A novel quality improvement (QI) initiative for guideline-directed medical therapy (GDMT) utilization increased angiotensin receptor-neprilysin inhibitor (ARNI) and mineralocorticoid receptor antagonist (MRA) prescriptions in outpatients with heart failure with reduced ejection fraction (HFrEF,) according to an implementation perspective paper published in JACC: Heart Failure.

The initiative centered on QI in patients with HFrEF, defined as a left ventricular ejection fraction ≤40% and NYHA functional class II to IV, in a large outpatient cardiology practice across 10 locations and affiliated with an integrated health care system in Northern Virginia. The researchers estimated that at the start of the study, consistent with national trends, prescription rates were low: <25% of patients eligible for an ARNI and <45% of patients eligible for an MRA.

The QI initiative aimed to increase ARNI prescriptions to >25% of eligible patients and MRA prescription to >60%. Achievement of these, among other quality metrics, was then tied to 5% of total provider compensation, and group progress toward the goal was reviewed during team meetings. Research teams identified possible qualifying patients and sent email alerts to clinicians on the date of the patient’s next appointment. Clinicians were given a simple, colorful one-page document to track a patient’s eligibility for ARNI or MRA and were asked to mark any specific contraindications.

The percentage of patients eligible for an ARNI or MRA was similar before and after the initiative (60.0% vs. 56.9% for ARNI, 62.6% vs. 59.3% for MRA). In all groups, major ineligibility reasons included hypotension, impaired renal function, hyperkalemia, prior ACEI/ARB or MRA intolerance and cost-prohibitive factors, with hypotension being the major disqualifier. The pre-initiative cohort (860 patients over 1,345 visits) was slightly older (median age 78 years vs. 74 years) than the post-initiative cohort (1,461 patients over 3,792 visits) and a larger percentage had a history of chronic kidney disease (9.9% vs. 5.3%) and ICD or CRT (42.8% vs. 37.2%).

Results showed that during the initiative, prescription of ARNI increased from 31.4% of eligible patients to 66.8% (odds ratio [OR], 4.40; 95% CI, 3.46-5.61; p<0.01). Prescription of MRA therapy increased from 27.7% of eligible patients to 66.0% (OR, 5.06; 95% CI, 3.97-6.45; p<0.01).

“This compelling finding has important implications on improving symptoms, morbidity and mortality for patients with HFrEF,” write authors Andrei Minciunescu, MD; Tariq M. Haddad, MD, FACC, et al. “The concepts within this strategy have wide-reaching potential applications.”

Clinical Topics: Heart Failure and Cardiomyopathies

Keywords: Angiotensin Receptor Antagonists, Patient Care, Mineralocorticoid Receptor Antagonists, Quality Improvement, Angiotensin-Converting Enzyme Inhibitors, Ventricular Dysfunction, Left, Delivery of Health Care, Integrated, Receptors, Angiotensin