Findings from a new study reveal an association between higher guideline-directed medical therapy (GDMT) score at discharge with lower mortality, hospitalization, more home time and lower costs. Conclusions drawn from the investigation place an emphasis on GDMT optimization in increasing health care value as higher hospital-level use of evidence-based heart failure medications were also favorably associated with components of health care value. “These findings suggest that efforts to improve nationwide optimization of GDMT for reduced ejection fraction (HFrEF) at time of hospital discharge may reduce unwarranted variation in outcomes and costs,” said the paper’s authors, led by Vincenzo B. Polsinelli, MD, from the University of Colorado in Aurora. “[This would] thereby improve the value of HF transitional care.” Main findings The retrospective cohort study of 41,161 patients found significant hospital variability in GDMT score at discharge (adjusted median odds ratio (AMOR): 1.23; 95% confidence interval [CI]: 1.21 to 1.26) and clinical outcomes (mortality AMOR: 1.17; 95% CI: 1.14 to 1.24). Further findings revealed that the HF rehospitalization AMOR value was 1.22 with a 95% CI range noted as 1.18 to 1.27. The mortality or HF rehospitalization AMOR value was 1.21 with a 95% CI of 1.18 to 1.26. The team of researchers also revealed a home time AMOR value of 1.07 with a 95% CI range of 1.06 to 1.10. Findings were also noted for the link between GDMT score and costs (AMOR: 1.23; 95% CI:1.21 to 1.26). The team also established the link between higher hospital GDMT score and lower hospital mortality (Spearman ρ: −0.22; 95% CI: −0.32 to −0.12; P<0.001), lower mortality or HF rehospitalization (Spearman ρ: −0.17; 95% CI: −0.26 to −0.06; P=0.002). Further analysis revealed the link between higher hospital GDMT score and more home time (Spearman ρ: 0.14; 95% CI: 0.03 to 0.24; P=0.01), and lower cost (Spearman ρ: −0.11; 95% CI: −0.21 to 0; P=0.047) but not with HF rehospitalization (Spearman ρ: −0.10; 95% CI: −0.20 to 0; P =0.06). Room for improvement “The observed variability in the use of GDMT suggests that there is considerable room for improvement,” said the authors of the paper, which was published in the September 25 issue of JAMA Cardiology. “Implementation program process measures may include documentation of next steps in the optimal use of GDMT in the medical record focusing first on HF medication class initiation followed by HF medication uptitration, multidisciplinary collaboration and early follow-up after discharge.” Discussing the implications of the study’s findings, the paper took a patient and societal perspective, in which its authors suggested episodes of care around major medical events such as hospitalization or surgery made more sense from a value lens than fee-for-service approaches. “Prior studies have operationalized the concept of value to measure and assess outcomes and costs after percutaneous coronary intervention at 30 days and 1 year,” the paper said. “The current analysis extends the concept of value measurement to HF transitional care and focuses on the 90 days after HF hospitalization, a clinical event and time period of interest specified by CMS in the most recent iteration of value-based, voluntary bundled payment models.” ‘Striking’ cost variations The paper went onto highlight that hospital-level variations in cost after HF discharge were striking and exceeded variations in clinical outcomes. The research team suggested that there was variability in underlying structures and processes of care. “Subsequent evaluations are needed to understand factors underlying the identified cost variations,” they said.The paper also noted that additional drivers of variability in cost may include emergency department visits and outpatient care. “HF medical therapy is cost-effective and is associated with an overall reduction in cost in the current analysis,” the paper’s authors concluded. “HF medication optimization among other components of preferred transitional care may thus curb unwarranted variation in costs. “More targeted use of post-acute care services similarly has the potential to yield increased cost efficiency.” Study methodology The retrospective cohort study enrolled 41,161 patients (median interquartile range [IQR] age: 78 [71-85] years; 62.1% male). Included for analysis were patients hospitalized for HFrEF in the Get With the Guidelines–Heart Failure Registry, a national hospital-based quality improvement registry. The primary outcomes of the study were hospital variability in GDMT score, 90-day mortality, HF rehospitalization, mortality or HF rehospitalization, home time and costs. Study data were analyzed from July 2022 to April 2023. Source: Polsinelli VB, Sun JL, Greene SJ, et al. Hospital Heart Failure Medical Therapy Score and Associated Clinical Outcomes and Costs. JAMA Cardiology. 2024 Sept 25 (Article in Press) Image Credit: C Davids/peopleimages.com - stock.adobe.com