Neutral results highlight importance of developing successful interventions for HF patients

Patients with heart failure with reduced ejection fraction (HFrEF) cared for in hospitals that adopted a postdischarge quality improvement intervention did no better in time to first rehospitalization for HF or death, or in measures of HF quality-of-care, compared with those in hospitals giving usual care, according to results from the CONNECT-HF study.

“Heart failure with reduced ejection fraction (HFrEF) affects more than an estimated 3 million people in the U.S. Despite the availability of multiple treatment options, outcomes remain suboptimal with high rates of rehospitalization and death. This is due, in part, to inadequate adoption of guideline-directed medical therapy. Heart failure quality improvement efforts by hospitals and health systems are common, but limited data exist from multicenter, randomized controlled studies to inform current quality improvement efforts for hospitals and health systems attempting to improve care for patients discharged with acute HFrEF. Previous recommendations for improving evidence-based care include educational outreach to clinicians on how to implement guideline recommendations and audit and feedback of clinical performance, such as use of guideline-directed medical therapy,” Adam D. DeVore, MD, MHS, of the Duke Clinical Research Institute, Durham, North Carolina, and colleagues explained in JAMA.

“The objective of this cluster randomized trial was to test the effect of a hospital and postdischarge quality improvement intervention compared with usual care on heart failure outcomes and quality of care. The intervention specifically focused on education delivered by external experts and use of audit and feedback for heart failure process measures, such as use of guideline-directed medical therapy for HFrEF,” they added.

DeVore et al enrolled 5,647 patients from 161 hospitals, who were followed after hospital discharge for acute HFrEF. Mean patient age was 63 years, 33% were women, 38% Black, 87% had chronic HF, and 49% reported recent hospitalization for HF. They assigned 2,675 to the intervention group and 2,972 to usual care.

The intervention consisted of regular education of physicians by a trained group of HF and quality improvement experts, and audit and feedback on HF process measures, including the use of guideline-directed medical therapy for HFrEF, and outcomes in 82 hospitals. Seventy-nine hospitals were randomized to usual care, comprised of access to a generalized HF education website.

Co-primary outcomes were a composite of first HF rehospitalization or all-cause mortality and change in an opportunity-based composite score for HF quality.

Rehospitalization for HF or all-cause mortality was seen in 38.6% of patients in the intervention group, compared with 39.2% of the usual care group (adjusted HR: 0.92; 95% CI: 0.81-1.05). Change from baseline quality-of-care scores were 2.3% versus −1.0%, respectively in these group (difference: 3.3%; 95% CI: −0.8% to 7.3%). Researchers found no significant difference in the odds of gaining a higher composite quality score at last follow-up between the two group (adjusted OR: 1.06; 95% CI: 0.993-1.21).

According to Ankeet S. Bhatt, MD, MBA, of Brigham and Women’s Hospital and Harvard Medical School, Boston, and colleagues, unraveling the reasons for these neutral findings is difficult, and noted they “are likely complex and multifactorial. The majority of hospitals were already participating in quality improvement initiatives for heart failure, and the study intervention may have been less effective against this augmented background care. In addition, a fragmented ambulatory care delivery model, consisting of visits that are often brief, infrequent, and focused on addressing symptom stability, may have further decreased the reach of the intervention. It is also possible that the nudges used were not strong enough; reinforcement with additional and generally stronger strategies, including gamification, in which site-specific performance is communicated as benchmarked data against peer sites, may have helped. In addition, adjustments to the timing of site-specific audit and feedback may have influenced adoption; prompts providing performance on implementation gaps timed to be delivered during or immediately before ambulatory encounters for heart failure may have boosted efficacy,” they wrote in their accompanying editorial.

Bhatt and colleagues also outlined the difficulties of implementing and assessing intervention programs in an accompanying editorial:

“Building successful implementation programs will require cross-collaboration among groups with diverse expertise, including clinicians, trialists, social and behavioral psychologists, and economists, among others. Several examples of effective implementation teams already exist. ’Nudge units’ integrated into a health system have demonstrated how seemingly unrelated variables such as the time of clinic appointment may have implications for statin prescription and have developed effective messaging strategies to promote influenza vaccination. Similar groups have even been embedded within health plans to incentivize healthy behaviors and practices aimed at reducing avoidable health care utilization,” they wrote.

“What is needed to create cardiometabolic nudge units that will prioritize dissemination and implementation science along with discovery science? Continued investments in strategy trials like CONNECT-HF will be a key foundation. Recognizing the potential broad-ranging merits of these efforts, the National Institutes of Health has designated dissemination and implementation as a research priority. A convergence of federal, foundation, and industry efforts may be the necessary momentum to firmly move dissemination and implementation science into prominence for cardiometabolic health,” concluded Bhatt and colleagues.

Limitations of the study were the inclusion of only hospitals that could perform a system-based quality improvement program, the inclusion of both integrated and nonintegrated care delivery systems, the inclusion of only patients who granted informed consent, and low patient enrolled due to Covid-19.

  1. According to results from the CONNECT-HF study, a hospital and postdischarge quality improvement intervention did not bring about better clinical outcomes or measure of quality of care for patients with heart failure with reduced ejection fraction.

  2. Results from hospitals implementing this intervention were no better than from those adhering to usual care for patients with HFrEF.

Liz Meszaros, Deputy Managing Editor, BreakingMED™

The trial was funded by Novartis Pharmaceuticals Corporation through an investigator-initiated trial program.

DeVore reported no disclosures.

Bhatt reported receiving personal fees from Sanofi Pasteur, Clarivate, and Verve Therapeutics.

Cat ID: 3

Topic ID: 74,3,730,3,192,925