Interventions for Optimization of Guideline-Directed Medical Therapy: A Systematic Review

Area of Science:

• Cardiology
• Health Services Research
• Implementation Science

Background:

• Guideline-directed medical therapy (GDMT) implementation in heart failure with reduced ejection fraction (HFrEF) remains suboptimal in real-world settings.
• Identifying effective interventions to overcome barriers to GDMT is crucial for improving patient outcomes.

Approach:

• A systematic review of randomized clinical trials (RCTs) published between January 2010 and November 2023 was conducted.
• Studies focused on quality improvement interventions aimed at enhancing GDMT use in HFrEF patients.
• Databases searched included PubMed, Embase, Cochrane, CINAHL, and Web of Science, with reference screening of related reviews.

Key Points:

• Twenty-eight RCTs involving 19,840 patients were analyzed, categorized into interdisciplinary interventions, clinician education, EHR initiatives, and patient education.
• Interdisciplinary titration clinics demonstrated significant increases in patients achieving target doses of beta-blockers (10-60%) and renin-angiotensin-aldosterone system inhibitors (2-53%) compared to usual care.
• Other interventions like audits and EHR alerts showed some improvement, but findings were inconsistent.

Conclusions:

• System-level initiatives utilizing interdisciplinary teams, especially nurses and pharmacists, show the most consistent positive impact on GDMT optimization in HFrEF.
• While various interventions offer some benefits, further large-scale randomized studies are required to ascertain long-term efficacy and sustainability.
• Optimizing GDMT through collaborative, team-based approaches is essential for improving care for HFrEF patients.