Expert Insights: The Impact of the Updated Performance and Quality Measures for Patients with Heart Failure

Joseph Saseen, PharmD, associate dean of clinical affairs and professor in the School of Pharmacy at the University of Colorado shares his insights regarding the updates to the 2020 American College of Cardiology and American Heart Association Clinical Performance and Quality Measures for adults with heart failure (HF). He discusses the benefits of these additional measures, the role of SGLT2 inhibitors, the potential health costs, and role of pharmacists in treating patients with HF.

The updates to the performance and quality measures will help decrease hospitalizations and and improve patient outcomes. Image Credit: © dragonstock - stock.adobe.com

Pharmacy Times: What are the key additions between the newly introduced quality measures and the performance measures for HF?

Joseph Saseen, PharmD: The best thing about these updated performance measures is they tie into evidence-based recommendations from guidelines that have been previously published, and those recommendations are class one recommendations with good levels of evidence. So overall, they aim to improve patient outcomes by prolonging life, decreasing [HF], hospitalizations and other adverse consequences of uncontrolled [HF]. So, the bottom line is, they aim to improve patient outcomes by mimicking the data that prove that these treatments are effective long term at decreasing cardiovascular harm.

Pharmacy Times: How might the use of SGLT2 inhibitors in patients with HFpEF and mildly reduced ejection fraction (HFmrEF) influence quality of care and patient outcomes?

Saseen: It really is a game changer. Previous to new data, which came out about 2-, 3-years ago, we really didn't have proven therapies for HFpEF, and also for HFmrEF, that prolonged life or decreased cardiovascular events or heartfelt hospitalizations in this population. But lo and behold, we had the introduction of SGLT2 inhibitors. They've been fully studied, two different ones, in this population and they've been shown to actually reduce adverse cardiovascular outcomes. So overall, the use of SGLT2 inhibitors in this particular population, which is HFpEF and HFmrEF, actually can significantly prolong life, decrease cardiovascular harm, and actually improve the quality of patient care, so it is a huge benefit to our patient population.

Pharmacy Times: Can you discuss any anticipated impacts of these additions on patient outcomes and health care costs?

Saseen: Overall, from an ivory tower perspective, using these therapies in this population, whether it be for patients with HFpEF, HFmrEF, or different types of [HR], ultimately will improve quality and improve health outcomes. But unfortunately, these performance measures don't require payment by insurance companies, so costs can be a problem. If these therapies are implemented, quality goes up and health care costs go down. But the glitch is that insurers aren't required to cover these therapies or aren't required to cover these therapies easily. We still see with some of these core therapies, the ones that are more expensive, such as stepped care, prior authorizations, which are nothing but [sic] with these proven diseases.

I completely respect the use of prior authorizations when appropriate, but we should be making these drugs easily accessible so healthcare costs will go down, but the cost to our patients, as far as their copays, and the headache that providers have to go through to comply with these performance measures, are really difficult to resolve with multiple payers involved. There also is the negative influence of pharmacy benefit managers that, based on their rebate structure and their FTC investigated pricing structure, which gouges money, can have a negative impact on our patients from an out-of-pocket perspective. But ultimately, that barrier needs to be overcome to make these medications accessible, affordable and easy to implement from a provider's perspective.

Pharmacy Times: What changes do you believe will have the most significant impact on patient outcomes and ongoing treatment of HF?

Saseen: I think maybe some of the most significant ones are pushing forward in these quality measures, and just the concept of the 4 pillars of [HF] therapy. But I think looking at those, that's not a new story. We've recommended that for a long period of time, but really pushing the early implementation. We don't have to stagger in these treatments. There are 4 pillars for most forms of [HF]. They can be started all at the same time. And having a quality measure which is related to hospitalizations, and having patients discharged on these medicines, will help out quite a bit; because if patients get discharged on the medicine, often they have an attachment to it and associate it as a more critical treatment. So maybe there's a higher likelihood of long-term persistence with those therapies. So that one is really important.

Another one I could call out is to focus in on HFpEF, not just the treatments such as SGLT2 inhibitors, but also appropriate blood pressure control in that population; which really might have a very long impact in our patients, because there still is controversy among some primary care docs that when they have a patient, how tightly they should control their blood pressure. And this performance measure clearly says in people with HFpEF to treat to less than 130 over 80, versus the American Association of Family Practice recommendation of less than 140 over 90 for most patients.

Pharmacy Times: How can health care organizations and clinicians implement these new quality measures to drive improvements in HF care?

Saseen: Health care organizations need to invest in clinicians to focus on cardiovascular care, not only by hiring people such as pharmacists or other cardiovascular team members. This is beyond the physician and beyond the PA and nurse practitioner. So, pharmacists are important player in the overall team-based care approach to implement and ensure optimal pharmacotherapy for these patients. The way to invest and hire these people is not just opening up new lines, but also advocating for appropriate payment for these individuals. So, supporting provider status for pharmacists so that we can actually receive payment for these activities, or simply using some of the value based monies, which may be an extension of these quality measures, to invest in. Whether you call it wraparound services or healthcare professionals that don't have a direct fee for service structure, this really is a way to support the cardiovascular team and holistically provide multiple professionals to focus in on optimizing medications in this frail population.