Optimizing Foundational Therapies in Patients With HFrEF: How Do We Translate These Findings Into Clinical Care?
Optimizing Foundational Therapies in Patients With HFrEF: How Do We Translate These Findings Into Clinical Care?
Given the high risk of adverse outcomes in patients with heart failure and reduced ejection fraction (HFrEF), there is an urgent need for the initiation and titration of guideline-directed medical therapy (GDMT) that can reduce the risk of morbidity and mortality. Clinical practice guidelines are now emphasizing the need for early and rapid initiation of therapies that have cardiovascular benefit. Recognizing that there are many barriers to GDMT initiation and optimization, health care providers should aim to introduce the 4 pillars of quadruple therapy now recommended by most clinical practice guidelines: angiotensin receptor-neprilysin inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose co-transporter 2 inhibitors. A large proportion of patients with HFrEF do not have clinical contraindications to GDMT but are not treated with these therapies. Early initiation of low-dose combination therapy should be tolerated by most patients. However, patient-related factors such as hemodynamics, frailty, and laboratory values will need consideration for maximum tolerated GDMT. GDMT initiation in acute heart failure hospitalization represents another important avenue to improve use of GDMT. Finally, removal of therapies that do not have clear cardiovascular benefit should be considered to lower polypharmacy and reduce the risk of adverse side effects. Future prospective studies aimed at guiding optimal implementation of quadruple therapy are warranted to reduce morbidity and mortality in patients with HFrEF.
President Biden Announced Strategy to Address the National Mental Health Crisis
On March 1, 2022, President Biden announced his strategy to address the national mental health crisis during his first State of the Union. This strategy will strengthen system capacity, connect more Americans to care, and create a continuum of support to transform our health and social services infrastructure to address mental health holistically and equitably.
As part of this strategy, President Biden included a goal to expand access to tele- and virtual mental health care options. More specifically:
- The Administration will work with Congress to ensure coverage of tele-behavioral health across health plans, and support appropriate delivery of telemedicine across state lines, to maintain continuity of access;
- The Department of Health and Human Services (HHS) will create a learning collaborative with state insurance departments to identify and address state-based barriers, like telehealth limitations, to behavioral health access; and
- The United States Office of Personnel Management will facilitate widespread, confidential, and easy access to telehealth services, in part by strongly encouraging Federal Employees Health Benefits Program carriers to sufficiently reimburse providers for telehealth services, and to eliminate or reduce co-payments for consumers seeking tele-mental service.
To read the full press release on this initiative, click here.
Remote Patient Monitoring During COVID-19
JAMA Network: Remote Patient Monitoring During COVID-19
COVID-19 has advanced patient safety in an unexpected way. Before the COVID-19 pandemic, patient monitoring for harm and many approaches to prevent harm were linked to where the patient was treated in the hospital.
A report based on data prior to the COVID-19 pandemic suggested that routinely monitoring hospitalized patients with continuous pulse oximetry and heart rate devices was associated with reduced mortality. In that study, arly recognition of hypoxemia and respiratory depression were largely responsible for the observed decrease in mortality, from 0 deaths among 111 ,487 patients in monitored units vs 3 deaths among 15 ,209 patients in unmonitored units. COVID-19 created a need to monitor patients treated in standard medical units, in emergency departments (EDs), and to also monitor some patients at home for clinical deterioration (eg, hypoxemia) to help increase hospital capacity. With the increased volume of patients coupled with high staffing ratios for all types of clinician workload, hospitalized patients are at increased risk for unrecognized clinical deterioration.
A recent cost-utility analysis estimated that daily assessment and 3-week follow-up of at-home pulse oximetry monitoring was projected to be potentially associated with a mortality rate of 6 per 1,000 patients with COVID-19, compared with 26 per 1,000 without at-home monitoring. Based on a hypothetical cohort of 3,100 patients, the study projected that remote monitoring could potentially be associated with 87 percent fewer hospitalizations, 77 percent fewer deaths, reduced per-patient costs of $11, 472 over standard care, and gains of 0.013 quality-adjusted life-years.
Patients can now be monitored based on risks and needs rather than location in the hospital. While enhanced monitoring at home could potentially improve safety and value, empirical evidence of the benefits of this approach are limited. Home monitoring and hospital at-home models offer the potential to transform care and potentially allow a substantial proportion of hospitalized patients to receive care from home. Yet, health systems will need to collaborate with technology companies to accelerate learning and produce greater value for patients, clinicians, and health care organizations.
