest prescribing rates. Further evidence has confirmed there is a lack of guideline adherence in outpatient prescribing. Use of provider reminders with decision support improves adherence to guidelines. Study Objectives: Determine the prescribing behaviors of advanced practice providers (APPs) and physicians before and after implementation of a provider reminder tool that offers decision support in outpatient prescribing. Methods: This scholarly project occurred over two months in the fall of 2020. Eligibility criteria to have reminders placed in the chart included adults with HFrEF with a left ventricular ejection fraction (LVEF) less than 40%, seen by an APP or physician in an outpatient cardiology practice. When patients were seen in the office for their scheduled visit, providers had access to their electronic medical record (EMR) with the reminder tool sent as a provider communication note for all visit types. An additional paper reminder tool was handed to the provider for in-person visits. Following patient visits, prescribed medications were recorded to allow for pre-post comparisons. Analysis included descriptive statistics and McNemar’s test for paired nominal data using StataCorp v.16 statistical software (2019). Subgroup analysis was performed by provider type and visit type. Results: A convenience sample of 120 consecutive provider-patient encounters was evaluated in a southeastern United States outpatient cardiology practice. Compliance with renin-angiotensin-aldosterone system (RAAS) inhibitors, beta blockers (BB), and hydralazine-isosorbide dinitrate (H-ISDN) were numerically improved, though not statistically significant. Compliance to aldosterone antagonists (MRA) showed significant improvement after the intervention for all patients (35.8% to 41.7%, p=.020), which continued after adjusting for contraindications by medication classification. Post intervention prescribing was improved in all visit types for all medication classes except RAAS inhibitors, beta blockers, and H-ISDN in virtual visit formats. Visit type influenced prescribing of RAAS inhibitors and MRAs. In-person RAAS inhibitor and MRA prescribing had significant improvement after the intervention (78.3% to 95.7%, p = .0455; 39.1% to 56.5%, p =.0455, respectively). Improvement in prescribing was noted for APPs and physicians, except for beta blockers among physicians. Subgroup analysis of provider type did not yield any statistical difference. Uptitration of medications were numerically increased for beta blockers and RASS inhibitors. Uptitration was significantly higher in heart failure providers for RAAS inhibitors as compared to non-heart failure providers (29%; 6.5%, p=.004). The opposite was true for beta blockers, with non-heart failure providers uptitrating more (19.2%), but it was not statistically significant. Conclusions: This scholarly project demonstrated that an electronically delivered, paper generated provider reminder tool with decision support can clinically impact guideline adherence. With in-person visit type, the tool was statistically impactful. These findings are consistent with the literature. Given the uptake in the frequency of virtual visits following the coronavirus disease pandemic, virtual visit type reduced initiation of RAAS inhibitors and beta blockers, which require vital sign data. Provider type did not impact guideline prescribing. Being a HF specialist positively impacted uptitration.