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April 15, 2024
4 minute read
Important points:
- A telemedicine model improved the implementation of guideline-based medical therapy for heart failure patients on the rural Navajo Nation.
- Low-cost strategies may also be useful in other rural settings where care is limited.
ATLANTA — Telephone-based telemedicine model increases refill rates for guideline-compliant class heart failure medications in pharmacies after 30 days in heart failure adults with reduced ejection fraction on the Navajo Nation with limited access to care. has improved.
“CV health disparities are prevalent among Native Americans, and access to treatment is limited, particularly in cardiac care, for many Native American patients treated through the Indian Health Service.” Lauren A. Eberly, MD, MPH; He is an assistant professor of medicine in the Department of Cardiovascular Medicine at the University of Pennsylvania and a staff cardiologist with the Indian Health Service at Gallup Indian Medical Center, in a presentation at an academic session of the American College of Cardiology. “With this in mind, and with community and stakeholder input, we designed a telemedicine model in rural Navajo Nation where guideline-based medication therapy is initiated over the phone and It is titrated with remote monitoring using a home blood pressure cuff.”
Addressing significant healthcare barriers
Eberly said Navajo residents endure significant barriers in accessing health care, adding that planning for the trial required input from community stakeholders to account for limitations.
Lauren A. Everly
“Due to the enduring effects of settler colonialism, one in three people living on the Navajo reservation lacks running water, and one third lacks electricity and transportation. [involves] It’s a dirt road,” Eberly said during a discussion after his presentation. “There are significant barriers to accessing care. Given broadband limitations and lack of connectivity when meeting with patient and community stakeholders, telephone-based communication is the optimal means for telemedicine.” Even when I made a reservation, it was difficult to get through, so I had to call several times to get in touch.
In the Heart Failure Optimization at Home to Improve Outcomes (Hózhó) trial, researchers looked at data from 103 adults with HFrEF being treated at two Indian Health Services facilities in rural Navajo Nation. was analyzed. The facility is defined as having a primary care physician with one clinical visit and one prescription. Filled out in the last 12 months. The median age of participants was 65 years, and 40.8% were female. Mean left ventricular EF was 32%. At baseline, 94.2% of participants were prescribed beta-blockers. 87.4% were prescribed ACE inhibitor/angiotensin receptor antagonist/angiotensin receptor neprilysin inhibitor (ARNI) therapy. 39.8% were prescribed mineralocorticoid receptor antagonist (MRA) therapy and 43.7% were prescribed SGLT2 inhibitor therapy.
In the telephone-based intervention, participants were fitted with a home blood pressure cuff and trained in their preferred language on how to use it. A member of the telemedicine team contacted participants by phone to discuss medication recommendations after reviewing the electronic medical record. Participants then received a “check-in” call with a Navajo-speaking nurse who assessed drug resistance, collected blood pressure, measured heart rate, provided continuing education, and discussed care. . Based on home blood pressure and heart rate measurements, ongoing initiation and titration of medical therapy according to guidelines was done over the phone and every one to two weeks until optimized, Eberly said. .
“The goal was to have all patients receive four treatments, or all targeted treatments, by day 30 at the latest,” Professor Eberly said.
The researchers assigned participants to either the telehealth model or usual care in stages, with five predetermined time points separated by 30 days until all patients transitioned into the intervention.
The primary outcome was an increase in the number of guideline-based class medications refilled from pharmacies at 30 days.
“What we considered a success was the addition of new guideline-based medications to the regimen, and the transition from ARBs or ACE inhibitors to ARNIs given their superior clinical benefit. We also counted,” Eberly said.
The survey results were announced at the same time JAMA Internal Medicine.
Improved uptake of therapeutic drugs
The primary outcome occurred more frequently in the intervention group compared with the control group (66.2% vs. 13.1%), with a 53% increase in intake of guideline-compliant class medications (OR = 12.99; 95% CI, 6.87- 24.53; P .001). The number of patients needed to receive the telemedicine intervention to yield a guideline-compliant drug class increase was 1.88.
At the end of the study, 97% of eligible patients were taking beta-blockers. 98% were taking renin-angiotensin-aldosterone system inhibitors. 84% were taking SGLT2 inhibitors. 78% received MRA and 81% were eligible for all four of his drugs and received quadruple therapy.
“We know that racially marginalized patient groups are less likely to receive specialized cardiology care and, even when seen by a health care provider, less likely to receive recommended treatment.” Eberly told Helio. “Our strategy leveraged EHRs at the health system level to identify underserved patients and optimize care without relying on in-person visits for specialty care. We believe models like this can promote equity and combat systemic racism.”
Eberly added that effective strategies to improve heart failure care need to be designed in communities and tailored to local conditions.
“This strategy has been designed with input from local stakeholders to meet community needs and address indigenous health determinants. “Designing a center-centered program is critical to achieving equity in heart failure care,” Eberly told Healio.
Eberly noted that the study’s sample size was small, it came from a single health system, the drug was provided free of charge to enrolled members, and the follow-up period was short.
“We believe this is a low-cost strategy that can be expanded to other rural settings where access to care is limited,” Eberly said during his presentation, noting that telehealth interventions will soon be available. It added that it will also be expanded to Indian Health Service facilities in Arizona.
“We are continually conducting qualitative research with stakeholders and patients to further understand barriers to cardiac care and how we can further optimize our model to meet the needs of our communities.” Eberly told Helio. “We next hope to design similar models with stakeholders to optimize lipid management and guideline-based care for coronary artery disease and peripheral artery disease. We look forward to working with patients and colleagues to design care delivery that promotes equity in cardiac care and beyond.”
reference:
For more information:
Lauren A. Eberly, MD, MPH; Please contact lauren.eberly@ihs.gov. X (Twitter): @eberly_lauren.
Information source/disclosure information
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Everly LA, et al. Clinical and research perspectives. Presentation location: American College of Cardiology Scientific Sessions. April 6-8, 2024. Atlanta.
Disclosure: The authors do not report any relevant financial disclosures.
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