Alliance Support Letter for Kansas SB 454
The Alliance submitted a letter of support to Sen. Richard Hilderbrand, Senate Majority Whip and Chair, Senate Committee on Public Health and Welfare, for Senate Bill 454.
Senate Bill 454 would amend the Advanced Practice Registered Nurse (APRN) authorized scope of practice to permit the prescribing of controlled substances without a supervising physician. This bill would help to eliminate barriers such as collaborative practice agreements with a supervising physician and grant full practice authority to improve access to care for Kansas patients.
Allowing APRNs to practice at the top of their licenses means allowing them to use all of their education and training to care for patients. Removing these restrictions on APRNs would increase consumer access to health care, address persisting barriers to care for vulnerable populations and/or patients living in provider shortage areas, and reduce unnecessary health care costs.
Read the full letter here and below:
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Open in new tab Alliance Support Letter for South Dakota SB 134
The Alliance submitted a letter of support to Sen. Erin Tobin, Vice-Chair of the Health and Human Services Committee, for Senate Bill 134.
Senate Bill 134 would modernize Physician Assistant (PA) practice and remove the outdated collaborative agreement with a physician in order to put all advanced practice providers on equal footing. The bill would allow experienced PAs to collaborate with, consult with, or refer to the appropriate member of the health care team. This important legislation would help increase patient access to health care services for all South Dakotans, especially as rural and medically underserved communities across the state are facing a serious health care provider shortage impeding their access to care.
The Alliance believes that PAs should be able to perform at the top of their licenses in order to expand access and eliminate barriers to health care. As a telehealth advocacy organization, the Alliance believes PAs are an essential component to expanding access to care through the use of telehealth. This is especially important for patients who live in rural or underserved communities or in provider shortage areas and therefore may not have access to services they need where they reside. PAs have also been critical to expanding access to care and filling gaps in the health care workforce throughout the pandemic.
Read the full letter here and below:
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Alliance Support Letter for Minnesota SB 2303
The Alliance submitted a letter of support to Paul J. Utke, the Chair of the Health and Human Services Finance and Policy Committee, for Senate Bill 2303.
The bill would adopt the Nurse Licensure Compact in the State of Minnesota. The Nurse Licensure Compact allows for the issuance of multistate licenses that allow nurses to practice in their home state and other compact states, without having to obtain additional licenses. This bill is critical because it allows for mutual recognition of state licenses between states participating in the compact.
One of the biggest barriers to telehealth becoming a regular patient and provider choice is the administrative burden caused by variation in licensure requirements from state to state. Alleviating such administrative burdens through establishing multistate compacts that have reciprocity and do not require additional licensing will help improve patient access to quality health care.
Read the full letter here and below:
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How remote patient monitoring (RPM) can increase access to care
How remote patient monitoring (RPM) can increase access to care
As the COVID-19 pandemic sweeps through the world, healthcare providers and patients are struggling to reconcile the need for continuity in care with the risks posed by the coronavirus. The crisis has also shed light on existing issues with access to care faced by patients in rural, hard-to-reach areas. Some of these problems can be solved by remote patient monitoring (RPM): a technology solution that collects patient data from devices such as weight scales and blood pressure monitors and transmits them wirelessly to providers, who can intervene when clinically necessary.
Alliance Support Letter for Virginia SB 1245
The Alliance submitted a letter of support to Sen. George Barker, Chair of Subcommittee on Health Professions Senate Education and Health Committee, for Senate Bill 1245.
Senate Bill 1245 would repeal the sunset provision included in a bill that passed in 2021 (House Bill 1737) that reduced the number of years of full-time clinical experience a nurse practitioner must have to be eligible to practice without a written or electronic practice agreement from five years to two years. By reducing the transition to practice requirement for nurse practitioners (NPs) to two years on a permanent basis, House Bill 1245 would allow NPs to use the full extent of their education and training to provide care to patients.
Allowing NPs to practice at the top of their licenses means allowing them to use all of their education and training to care for patients. Removing restrictions on NPs to allow them to practice to the full extent of their education and training would increase consumer access to health care, address persisting barriers to care for vulnerable populations and/or patients living in provider shortage areas, and reduce unnecessary health care costs.
