Remote, Navigator-Directed Care Improves Medication Use Among Heart Failure Patients

COVID-19 has acted as an accelerant and normalizer of telehealth, with large number of people finding that they seeing a clinician by way of a video call on their phone, tablet, laptop or personal computer is just fine and, in some cases better than seeing the clinician in person

But there are other ways of delivering care remotely that may get a boost from COVID-19. Favorable results for one of them reported in today’s JAMA Cardiology adds more to the body of evidence that may topple the in-person visit with a doctor as the primary mode for delivering health care.

Akshay S. Desai, M.D., medical director of the Cardiomyopathy and Health Failure Program at Brigham and Women’s Hospital, and his colleagues report that a program that used telephone calls from nonphysician “navigators” to make medication adjustments for heart failure patients was successful in increasing the use of renin-angiotensin inhibitors — a group of medications that includes ACE inhibitors, ARBs and ARNIs (angiotensin receptor-neprilysin inhibitors) — and beta blockers. However, the proportion of patients using mineralocorticoid receptor antagonists did not increase.

Currently, a large percentage (they don’t say how large) of heart failure patients with low ejection fractions don’t receive guideline-directed medical therapy, noted Desai and his co-investigators.

Akshay S. Desai, M.D.

“Our data suggest that many of the barriers to the GMDT (guideline-directed medical therapy) might be overcome at scale by engaging nonphysician personnel to supplement clinic-based follow-up and support the process of pharmacological optimization,” they wrote in the conclusion section of their paper published in JAMA Cardiology.

The study was short — only three months — and did not include clinical outcomes, so its contribution to the body evidence is a rather modest, incremental one. What’s more, the tested intervention combines remote care — old-fashioned phone calls — with care by a nonphysician navigator, so it is not "pure" test of either. The study was conducted between August 2017 and August 2019, so well before the COVID-19 pandemic. Designed as a case-control study, it compared 197 patients in the remote care, navigator program with 831 heart failure patients who declined to participate in it.

The remote care program empowered navigators to adjust medications using an algorithm based on American College of Cardiology (ACC) an American Heart Association (AHA) guidelines for heart failure patients. They worked under the supervision of a nurse practitioner and Desai.

The primary outcome was the proportion of patients receiving medication that matched the recommendations in the ACC-AHA heart failure guidelines. After an average follow-up period of three months, the results showed the proportion of navigator-assisted patients who used renin-angiotensin inhibitors rose from 70% to 86%, and a similar jump in the proportion using beta blockers (77% to 92%), although there was no increase the use of the mineralocorticoid receptor antagonists (26% vs. 31%). There were no such increases in the control group consisting of patients who declined to participate in the program.

During the three-month period that that Desai and his colleagues focused on for this study, the navigators made, on average, 8.6 phone calls per patients and spent a total of about four hours on the phone with each patient. The navigators made a total of 794 medication adjustments.

“Remote drug titration was orchestrated with a low rate of adverse events without disruption of the physician-patient relationships,” commented Desai and his colleagues in the JAMA Cardiology paper. "This approach may represent a scalable, population-level strategy to close the gap between guidelines and implmentation of GDMT in clinical practice."