Healthcare utilisation and clinical outcomes following implementation of an accelerated treatment pathway for patients with HFrEF

Background/Introduction

An Accelerated Treatment Pathway (ACT) was implemented for patients admitted with HFrEF and achieved the goals of safe, early and rapid initiation and titration of quadruple guideline-directed medical therapy (GDMT) to maximum tolerated doses within 4-weeks post-hospitalisation.

Purpose

To describe 12-month healthcare utilisation, GDMT use and clinical outcomes for patients following rapid optimisation of GDMT through the ACT pathway.

Methods

The ACT Pathway is a nurse-led, cardiologist supported, clinical pathway designed to facilitate early in-hospital initiation of quadruple therapy and rapid post-discharge titration for patients admitted with HFrEF. Low-dose quadruple therapy was initiated prior to discharge, followed by weekly clinical review for 4-weeks to support individualised medication up-titration to maximally tolerated doses. Subsequent follow-up was individualised according to standard HFrEF management. This report describes healthcare utilisation, GDMT use and clinical outcomes for the pilot ACT cohort over 12 months following the index hospitalisation.

Results

The ACT pilot included 103 patients, mean age 57yrs, 20% women and 67% non-NZ European. High rates of GDMT initiation and titration by 4 weeks have been previously reported. During 12 months, 1 patient died (following a high-risk coronary intervention), 1 relocated overseas and 2 were lost to follow; 99 patients were thus included in this analysis.

A total of 27 patients (27%) required 1 additional clinic visit beyond the first month to optimise GDMT: the majority of visits were conducted face-to-face. GDMT use and dosage remained high over the 12 months: RAAS inhibitors and beta-blocker use remained high (>90%) at 6 and 12 months; MRA use attenuated slightly at 12 months yet remained at 77% (see Table); SGLT2 inhibitors were not publicly funded in New Zealand during this period but more than 2/3 of patients received this therapy. Diuretic therapy continued to decrease and by 12 months only 15% of patients needed regular diuretic.

Within 12 months following hospitalisation, only 13 patients (12%) had unplanned admissions, of which 9 (69%) were non-cardiovascular causes and only 3 patients had decompensated HF. 39 patients had planned admissions: 12 (23%) coronary revascularisation, 7 AF-ablation procedures (14%), and 7 (14%) HF-device procedures.

Conclusion

Implementation of an accelerated treatment pathway into clinical practice enabled early initiation and rapid titration of quadruple GDMT, with high levels of use and optimal dosing maintained at 6- and 12-months. Optimisation of GDMT supported subsequent comprehensive, individualised management strategies such as revascularisation, rhythm control and device therapy, while achieving low rates of mortality (1%) and heart-failure readmissions (3%) over 12 months. These findings support the feasibility, implementation and ongoing clinical value and safety of an ACT model of care.GDMT utilization over timeFor image description, please refer to the figure legend and surrounding text.