Medical Therapy for Heart Failure With Reduced Ejection Fraction: The CHAMP-HF Registry
Medical Therapy for Heart Failure With Reduced Ejection Fraction: The CHAMP-HF Registry
Background:
Guidelines strongly recommend patients with heart failure with reduced ejection fraction (HFrEF) be treated with multiple medications proven to improve clinical outcomes, as tolerated. The degree to which gaps in medication use and dosing persist in contemporary outpatient practice is unclear.
Objectives:
This study sought to characterize patterns and factors associated with use and dose of HFrEF medications in current practice.
Methods:
The CHAMP-HF (Change the Management of Patients with Heart Failure) registry included outpatients in the United States with chronic HFrEF receiving at least 1 oral medication for management of HF. Patients were characterized by baseline use and dose of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB), angiotensin receptor neprilysin inhibitor (ARNI), beta-blocker, and mineralocorticoid receptor antagonist (MRA). Patient-level factors associated with medication use were examined.
Results:
Overall, 3,518 patients from 150 primary care and cardiology practices were included. Mean age was 66 ± 13 years, 29% were female, and mean EF was 29 ± 8%. Among eligible patients, 27%, 33%, and 67% were not prescribed ACEI/ARB/ARNI, beta-blocker, and MRA therapy, respectively. When medications were prescribed, few patients were receiving target doses of ACEI/ARB (17%), ARNI (14%), and beta-blocker (28%), whereas most patients were receiving target doses of MRA therapy (77%). Among patients eligible for all classes of medication, 1% were simultaneously receiving target doses of ACE/ARB/ARNI, beta-blocker, and MRA. In adjusted models, older age, lower blood pressure, more severe functional class, renal insufficiency, and recent HF hospitalization generally favored lower medication utilization or dose. Social and economic characteristics were not independently associated with medication use or dose.
Conclusions:
In this contemporary outpatient HFrEF registry, significant gaps in use and dose of guideline-directed medical therapy remain. Multiple clinical factors were associated with medication use and dose prescribed. Strategies to improve guideline-directed use of HFrEF medications remain urgently needed, and these findings may inform targeted approaches to optimize outpatient medical therapy.
Why Congress’s Opioid Effort is a Major Step Forward for Telehealth Reimbursement
Over the past several weeks, the House of Representatives passed 58 opioid-related bills. The Senate is in the midst of considering their own legislation. The intent of congressional leaders in both chambers is to reconcile these legislative packages and send a final bill to the President this year. This effort is key to solving a major national problem and demonstrates that Congress can come together to support people, families and communities in need.
It also happens to be a significant step for Medicare reimbursement of telehealth. Telehealth supporters have long tried to overturn outdated statutory language that requires Medicare beneficiaries who are enrolled in traditional fee-for-service (FFS) to be in specific institutional sites in rural areas for their providers to qualify for Medicare coverage. About 80 percent of Medicare beneficiaries live in 1,200 metropolitan counties that are not considered “rural” under HHS’ definition, and making people go to a clinic or hospital to receive telehealth services defeats the purpose of the technology.
Our challenge as advocates has been assumptions by the Congressional Budget Office (CBO) that increasing access to telehealth for seniors will increase utilization without a subsequent decrease in utilization of other forms of care. In other words, they think people will use telehealth and also go to the doctor in person, thereby increasing costs. Studies showing that telehealth substitutes for in-person care, reduces re-admissions and increases preventive care have not convinced them, nor have the major investments that capitated insurers have made in telehealth services.
The opioid effort in Congress has changed the course of this debate. As a result of the dire need for behavioral health services to help mitigate the crisis, both the House and Senate have moved bills to lift telehealth restrictions in Medicare to enable more mental health and substance abuse providers to see patients via telehealth, and thereby expand access to care. The eTREAT Act (S. 2901) in the Senate would entirely lift Medicare’s originating site restrictions on reimbursement for patients suffering from substance use disorder (SUD). The Access to Telehealth Services for Opioid Disorders Act (H.R. 5603) in the House would give the Secretary of HHS authority to waive telehealth restrictions for opioid abuse disorder.
These bills, led by a powerful group of bipartisan lawmakers, have cracked the CBO code. They demonstrate what telehealth advocates have been trying for years to convey – allowing telehealth coverage in Medicare will not significantly impact the federal budget. According to CBO, the House version would cost a mere $11 million over 10 years. The Senate bill, which entirely lifts the restrictions, is only $14 million. That’s out of a program that will spend as much as $10 trillion over the same time period.
The relatively small price tag and bi-partisan support of these bills sets the stage for Congress to consider future legislation that would remove even more barriers to telehealth, and could pave the way for originating site restrictions to be lifted for all patients. In the meantime, Medicare patients with substance abuse disorders will be able to access care remotely. This is a huge step forward.
The impact of telehealth remote patient monitoring on glycemic control in type 2 diabetes: a systematic review and meta-analysis of systematic reviews of randomised controlled trials
BMC Health Serv Res: The impact of telehealth remote patient monitoring on glycemic control in type 2 diabetes: a systematic review and meta-analysis of systematic reviews of randomised controlled trials
Background: There is a growing body of evidence to support the use of telehealth in monitoring HbA1c levels in people living with type 2 diabetes. However, the overall magnitude of effect is yet unclear due to variable results reported in existing systematic reviews. The objective of this study is to conduct a systematic review and meta-analysis of systematic reviews of randomised controlled trials to create an evidence-base for the effectiveness of telehealth interventions on glycemic control in adults with type 2 diabetes.
