Effectiveness of Virtual Care Team Guided Management of Hospitalized Patients with HFrEF by Ethnicity

Abstract

Background

The Implementation of Medical Therapy in Hospitalized Patients with Heart Failure with Reduced Ejection Fraction (IMPLEMENT-HF) study demonstrated that a virtual team–based care strategy was safe and improved prescription of guideline-directed medical therapy (GDMT) in hospitalized patients with heart failure and reduced ejection fraction (HFrEF). We evaluated differences in efficacy and safety outcomes by ethnicity in IMPLEMENT-HF.

Methods

IMPLEMENT-HF evaluated a provider-facing virtual team–based care strategy versus usual care in hospitalized patients with HFrEF from October 2021 to June 2022. The primary outcome was change in a GDMT optimization score from hospital admission to discharge, with positive changes reflecting net optimization. In this post-hoc analysis, we assessed heterogeneity in treatment effects by ethnicity (Hispanic vs. non-Hispanic). Outcomes included prespecified primary and secondary effectiveness outcomes and adjudicated safety events.

Results

Of 808 screened patient admissions, 252 (31%) from 198 unique patients met inclusion criteria. Hispanic patients (n = 43) were more likely to have diabetes and end-stage kidney disease than non-Hispanics; 70% spoke Spanish as a primary language. GDMT optimization score was lower among Hispanic versus non-Hispanic patients (–0.44; 95% CI –1.88 to 0.99 vs. +1.62, 95% CI +1.02 to +2.21; P value of interaction by ethnicity = .002). Allocation to the virtual care team intervention versus usual care increased the proportion of patients experiencing >1 new initiation or dose up-titration among non-Hispanic patients but did not among Hispanic patients (absolute difference non-Hispanic vs. Hispanic: +31% vs. –19%; P value of interaction = .003). Similar trends were seen among individual HF therapy and for the proportion of patients with optimization score >0 (absolute difference non-Hispanic vs. Hispanic: +29% vs. –20%; P value of interaction = .005). Safety outcomes were similar among Hispanic and non-Hispanic patients.

Conclusion

A provider-facing, virtual care team–guided strategy for HFrEF GDMT optimization was less effective in Hispanic patients. Efforts to identify and reduce bias and equity assessments in implementation studies are needed.