Heart Failure Management: Updating Hospital Order Sets

In this segment, Akshay Desai, MD; Peter L. Salgo, MD; Scott Solomon, MD; and Orly Vardeny, PharmD, MS, provide insight on the establishment of hospital order sets in heart failure and the rationale for timely, evidence-based updates.

Peter L. Salgo, MD: We’ve got to talk about, in the hospital, the order sets that exist—whether they be order sets that most people have in the hospital, most physicians have access to, most nurses have access to, and pharmacologists set up, and whether these (given the results that we’ve been talking about), are current, and whether they’re the best that we can do. Where do we start? Orly, do you want to start?

Orly Vardeny, PharmD, MS: Sure. If we take a step back and think about the reason that order sets were created, it is because we’re busy clinicians and we want to be able to click on something and have everything magically appear that we want the patient to be on in a particular scenario. So, those are mainly based on guidelines, and when guidelines are updated to include new medications, the order sets need to be updated as well to include those new medications. Some order sets as of the past year have been updated to include some of the new medications that we talked about, but most of the time, not yet. Some places have adopted and incorporated into order sets, but not everywhere.

Akshay Desai, MD: It’s challenging though. I think heart failure management is well suited to admission order sets that give you a start. But, Orly, you said it nicely, that this is not a recipe driven strategy—it’s a bit more of what someone called a Chinese menu. There’s a little bit from each—column A; or we know that you had ACE (angiotensin-converting enzyme) inhibitors or ARBs (angiotensin receptor blockers); and we know you need beta blockers. We know some people need spironolactone or eplerenone. We know that some people need sacubitril/valsartan. And then, there are alternatives we haven’t even begun to talk about. So, it becomes very difficult to script the right regimen for every patient. But I think you can stimulate clinicians to think through the decision making by giving them options when the patient comes into the hospital, and if they’re not on classic medications, asking them why not.

Peter L. Salgo, MD: What comes to my mind is the research that we discussed, which was pretty dramatic, in terms of showing that there’s an advantage to the ARNIs (angiotensin receptor neprilysin inhibitors). Are the ARNIs, now, as far as we know, on some of these order sets? Are they on discharge order sets? Admission order sets? And if not, why not, and what can we do to change that?

Orly Vardeny, PharmD, MS: I think, as Akshay was saying, it’s not an automatic that everyone should be switched or should be taking one particular medicine or another. It’s individualized. Therefore, it’s difficult to put it on the order set—to automate that piece.

Peter L. Salgo, MD: Let me just stop you, because I heard that argument when order sets were first initiated. “Every patient is different.” “Nobody is a classic patient.” “You can’t tell me what to do on a piece of paper.” And, “Nobody’s asking you to do that.” I’ll give you an example. If you’re sending somebody home with a diagnosis somewhere in your electronic medical record of congestive heart failure (and I know we don’t use congestive heart failure anymore, but let’s say heart failure), you can have a box pop up that asks, “Did you consider ARNIs?” That’s not so bad, and it flies in the face of your argument that everybody is different.

Orly Vardeny, PharmD, MS: There’s a minor, minor complication. It’s only minor. The minor, minor complication is that in this very, very large trial, outpatients with symptomatic heart failure were studied, not patients who were acutely decompensated and in the hospital. In terms of the label and how it’s indicated, it does not include starting therapy in acutely decompensated patients as of right now.

Scott Solomon, MD: Right, and I think this is a really important point. We didn’t study, in PARADIGM, acutely decompensated heart failure patients. We also didn’t study patients who were in the hospital and then stabilized. We studied, for the most part, outpatients. Now, I don’t believe there’s any such thing as a stable heart failure patient. These patients are all very high risk, but some would argue that before we start using this in the setting of acute decompensation, we need more data. Now, the current guidelines and the FDA label does not prohibit use of the drug and starting the drug in the hospital. And, frankly, as a clinician, I would say that in a patient who’s been hospitalized for acute decompensated heart failure and is then stabilized and is getting toward being ready to go home, as far as I’m concerned, that’s a perfect time to think about switching a patient.

Peter L. Salgo, MD: I was listening to you earlier when you said that being put on an ARNI decreased the risk of readmission by somewhere around 20%, give or take. That implied they were admitted?

Scott Solomon, MD: Akshay said that, not me.

Peter L. Salgo, MD: I did hear it. But the point is, it decreased the risk of readmission. Doesn’t that imply that they were using it on hospitalized patients and that it was part of their discharge medications?

Akshay Desai, MD: The challenge in the trial was that patients were randomly assigned to one drug or another during a period of stability in the ambulatory setting, and then they became hospitalized. And so, when we were looking at readmissions there, we were looking at readmissions that happened during the natural evolution of their disease. So, it’s a little bit of a different situation. Scott’s point is valid. I think it ultimately also makes the point that, really, the challenge in implementing this strategy is that our historical approach to heart failure therapy is that when patients get sicker, we add medications. And that’s not the case with this particular compound. It seems to be the case that it’s the patient who is the walking, talking, ambulatory patient, who is mildly or moderately symptomatic with low ejection fraction, who really deserves the switch. So, we’re not waiting for instability to make a change.