Guideline Directed Medical Therapy In A Safety Net Hospital, Where Do We Stand?

Abstract

<h3>Background</h3> : Despite a clear mandate to maximize guideline directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF), large registries have shown sub-optimal rates of both prescription and uptitration. Rates of GDMT in large community safety net hospitals are not well known. Moreover, the patient population of safety net hospitals is markedly different than contemporary registries. Our aim was to create an accessible, self-maintained, electronic health record (EHR) based registry of HFrEF patients that can be leveraged to describe rates of GDMT, and support quality improvement initiatives in a large safety net hospital. <h3>Methods</h3> : Left ventricular ejection fraction (LVEF) was recently made to be a mandatory field for all transthoracic echocardiograms, which is then pulled into the EHR as a discrete field. Using this data, we enrolled all patients with an LVEF ≤ 40% from August 2019-April 2021 at Parkland Health and Hospital System, a large 860 bed safety net hospital for Dallas, Texas (n=2,624). The registry was then queried for an ICD10 diagnosis of heart failure (n=2,555, 97.3%) and patients without an ICD10 diagnosis of heart failure (n=69) were adjudicated manually. Patients with a most recent LVEF ≤ 40% (n=2,447) were queried for heart failure pharmacotherapies and doses. <h3>Results</h3> : Our registry comprises a young, male predominant cohort that is racially and ethnically diverse as seen in table 1. In figure 1a we find prescription rates of GDMT on par with national cohorts with excellent prescription rates of ARNI and SGLT2 inhibitors, particularly in the 1,417 (57.9%) who have been seen in Cardiology or CHF clinics in the last 2 years. We found that the majority of patients on GDMT are on less than 50% of the goal dose as seen in figure 1b. <h3>Conclusion</h3> : The HFrEF population in a large safety-net hospital system was a young diverse population with rates of GDMT prescription similar to national cohorts, with higher rates of ARNI and SGLT2-inhibitors. The registry provides a platform for future quality improvement initiatives to increase GDMT prescription and uptitration.