Background: In the U.S., hospitalizations related to Congestive Heart Failure (CHF) are amongst the most frequent and costly, yet a unified approach toward improving outcomes remains elusive. In 2022, the AHA/ACC/HFSA released updated guidelines for the management of heart failure. Recommendations include prescribing four classes of medications for eligible patients, known as guideline-directed medical therapy (GDMT). Despite the evidence, history has shown that adoption of new guidelines is slow, and poor adherence correlates with worse outcomes.Studies have identified as few as 6.8% of eligible patients receiving any dose of all four pillars of GDMT. Insufficient provider access to timely/reliable medication data contributes to this pattern. In this study, we sought to reduce prescribing gaps and improve adherence with GDMT using a unique, prescription-oriented digital tool through a Nurse Navigator program.
Methods: We partnered with a third-party vendor for access to medication history for CHF patients in near real time via a user interface that measures adherence gaps at the population level. Our Nurse Navigator followed the following process:Step 1. Identify patients: Patients with a diagnosis of heart failure with reduced ejection fraction (HFrEF) are identified during hospitalization. The Nurse Navigator introduces the patient to the program, provides education, reviews medications, and discusses barriers to compliance. Prescribing gaps in GDMT are resolved or addressed prior to discharge. Step 2. Phone call 72 hours post-discharge: A nurse calls to follow up, performs a medication review using the population health solution, and ensures follow up appointments are scheduled.Step 3. Follow up 30 to 60 days post-discharge: A nurse refreshes medication history data to assess and address medication adherence to GDMT between patient visits. Three attempts are made to contact the patient at each step.
Results: Over 10 months, we enrolled 501 patients in the program. Overall, patients saw improvement in GDMT medication management across all drug classes: First fill rates increased 23.9% overall and across all four GDMT categories after Nurse Navigator interventions: • SGLT2s – 52.9%• ARNI/ACE/ARB – 6.5%• Beta Blockers – 8.0%• MRAs – 81.6%GDMT medication management improved across all drug classes after Nurse Navigator interventions:• % of patients who filled any GDMT pre-intervention: 79.27%• % of patients who filled any GDMT post-intervention: 100.00%• % of patients who filled all GDMT pre-intervention: 8.81%• % of patients who filled all GDMT post-intervention: 14.51%
Conclusions: These results demonstrate effective improvement in GDMT prescribing and adherence when a Nurse Navigator has access to real time prescription fill data. Compounding improvements in prescription fill rates were observed in parallel with Nurse Navigator interactions. For SGLT2s in particular, fill rates increased after each subsequent phone call, representing a dramatic improvement in the adoption of current guidelines by both patients and providers. Our rate of patients filling all GDMT medications post-intervention was 7.71% higher than the average reported in the clinical literature.Equipping care teams with access to real time, reliable prescription data is paramount in helping overcome the clinical inertia propagated by care silos. The potential for improved patient-centeredness and safer prescribing may be achieved by the more proactive approach of contacting patients between visits.