Exploring Updated Heart Failure Quality Measures and the Role of Pharmacists in Patient Care

In an interview with Pharmacy Times®, Craig Beavers, PharmD, FACC, FAHA, FCCP, BCCP, CACP, cardiovascular clinical pharmacist, adjunct associate professor with the University of Kentucky College of Pharmacy, and vice president of professional services with Baptist Health Paducah in the Baptist Health System, discusses the updates to the 2020 American College of Cardiology and American Heart Association Clinical performance and Quality Measures for adults with heart failure and their expected impacts on patient care outcomes. He shares the significance of optimizing medical discharge and monitoring and the crucial role of pharmacists in managing patients with heart failure (HF).

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

Craig Beavers, PharmD, FACC, FAHA, FCCP, BCCP, CACP: They did add a lot of additional metrics, a lot of data that has been generated, understanding of the best way to optimize therapy, or really to change the paradigm of how we're managing heart failure patients. One of the biggest, most significant changes is really about optimizing or starting guideline-directed medical therapy at hospital discharge, knowing that it’s probably the best time to get therapy on board, to have what is “a captive audience,” and really make sure the patient can get them and tolerate them. And we've seen literature and success that patients who get them prescribed at discharge end up staying and maintaining on them over 30-, 60-, 90-, 180-days, which really turns into improved outcomes, reducing your readmissions, improved quality of life, reduced mortality and so forth. So that's one of the biggest ones.

The AHA and ACC updated measures included an emphasis on use of SGLT2s. Image Credit: © piter2121 - stock.adobe.com

The other big one is ensuring that patients are getting SGLT2 inhibitors that meet criteria across the entire spectrum, both from reduced ejection fraction, intermediate ejection fraction, or mid-range ejection fraction to all the way to preserved ejection fraction. The other big thing is monitoring quality is retaining or keeping guideline directed medical therapy on patients who have improved ejection fraction. That means they were reduced but have gone up above 40%, and knowing that we see poor outcomes when patients have those therapies removed.

The other is just good quality management of patients, making sure that their blood pressure target for patients with heart failure and optimizing that, especially the preserved population. And then really looking at knowing a challenge to keeping guideline directed at medical therapy on board is really understanding and evaluating social determinants of health, knowing that to set the patient up for success, we have to evaluate all the things that could be contributing or put them at risk for not being able to be successful with their management of [HF]. And it's a really important conversation.

Another important consideration is talking about contraception, or taking women who are of childbearing age and understanding how we need to have those conversations with them. Understand their risk benefits of having a child or bearing children with a disease state, and what does that look like from that standpoint? So, it's really overall around the conversation of having that discussion and that shared decision making conversation with women of child bearing age.

Pharmacy Times: In what ways do the updated performance measures reflect advancements in the understanding and management of heart failure?

Beavers: It really hones in on the fact that the best way to manage the patient, and really to optimize them, is to get all of the major 4 pillars on as quickly as possible, in a safe manner that's possible. But really striving to do that at that inpatient admission and not delaying them. That does require follow up and aggressive follow up early on. And what really speaks to me, and it's not necessarily embedded in there specifically with the metric, but one of the big ways to meet these metrics is really emphasis on team-based care. That includes pharmacists being engaged in this process and developing programs where pharmacists can maybe do telehealth visits or see [patients] in clinic to titrate therapy or monitor labs or get them within that 7-day window that they can be seen from that standpoint. I think the big connection point is, looking at all the metrics, whether it be the post discharge meds, getting them on SGLT2s. You're talking about social determinants of health, or you're talking about blood pressure management. All those things really speak to how a pharmacist can be super helpful in terms of managing and optimizing these patients. The big takeaways are to get those 4 pillars on, don't be afraid to balance out the risk benefit, team-based care and pharmacists have a strong role.

Pharmacy Times: How do the quality measures address the integration of social determinants of health and patient-centered counseling in the management of heart failure?

Beavers: We are really at the stages of appreciating the importance of how social determinants impact a variety of different disease states, including heart failure and cardiovascular disease. And to bring change, we have to incorporate and include these conversations, the data that exist to raise awareness of what could be impacting them, and identify the things that can be changed on the level of the individual patient or within the health system or the community knowing that we can't change everything. There are things that require a broader brush to do, but taking and identifying what we can impact and fix. Part of that is just identifying those things, whether that's screening, and then coming up with solutions of those screening, as well as understanding how we collect data to understand where our gaps are in terms of health equity from that standpoint. I think it forces us to incorporate that into the construct of the dialogue. It forces us, with the quality measure, to really ask those questions and identify them, because you can't really start to understand what you need to fix or change or how to impact your patient population without looking at the data and pulling back the layers from that standpoint. But I think having that constant awareness and realizing it's an important consideration in terms of how we're going to get to the success of managing these patients.

Pharmacy Times: What additional performance and quality measures do you believe will have the most significant impact on patient outcomes and ongoing treatment of heart failure?

Beavers: I think the biggest change is this continued evolution away from a sequential approach to adding management of medication therapy or guideline directed agents to moving to doing the 4 pillars at once and optimizing that from that strategy. And I hope that the both the guidelines and the changes with the metrics will encourage people to continue to promote and move that activity down the line. And then, I think the other big thing is, we know SGLT2s are of huge value from a variety of different stand points to the SGLT2s inhibitors, in terms of across the spectrum of heart failure. They both reduce major adverse cardiovascular events and specifically readmissions, but they also allow us to get other therapies on board and help regulate the patient population. Of course, they have a lot of other comorbidities, whether it be CKD [chronic kidney disease] or diabetes, and things that will benefit from that. I think that's a big game changer to really promote that, and it's a nice time to have these types of metrics. Especially if you think about the announcement of what the Medicare negotiations are going to be in the next year and knowing that SGLT2s are a part of that conversation, as well as ARNIs [angiotensin receptor/neprilysin inhibitor] and some of our other heart failure therapies. So, I think it's a good time to really figure out the ways to continue to integrate and address these issues and barriers.

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

Beavers: To optimize these patients, [we must understand that] they're complex, they're resource intensive, and they need a lot of additional help. I think it's really the best way to figure out ways to move into a value-based system or you can still do it in a fee-for-service-based system, but really integrating that team-based care approach and working with peers or partners who are doing this to figure out how you can do it. Every model is different, and everybody has different resources, but it can be done. It's important to be done. And I think it all starts out with data and understanding where you're at from readmissions to social determinants, to how well you're doing with GDMT [guideline-directed medical therapy] and optimizing that, and then painting a picture of what you need to do and how you're going to put the resources in place to accomplish that. Then going from there, taking some goals and metrics and chipping at them, as well as adding in quality metrics and measures. I think one of the things that we've done specifically in our organization is we've partnered and used the ACC [HF] accreditation framework, or you could use Get With The Guidelines with AHA, or a framework to really structure that in that conversation and get metrics and data and implement those interventions.