Aferdita Spahillari, MD, MPH Duke University

1. Multidisciplinary Strategies for Improved
Care Coordination in Heart Failure
Aferdita Spahillari MD, MPH
Associate Professor of Medicine
Duke HF symposium
May 4, 2024

2. Large implementation gap in HF care
With HF by 2030 in US
Will die at 5 years of HF Dx
On 4-drug GDMT at hospital
discharge1
1. Greene SJ et al JACC:HF 2024
15.3%
~8 million
56%

3. Addressing this
gap should be
easy… right?
Titian: Sisyphus, 1548–49

4. Many factors contribute to implementation gap
HF type
HF severity
Risk Factors
Age, sex
Race/ethnicity
Lifestyle
HF therapies
Prognosis
SDOH
Education
Income
Insurance
Food/housing
Transport
Caregiver support
Access to care
Med Cost
Specialist care
End of life care
Comorbidities
Side
Effects
Values
Wishes
Care Complexity
Med regimen
Many providers
Novel interventions
Frequent visits
Inadequate
Staff
Time
Resources
EHR burden
Burnout
Cost of
Care
Provider
Perceptions re:
effectiveness
Biases
Patient specific drivers Healthcare system drivers
Medication
Adherence

5. Interventions aimed at improving GDMT prescription
Clinician level
Education
Audits
Financial
Incentives
Order
now
EHR alerts
Decision
support tools
Patient level
Education
Patient
engagement
Both
Multidisciplinary
Teams
RN/pharmD/NP/PA
Harrington J et al. JCF 2024

6. 1. Tang A et al. JAMA Cardiology 2024
Multidisciplinary clinics improve rates of optimal GDMT
• Multidisciplinary clinics
• Greater % of patients
taking target doses of
GDMT
• Other interventions
• Did not consistently
improve % GDMT
achieved.

7. The STRONG-HF trial: leveraged hospitalization in GDMT
optimization
• 1078 patients (14 countries) hospitalized for
HF: randomized to high intensity care vs.
usual care
• GDMT to 50% max tolerated dose by hospital
discharge, and to 100% max tolerated by 2
weeks of hospital discharge
• 34% RR reduction in HF readmission or all-
cause death at 180 days
• Rapid up-titration of HF therapies under close
follow-up (exam, NT-proBNP): safe, effective
& improves patients’ QoL
Probabbility
of
event-free
survival
(%)
High intensity care
Usual care
Time since randomisation (days)
180-Day readmission for heart
failure or all-cause death
Mebazaa et al Lancet 2022

8. Multidisciplinary strategies to facilitate GDMT titration in
the hospital
• Virtual peer-to-peer communication
• Recommendations for eligible GDMT
• Out-of-pocket cost estimates
• Medication prior authorization completion
• Assistance with HF clinic follow-up
• Increases in ACEi, ARB, and ARNI prescriptions (71% vs 49%;
P = .04)
Rao VN et al Lancet 2022. Circ Heart Fail. 2023;16(2)

9. Benefits of multidisciplinary interventions
• Reduction in HF admissions, all-cause hospitalizations, all-
cause mortality1
• Pharmacist involvement2 in HF team reduces HF and all-
cause hospitalizations
• Pharmacist delivered interventions improve adherence3
• Nurse-led interventions improve GDMT perscription4
1. Takeda A et al. Cochrane Database Syst Rev. 2019 2. Parajuli DR et al. J Card Fail 2019
3. Conn VS, Ruppar TM Preventitive Medicine 2019 4. Zheng J. J Card Fail 2023

10. ACC/AHA/HFSA Guidelines recommend multidisciplinary,
and patient-centric care
• HF interventions must be
multidisciplinary, multifactorial,
and personalized
• Patient at the center, shared-
decision making
• Close communication and
collaboration among different
providers and specialists
1. Heidenreich PA et al. Circulation 2022
2. Maddox TM et al. JACC 2024

11. Outpatient
Multidisciplinary HF Team Model
• All HF patients
• EHR referral
• Shared care
• EHR updates at
critical points of
care and at
discharge from
GDMT clinic
• Hybrid visits (tel,
video, in-person)
• Regular group
meetings
Inpatient
Referral
Nutrition
Genetic Testing
Cardiac Rehab
Palliative Care
Psychiatry
Advanced HF
HF physician
Nurse
GDMT clinic
Pharmacist
Pharmacy
Technician
HF Access
HF NP/PA/MD
Remote monitoring
Post dc, IV diuresis,
Routine f/u
Referral

12. Multidisciplinary care of HF
• There are multiple barriers to HF care
• Multidisciplinary approaches are optimal as they address
barriers at different levels in the outpatient and inpatient settings
• HF care collaboration and coordination is paramount!

13. Thank You
• Stephen Greene, MD, co-
director
• Morgan Lewis, RN
• Oksana Kamneva, PharmD
• Erika Nicolsen, PharmD
• Jocelyn McAdoo, CPh
• Todd McVeigh, PA-C
• Margaret Bowers, DNP

14. Harnessing patient engagement in HF care may improve
outcomes
• EPIC-HF1:
• 3 min video and 1 page checklist before a cardiology visit
• Increased Beta blockers (22.1% in intervention vs 11.0% in control; P = .02)
• Connect HF: Digital app group ~ 400 digital users (20%) matched with
non-users at hospital discharge2
• App Design: HF education, interventions to increase adherence
• Slightly improved GDMT
• Greater enrollment in HF disease management program, cardiac rehab or HF
group educational classes
• Digital users: 24% lower risks of HF rehospitalization or all-cause mortality at 1
year
1. Allen LA et al. Circulation 2020 2. Rao VN...Devore AD. JCF 2022