Read the full letter here and below:
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Alliance Submits Comments to FSMB Draft Report on Appropriate Use of Telemedicine Technologies
The Alliance for Connected Care submitted comments in response to the Federation of State Medical Boards (FSMB) request for comments on the draft document entitled “Report on the Appropriate Use of Telemedicine Technologies in the Practice of Medicine.” The Alliance offered comments we hope the FSMB Workgroup on Telemedicine will consider as it finalizes this document in the coming weeks. We primarily offer recommendations around the provision of audio-only telehealth, reforming licensure laws and regulations, removing restrictive in-person requirements for establishing a provider-patient relationship, and addressing health equity through broadband access and affordability. Summarized below are takeaways from our response:
- Provision of Audio-only Telehealth – The Alliance proposed an edit to the definition included on “telemedicine,” specifically the provision that relates to audio-only telehealth. We encouraged FSMB to modify this definition to account for the fact that providers and patients should be the ones to make the decision about the most appropriate modality for a telehealth visit, not regulators.
- Reforming Licensure Laws and Regulations – The Alliance believes that one of the biggest barriers to telehealth becoming a regular patient and provider choice is the administrative burden caused by the variation in licensure requirements from state to state. The Alliance offered comments on the recommendations made in the draft document around exceptions that may be made to permit the practice of medicine across state lines without the need for licensure in a jurisdiction where the patient is located:
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- Consultations and Screenings – The Alliance appreciated the inclusion of physician-to-physician consultations and prospective patient screening for complex referrals as exceptions to licensure. This is important for patients with rare diseases or chronic conditions that might need multiple consultations to ensure they find a provider who can meet their specific health care needs.
- Limited Follow-Up Care – The Alliance recommended an expansion to this section to acknowledge the need for continuity of care for certain populations, beyond the groups of patients listed who may need episodic follow-up care or follow-up care after travel for a surgical/medical treatment. Specifically, the Alliance encouraged FSMB to consider elderly populations and those in need of specialty care who cannot access it where they reside, in addition to those traveling for vacation, business or education. Telehealth has been critical for continuity of care for these populations to ensure they can receive the ongoing care they need where they reside.
- Clinical Trials – The Alliance recommended that FSMB consider an additional category to consider in this section to address state licensing limitations in clinical trials. State licensing limitations effectively prohibit clinicians working on clinical trials from recruiting patients outside the state where the clinician is licensed, thereby diminishing the impact of initiatives to decentralize and modernize clinical trials. State regulators have a role in breaking down additional barriers in using digital technology, and ensuring clinicians can recruit clinical trial participants across state lines can help improve recruitment, retention, diversity, and participation in clinical trials.
- Removing Restrictive In-Person Requirements – The Alliance and its members strongly believe that an in-person requirement is not necessary or appropriate for a telehealth service. The Alliance encouraged FSMB to maintain the provision in the Standard of Care section that asserts that a physician-patient relationship may be established using telemedicine technologies without the requirement of a prior in-person meeting.
- Addressing Health Equity through Broadband Access and Affordability – The Alliance believes telehealth has the potential to broaden access to care and improve patient engagement, and we agree it demands thoughtful consideration to ensure all Americans are provided equal and equitable access. We appreciated the section in this draft directly addressing equity in health care access via telehealth, and commented on the inclusion of broadband as a means to addressing equity in health care delivery via telemedicine. We provided several recommendations FSMB could consider adding to this section as states pursue broadband policies.
See the comment letter here or below:
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Alliance Support Letter for Utah SB 151
The Alliance submitted a letter of support to Sen. Curtis S. Bramble, Chair of the Utah Senate Business and Labor Committee, for Senate Bill 151.
Senate Bill 151 would adopt the Advanced Practice Registered Nurse Compact. Under this compact, Advance Practice Registered Nurses (APRNs) licensed in a Compact member state may practice in another Compact member state, allowing APRNs to have one multistate license with the ability to practice in all Compact states without having to obtain additional licenses.
The APRN Compact would establish multistate compacts that have reciprocity and that do not require additional licensing, while simultaneously helping to improve patient access to quality health care. Additionally, removing the requirement for collaborative practice agreements for licensure purposes through Senate Bill 151 would allow APRNs to practice at the top of their licenses, allowing them to use all their education and training to care for patients.
Read the full letter here and below:
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