Ryan Haumschild, PharmD, MS, MBA: Let’s talk about access and affordability. It’s great to have wonderful therapies for heart failure, but if the patients aren’t able to fill them or they aren’t staying adherent to these therapies, we aren’t going to see those positive health benefits. How do we discuss the population health-management approaches for heart failure but also identify an opportunity for us to improve care? I want to start this first question to Dr Uppal. We talked earlier about how we’re going to treat a lot of these patients the same, whether they have preserved or reduced ejection fraction [EF]. But how do we start to identify and treat patients with heart failure who are at risk for poor health outcomes between one another? How do we stratify those risks to identify those who need more timely intervention or intensive therapy earlier to slow the progression and give them better outcomes?
Rohit Uppal, MD, MBA, SFH: Great question. The benefit of being a hospitalist is that we have a lot of data at our disposal. A lot of the indicators of high risk, especially for morbidity and mortality, are available in the hospital setting. We always have a BNP [brain natriuretic peptide]. We have the patient’s GFR [glomerular filtration rate]. These patients are on telemetry, so we’re identifying ventricular arrhythmias. We know their EF. We know if they’ve required inotropes. We’ve taken our history, so we know their NYHA [New York Heart Association] class. We know if they’ve been intolerant to medical therapy. All these clues help us stratify patients who are high risk based on their medical features. You have to combine that with the social determinants of health, which also add to that risk.
Once you identify the high-risk patients, it’s a daunting challenge for any clinician, and certainly for hospitalists, to address all the medical and social issues of this population. We just talked about team care. It takes a village to treat these very high-risk patients. One way we train our clinicians is to give them the knowledge and skills to have effective advanced care planning conversations with these patients. Making advanced care planning a standard component of our care for these patients is essential. That improves their quality of life and has an impact on cost of care.
Emphasizing that team-based approach, you have to have an effective multidisciplinary team that includes nurses, case managers, pharmacists, social workers, and nutritionists. Hopefully you have a palliative care team and hospice practitioners at your facility or within your community. Another important part of the team for these patients is the advanced heart failure team or cardiologists. You want to get them involved early to help manage some of these important decisions.
Ryan Haumschild, PharmD, MS, MBA: Dr Uppal, you talked about team-based care and so many great team members that come into play. Another one that I think of a lot is the payer. They’re a part of the team in terms of taking care of the patient. They provide support. Dr Murillo, from your perspective, what are some of the payer-level support programs for patients with heart failure, whether for case management or some type of navigator? Is there a better opportunity for us to work closer together for these at-risk patients to enroll them in these programs and have better management and oversight?
Jaime Murillo, MD: I love that question. Thank you for asking that. As I mentioned earlier, the health plans are playing a more active role in helping people be healthier and helping the system work better for everyone. There are many ways. There are pilots all over the country from different payers about remote patient monitoring and working with ACOs [accountable care organizations], health systems, and employers about how to better care for those patients, how to better prevent them from having complications, and so on.
You’d be surprised to hear that health plans are eager to collaborate and establish innovative interventions to help people. Heart failure is a critical area. If there’s an area where there’s an opportunity to collaborate with a health plan, and there’s innovative thinking about it, I’d encourage our viewers—especially those who are practicing medicine—to go to health plans and say, “Let’s work together.” It isn’t just about negotiating a contract regarding how to pay. Ask, “What can we do together to make our patients better?” They will be very receptive. Thank you for that question.
Ryan Haumschild, PharmD, MS, MBA: Yes, I love that approach too. It’s a collaborative front. Dr Uppal, when we’re thinking about population health, when I think about any patient type, specifically heart failure, we’ve got to have some measures of success. We want to know that our interventions have been successful. We’re able to monitor and track them over time. As a scientist and a physician, you’re familiar with this. What interventions are you trying to do? What metrics are you monitoring to see what type of impact they’re having on our patient outcomes?
Rohit Uppal, MD, MBA, SFH: One challenge we have across the continuum is integrating all the data sources we have. Within the hospital space—we also get some data from payers—some of the metrics we monitor are the inpatient length of stay; readmission rates at 3 days, 7 days, 30 days, and 90 days; mortality rates; rates of referral to hospice and palliative care; and rates of cardiology referral. We also look at our patient experience scores, which are a strong driver of patient adherence once they leave the hospital.
Ryan Haumschild, PharmD, MS, MBA: Dr Anderson, I have a question for you. Can you discuss some of the best practices at your organization for guiding appropriate care? Do you have treatment pathways? Do you have specific guidelines, policies, EMRs [electronic medical records]? How can that guideline-based pathway influence heart failure treatment from the payer perspective as well?
John E. Anderson, MD: That’s a great question. I’ll answer it in 2 parts. In the hospital, we have great guideline-based therapy. We have expectations from a number of organizations about what’s expected and what’s guideline-based therapy. When you get to the outpatient setting, some have it and some don’t. For example, I don’t have anything embedded in my EMR system that prompts SGLT2 inhibition or an ARNI [angiotensin receptor-neprilysin inhibitor]. We could do a better job of having a systematic approach.
Ryan Haumschild, PharmD, MS, MBA: It sounds like systematic approach is probably the right way to go because you want to create consistency. Dr Januzzi, what are some of the best practices you’ve seen? Is it order sets in the EMR? What are you seeing to create that consistent practice?
Jim Januzzi, MD: Every institution has a different opportunity. We use the guideline-directed medical therapy [GDMT] clinic approach. Embedding in the electronic medical record is an interesting approach that hasn’t been explored enough. The recent PROMPT-HF trial out of the Yale University system showed that an EMR-prompt approach improved GDMT. Importantly, it took 10 prompts before 1 change was made, so it’s necessary to emphasize that even though it seems like a potentially useful way to improve care, more work needs to be done to better understand how to encourage clinicians to follow the prompts we’re telling them. Because you can prompt all day, but if they don’t make the changes, it isn’t going to necessarily improve care.
Ultimately, it comes down to education. The American College of Cardiology Expert Consensus Decision Pathway document that focuses on this approach also comes with a smartphone app that clinicians can use at the bedside or in the office. That’s another way of leveraging newer techniques and technologies for learning how to use GDMT effectively.
Ryan Haumschild, PharmD, MS, MBA: I like the strategies. There are a lot of apps, but if it’s at the touch of your fingertips and it provides better practice, it isn’t a bad thing to have.
Transcript edited for clarity.