Impact of a pre-discharge checklist on temporal trends in gdmt prescription and clinical events in patients with heart failure
J H Jang, D Y Kim, S H ShinAbstract
Background
Early initiation and intensification of guideline-directed medical therapy (GDMT) are crucial for patients with heart failure with reduced ejection fraction (HFrEF). However, in real-world practice, GDMT prescription rates and dosing often remain suboptimal due to clinical inertia during hospital-to-home transitions.
Purpose
To evaluate the impact of electronic medical record (EMR)-embedded DCL on the temporal trajectory of GDMT optimization and its subsequent effect on clinical outcomes.
Methods
This real-world cohort study included 661 patients hospitalized with HFrEF (LVEF ≤ 40%) at a tertiary academic center. The DCL utilized in this study was adapted from the standardized template provided by the KSHF and integrated into the hospital's EMR system. Patients were categorized into a DCL group (n=369) and a non-DCL group (n=292, comprising historical and concurrent controls). Modified version of the Heart Failure Collaboratory (mHFC) score was calculated and assessed the mHFC score at discharge and longitudinally at 3, 6, and 12 months to evaluate the trajectory of medication titration.The primary outcome was a composite of all-cause death or HF hospitalization at 12 months.
Results
DCL implementation was associated with significantly higher prescription rates across core GDMT pillars: renin-angiotensin system inhibitors (RASi; 90.2% vs. 69.5%, P < 0.001), beta-blockers (86.2% vs. 72.3%, P < 0.001), and SGLT2 inhibitors (51.2% vs. 12.3%, P < 0.001). Notably, the use of angiotensin receptor-neprilysin inhibitors (ARNI) was substantially higher in the DCL group (82.4% vs. 19.2%, P < 0.001). Consequently, the overall quality of medical therapy, quantified by the mHFC score, was significantly higher in the DCL cohort (5.9 ± 2.2 vs. 3.6 ± 2.0, P < 0.001). Longitudinally, the DCL group consistently maintained these higher prescription rates and optimal dosing trajectories throughout the 12-month follow-up. Consequently, the DCL group was associated with a 61% reduced risk of the primary composite outcome (Adjusted Hazard Ratio 0.39; 95% Confidence Interval 0.25–0.59; P < 0.001), which was primarily driven by a marked reduction in HF readmissions (10.8% vs. 22.9%, P < 0.001).
Conclusion
An EMR-embedded DCL significantly enhanced the early optimization of GDMT and successfully maintained therapeutic intensity over time and improved event-free survival.figure 1figure 2