Stubborn Gaps in Heart Failure Persist Despite Clinician Education, Feedback

An attempt to tie together the fragmented nature of heart failure (HF) care ultimately made no difference on clinical outcomes or care processes in the CONNECT-HF trial.

U.S. centers randomized to a quality improvement intervention had patients with a cumulative incidence of a first HF rehospitalization or death approaching 40% at 1 year, similar to usual care (adjusted HR 0.92, 95% CI 0.81-1.05), reported Adam DeVore MD, MHS, of Duke University School of Medicine in Durham, North Carolina.

Overall HF care quality too was indistinguishable between the intervention and control arms too. For example, intervention hospitals showed no meaningful improvements in getting more people on >50% target dosing of angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and angiotensin receptor-neprilysin inhibition.

DeVore presented the results of CONNECT-HF during a late-breaking trial session at the virtual American College of Cardiology (ACC) conference.

The cluster-randomized trial had 161 hospitals randomized to the intervention or usual care. Included were 5,647 patients who had been admitted with acute decompensated HF and a left ventricular ejection fraction (LVEF) of 40% or below.

The quality improvement intervention was focused on clinician education and audit and feedback of HF quality of care at hospitals treating patients after a hospitalization for heart failure with reduced ejection fraction (HFrEF). Hospitals drove their own quality improvement such that the intervention was slightly different at each institution.

Patients who were discharged from participating hospitals resumed usual local care and had follow-up coordinated through a remote call center advising them on medication changes and recording their clinical outcomes.

The negative results of CONNECT-HF were “surprising” for ACC president Dipti Itchhaporia, MD, of Hoag Heart & Vascular Institute and the University of California, Irvine, who, during the session, highlighted the lack of budging on guideline-directed medical therapy (GDMT) utilization in particular in the trial.

DeVore said that was “the most disappointing finding” of CONNECT-HF, as GDMT use continues to be low across the U.S. Factors such as delivery of care, knowledge, and the structure of the healthcare payer system need to be addressed, he suggested.

“We know we have great medications [that] work. The big question is how can we improve the utilization of these medications,” said Gurusher Panjrath, MD, of the George Washington University Hospital in Washington, D.C., who spoke at an ACC press conference. He emphasized the importance of enhanced community partnerships and greater clinician education across provider levels.

It is unclear how much cost acted as a barrier, and DeVore said his group did not see the issue of cost show up in their analyses.

“I don’t know that my colleagues always know what the costs of these drugs are around their community, which can vary pharmacy to pharmacy,” said Ileana Piña, MD, MPH, of Central Michigan University in Mount Pleasant. She noted that prices vary so widely that even generic drugs can be very expensive after copays, affecting patient choice and patient adherence to medications.

Piña suggested giving local cost data to clinicians to help them tailor each patient’s drug regimen.

Ultimately, stagnant HF care is a “complex problem” that “will require a lot to move the needle,” DeVore concluded, suggesting that new approaches are needed to improve care, not just in the hospital or in the clinic, but across the patient’s journey through the fragmented HF landscape.

In CONNECT-HF, fewer than a quarter of participating hospitals were teaching hospitals; 97% had interventional cardiology services.

Patients averaged 63 years of age. Women accounted for a third of the cohort; and Black patients, about 40%. Mean LVEF was 26% upon admission, and half the patients had had one or two recent HF admissions beforehand.

An ancillary analysis of the digital component of the trial will be presented separately, DeVore announced.