Education, Feedback Boosts Pharmacists’ HF Medication Rates

Giving pharmacists in the Veterans Health Administration (VHA) education and feedback on their patients’ heart failure (HF) medication rates helped boost visits and prescribing of newer guideline-directed therapies,¹ according to data presented Saturday at the 2024 American Heart Association (AHA) Scientific Sessions, taking place in Chicago through Monday.

However, adding personalized physician feedback and patient information to the education sessions did not increase HF medication prescribing as much as investigators had hoped, highlighting the challenge of getting uptake of new therapies in clinical practice.

Alexander T. Sandhu, MD, MS | Image credit: Stanford University

Lead study author Alexander T. Sandhu, MD, MS, a heart failure specialist from Stanford University, said at a press conference Saturday that the team will evaluate the behavior behind the results.

“Looking at the long-term impact beyond 6 months will be critical to understand behavior change over time as well as maintenance, and we'll be evaluating that,” Sandhu said. “We're also currently undergoing a qualitative assessment of the intervention to adapt it before further testing across 3 additional VA regions next year.”

The study, known as PHARM-HF A&F, for audit and feedback, included 120 VHA primary care pharmacists who were responsible for 7224 patients on their rosters with HF. The VHA was considered the ideal setting for this type of study, because patients have low cost-sharing and providers do not face many of the barriers present with commercial insurance.

The “4 pillars” in HF treatment for patients with reduced ejection fraction (< 40%) are beta-blockers, angiotensin receptor-neprilysin inhibitors, sodium glucose cotransporter-2 (SGLT2) inhibitors, and mineralocorticoid receptor antagonists (MRAs); this last class now has a nonsteroidal therapy, finerenone (Kerendia). The pattern for many years was to introduce these drugs one at a time, starting with beta-blockers, but current guidelines call for starting patients on all 4 together. In the real world, this does not always happen, however.

For the VHA study, investigators randomized the 120 pharmacists into 3 groups: all received education on current HF medication best practices and titration protocols, with 62 in the usual care (UC) arm receiving education only. Of the 58 in the audit and feedback group, 28 received individual feedback about how they were doing with HF prescribing relative to their peers (AF arm), and 30 received this feedback along with targeted patient reports (AF+ arm), which investigators thought might prompt additional HF visits.

Results were as follows:

• The patients were located in Northern and Central California, Nevada, Hawaii, American Samoa, and Guam. The mean age was 75 years, 98% were men, 65% were White, 14% were Black, 5% were Asian, 4% were Pacific Islander, 1% were Native American, and 11% were of unknown race
• Before the study, each pharmacist averaged 2.1 encounters per month related to HF and 0.4 encounters for an HF medication adjustment
• The primary end point was the difference in the rate of HF medication encounters between the combined AF/AF+ arms and UC arm during the 3 to 6 months after randomization
• The UC arm had an increase in monthly HF encounters (0.5 95% CI, 0.0 to 0.9); the AF and AF+ arms had an additional increase of 1.2 (95% CI, 0.8-1.7) monthly HF encounters compared with the UC arm
• There was no significant difference between between the AF+ and the AF arms (0.1; 95% CI, –0.6 to 0.8)
• The UC arm had an in increase in monthly encounters in which HF medication was adjusted (0.2; 95% CI, 0.1-0.4); there was an additional increase in the AF arms compared with the UC arm (0.2; 95% CI, 0.1-0.4)
• There was no significant increase from providing pharmacists with patient-specific data

Sandhu said it was surprising that providing patient-specific data did not lead to appreciable increases in medication adjustment, and the study team will examine why this occurred. “We know pharmacists can help improve medical therapy for patients with heart failure; however, most pharmacists are not providing heart failure care even when they are allowed to,” he said.

Brahmajee Nallamothu, MD, MPH, FAHA | Image credit: University of Michigan

One major limitation was that the patient-specific data provided to pharmacists was not restricted to their own roster of patients. On the positive side, investigators found an increase in uptitration in the AF arms compared with the UC arms (11.6% vs 9.2%), and they also observed a small increase in MRA initiation, which Sandhu said, “is noteworthy for being the most historically underprescribed component of guideline-directed medical therapy.”

Brahmajee Nallamothu, MD, MPH, FAHA, a professor in the Division of Cardiovascular Diseases at the University of Michigan, who was invited to comment on the study, said the results of PHARM-HF A&F highlighted a “really important problem.” 

Known as clinical or therapeutic inertia, this issue has received considerable attention in recent years, as guidelines called for adding SGLT2 inhibitors and MRAs alongside older therapies in HFrEF. In their 2021 article, Stephen J. Greene, MD, of the Duke Clinical Research Institute, and Gregg C. Fonarow, MD, of the Abramson-UCLA Cardiomyopathy Center discussed the phenomenon in which primary care physicians are reluctant to increase doses or add new therapies to regimens.² DCRI has an ongoing project to address this problem.

Greene and Fonarow wrote, “In the care of patients with heart failure (HF) with reduced ejection fraction (HFrEF), multiple lines of evidence suggest a strong culture of hesitancy, needlessly prolonged sequencing of beneficial therapies, and clinical inertia towards making medication changes in routine outpatient practice.”²

Other specialties are using technology to address this issue. In oncology, investigators have experimented with the use of digital nudges to prompt physicians to speak with patients about steps such as palliative care, which are called for in guidelines but implemented at suboptimal levels.

Nallamothu said the fact that PHARM-HF A&F results occurred within the VHA, a highly integrated health system, illuminates the challenges of bringing guideline-directed therapy to every patient with HF who needs it. “If we can't do this in the VA system, it's really difficult to imagine how this type of model can work outside of that type of setting,” he said.

References

1. Sandhu AT, Steverson A, Sahay A, et al. Evaluation of randomized audit and feedback to increase heart failure medication optimization among primary care pharmacists in the Veterans Health Care system. Presented at: American Heart Association Scientific Sessions, November 16-18, 2024; Chicago, IL. Abstract LBS.03.

2. Greene SJ, Fonarow GC. Clinical inertia and medical therapy for heart failure: the unintended harms of ‘first do no harm.’ Eur J Heart Fail. 23(8):1343-1345. doi: 10.1002/ejhf.2252