Rapid inpatient guideline-directed medical therapy implementation for heart failure with reduced ejection fraction in a public safety-net hospital (RGDMT-HF study)
D Zhuo, R Azees, C Agu, T Esomonye, S Hasham, S Miller, D Parks, A OnwuanyiAbstract
Background/Introduction
Guideline-directed medical therapy (GDMT) represents a key component of heart failure with reduced ejection fraction (HFrEF) management. However, despite the STRONG-HF trial showing improved outcomes with rapid GDMT titration, implementation in a real-world setting remains suboptimal, particularly in patient populations adversely affected by social determinants of health.
Purpose
The purpose of this study was to evaluate GDMT implementation for hospitalized HFrEF patients in a large public safety-net hospital. We hypothesized that higher GDMT implementation levels were associated with a reduction in heart failure readmissions.
Methods
We conducted a retrospective study of adult HFrEF patients admitted to a single public safety-net hospital from 2022-2024, using the primary endpoint of 30-day heart failure readmissions, and a secondary endpoint of 90-day heart failure readmissions. Patients were divided into three groups by total GDMT score: Group 0 (low implementation: score 0-3); Group 1 (moderate implementation: score 4-6); and Group 2 (high implementation: score 7-9). Stabilized inverse probability treatment weighting (sIPTW) was used to address confounding. Associations between GDMT groups and both endpoints were then assessed via sIPTW-adjusted logistic regression. We employed tipping point analysis to identify potential timeframes from discharge to therapeutic effect.
Results
370 eligible HFrEF patients were identified, of which 111 (30.0%) were female, and 340 (91.9%) were of Black race/ethnicity. The mean age was 59.9 years (SD 12.2 years), and the mean left ventricular ejection fraction was 26.9% (SD 8.3%). There were no significant differences in 30-day readmissions between GDMT groups (Group 0 vs. Group 2: OR 3.80, 95% CI 0.63-22.81, p=0.15; Group 0 vs. Group 1: OR 0.79, 95% CI 0.43-1.40, p=0.46; Group 1 vs. Group 2: OR 4.79, 95% CI 0.81-28.29, p=0.08). However, both low and moderate implementation groups were associated with increased 90-day readmissions compared to the high implementation group (Group 0 vs. Group 2: OR 4.10, 95% CI 1.43-11.74, p=0.01; Group 1 vs. Group 2: OR 3.87, 95% CI 1.36-10.97, p=0.01). Tipping point analysis revealed peaks of significant therapeutic effect at 55 days and 100 days following discharge, respectively (Figure 1).
Conclusion(s)
In a predominantly Black population of admitted HFrEF patients, higher levels of GDMT implementation were not associated with a significant change in 30-day readmissions, although there may be a signal toward reduction in 90-day readmissions. Tipping point analysis also suggests that there could be specific timeframes for therapeutic effect to manifest, with windows of approximately 55 and 100 days after discharge. Further studies are needed to clarify the efficacy of rapid GDMT implementation in safety-net hospital settings, as well as the accuracy of timeframes related to heart failure readmission quality metrics.Figure 1.Tipping point analysis.For image description, please refer to the figure legend and surrounding text.