Methods: Electronic databases including The Cochrane Library, MEDLINE, EMBASE, HMIC, and PsychINFO were searched to identify relevant systematic reviews published between 1990 and April 2016, supplemented by references search from the relevant reviews. Two independent reviewers selected and reviewed the eligible studies. Of the 3279 references retrieved, 4 systematic reviews reporting in total 29 unique studies relevant to our review were included. Both conventional pairwise meta-analyses and network meta-analyses were performed.
Results: Evidence from pooling four systematic reviews found that telehealth interventions produced a small but significant improvement in HbA1c levels compared with usual care (MD: -0.55, 95% CI: -0.73 to – 0.36). The greatest effect was seen in telephone-delivered interventions, followed by Internet blood glucose monitoring system interventions and lastly interventions involving automatic transmission of SMBG using a mobile phone or a telehealth unit.
Conclusion: Current evidence suggests that telehealth is effective in controlling HbA1c levels in people living with type 2 diabetes. However there is need for better quality primary studies as well as systematic reviews of RCTs in order to confidently conclude on the impact of telehealth on glycemic control in type 2 diabetes.
Complex Surgical Infants Benefit From Postdischarge Telemedicine Visits
Complex Surgical Infants Benefit From Postdischarge Telemedicine Visits
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Open in new tab Comparative Effectiveness of Implementation Strategies for Blood Pressure Control in Hypertensive Patients: A Systematic Review and Meta-analysis
Comparative Effectiveness of Implementation Strategies for Blood Pressure Control in Hypertensive Patients: A Systematic Review and Meta-analysis
Background: The prevalence of hypertension is high and is increasing worldwide, whereas the proportion of controlled hypertension is low.
Purpose: To assess the comparative effectiveness of 8 implementation strategies for blood pressure (BP) control in adults with hypertension.
Data sources: Systematic searches of MEDLINE and Embase from inception to September 2017 with no language restrictions, supplemented with manual reference searches.
Study selection: Randomized controlled trials lasting at least 6 months comparing the effect of implementation strategies versus usual care on BP reduction in adults with hypertension.
Data extraction: Two investigators independently extracted data and assessed study quality.
Data synthesis: A total of 121 comparisons from 100 articles with 55 920 hypertensive patients were included. Multilevel, multicomponent strategies were most effective for systolic BP reduction, including team-based care with medication titration by a nonphysician (-7.1 mm Hg [95% CI, -8.9 to -5.2 mm Hg]), team-based care with medication titration by a physician (-6.2 mm Hg [CI, -8.1 to -4.2 mm Hg]), and multilevel strategies without team-based care (-5.0 mm Hg [CI, -8.0 to -2.0 mm Hg]). Patient-level strategies resulted in systolic BP changes of -3.9 mm Hg (CI, -5.4 to -2.3 mm Hg) for health coaching and -2.7 mm Hg (CI, -3.6 to -1.7 mm Hg) for home BP monitoring. Similar trends were seen for diastolic BP reduction.
Limitation: Sparse data from low- and middle-income countries; few trials of some implementation strategies, such as provider training; and possible publication bias.
Conclusion: Multilevel, multicomponent strategies, followed by patient-level strategies, are most effective for BP control in patients with hypertension and should be used to improve hypertension control.
Routes to diagnosis of heart failure: observational study using linked data in England
Routes to diagnosis of heart failure: observational study using linked data in England
Objective Timely diagnosis and management of heart failure (HF) is critical, but identification of patients with suspected HF can be challenging, especially in primary care. We describe the journey of people with HF in primary care from presentation through to diagnosis and initial management.
Methods We used the Clinical Practice Research Datalink (primary care consultations linked to hospital admissions data and national death registrations for patients registered with participating primary care practices in England) to describe investigation and referral pathways followed by patients from first presentation with relevant symptoms to HF diagnosis, particularly alignment with recommendations of the National Institute for Health and Care Excellence guideline for HF diagnosis.
Results 36 748 patients had a diagnosis of HF recorded that met the inclusion criteria between 1 January 2010 and 31 March 2013. For 29 113 (79.2%) patients, this was first recorded in hospital. In the 5 years prior to diagnosis, 15 057 patients (41.0%) had a primary care consultation with one of three key HF symptoms recorded, 17 724 (48.2%) attended for another reason and 3967 (10.8%) did not see their general practitioner. Only 24% of those with recorded HF symptoms followed a pathway aligned with guidelines (echocardiogram and/or serum natriuretic peptide test and specialist referral), while 44% had no echocardiogram, natriuretic peptide test or referral.
Conclusions Patients follow various pathways to the diagnosis of HF. However, few appear to follow a pathway supported by guidelines for investigation and referral. There are likely to be missed opportunities for earlier HF diagnosis in primary care.
Remote Monitoring In A Fee For Service World
Politico | November 6, 2017
Excerpt:
“The reason this is going to facilitate more use of remote patient monitoring is most medical providers want their patients to get better, and they realize that most care happens outside the medical facility,” Krista Drobac, executive director of the Alliance for Connected Care, told Morning eHealth. “Viewing data digitally transmitted from a patient’s home gives the provider a clearer picture of what’s happening, and providers want that for purposes of good care.”
Drobac said Medicare’s policy shift will also make it easier for doctors to convince unwilling hospital CFOs to follow suit.