UPMC Experts Enhance Heart Failure Care, Address Barriers Through Medication Optimization Clinic

Approximately 800,000 people are hospitalized annually in the United States for heart failure. Comprehensive disease-modifying quadruple therapy is the standard of care to treat the nearly three million people in the country currently living with heart failure with reduced ejection fraction (HFrEF) – previous studies have estimated that quadruple therapy reduces relative risk in all-cause mortality by 73% over two years.

“It proves difficult to get patients on quadruple therapy,” said Jennifer Kliner, CRNP, co-founder of the Medication Optimization Clinic at the UPMC Advanced Heart Failure Center. “We need to add on four medications, two of which have significant dose increment adjustments, so it typically takes an extended period of time.”

Sequential prescribing and up-titration alone can take six months or longer. Moreover, patients may experience several other limitations including in-office visits, frequent dose adjustments, and high costs. As quadruple therapy has recently become the gold standard for treating HFrEF – as the latest guidelines from the American Heart Association (AHA), American College of Cardiology (ACC), and Heart Failure Society of America (HFSA) all strongly recommend – experts at UPMC knew these barriers had to be addressed to provide more efficient and accessible treatment.¹

Therefore, Jennifer and her team brainstormed a pathway to better provide quadruple therapy, and what resulted was a completely virtual medication optimization clinic within the UPMC Advanced Heart Failure Center that aimed to rapidly initiate and up-titrate guideline directed medical therapy (GDMT).

She created the Medication Optimization Clinic – a referral-based clinic that leverages telemedicine and is staffed by a multidisciplinary group of advanced practice providers (APPs) and pharmacists – in collaboration with Mary Keebler, MD, medical director, UPMC Advanced Heart Failure Center, who serves as the attending physician; and Jim Coons, PharmD, FCCP, FACC, BCCP.

More than 700 patients have been seen at the clinic since it began in 2020, and just 6% of the first 206 patients were on quadruple therapy at baseline. An analysis of the first 18 months of data gathered from the clinic, published in the American Journal of Cardiology, showed 49% of patients successfully reached quadruple therapy at clinic discharge, target doses for GDMT classes were higher, and propensity matching showed that heart failure and cardiovascular hospitalization were significantly decreased at both three and six months compared to control.

An Efficient Sequencing Approach

Jennifer initiated the Medication Optimization Clinic with just four patients. During the first visit, she sees patients through a video call and reviews the structure of the clinic, which includes:

• 12 consecutive weekly telemedicine visits. Patients are scheduled in a block format – they keep a consistent meeting time and date throughout their duration at the clinic.
• Monitor and review vital signs, symptoms, and side effects of medications.
• Incremental medication adjustments weekly as tolerated.
• Monitor laboratory values.
• Co-pay/prior authorization assistance.
• General cardiovascular education.

The traditional approach to treatment was prescribing medications sequentially, with titration to target doses prior to a subsequent therapy being initiated. Once patients begin treatment, their vital signs are monitored for a week, followed by dose up-titration if necessary, and the process continues until the target GDMT or highest tolerated dose of ACE/ARB or ARNi, beta blocker (BB), aldosterone antagonist (MRA), and sodium glucose co-transporter-2 inhibitor (SGLT2) is achieved.

Not only is the process streamlined at the Medication Optimization Clinic under the care of advanced heart failure specialists using structured algorithms, but patients can also qualify for financial assistance for the medications they need and at-home blood pressure monitoring devices.

“We will reach out to the drug manufacturers and fill out patient assistance paperwork,” Jennifer said. “We have been very successful getting patients who need financial assistance coverage for these medications.”

If patients have UPMC Health Plan, an at-home blood pressure monitoring device will be provided to them. For patients who don’t have UPMC Health Plan, the Medication Optimization Clinic secured funding to help provide devices through the Collaborative Care Grant for Nurses and Pharmacists, an award given once a year through the American Society of Health-System Pharmacists and American Nurses Foundation.

The team at the Medication Optimization Clinic condenses the traditional five step process to three steps achieved within 12 weeks. If patients are RAASi and BB naïve upon first visit, they are prescribed an appropriate dose of each. If they’re already on a beta-blocker, an SGLT2 is added as well. The second step is initiation of MRA and titration of the beta-blocker and ARNi based on a review of vitals. Lastly, all four drugs are titrated as necessary until target doses are reached. The goal is for patients to be on four drugs by week four with subsequent titrations thereafter.

The team then discharges patients back to the referring physician, who reassesses left ventricular function after three months of optimal therapy.

Innovative Heart Failure Care Offered at Several UPMC Locations

The Medication Optimization Clinic is comprised of UPMC experts from Pittsburgh, Erie, Harrisburg, and other areas across Pennsylvania. But because it’s completely virtual, patients have access to the clinic no matter their location.

“We like the first visit to be conducted via a video call, and then all visits thereafter via phone call, but if they don’t have video capacity, that’s fine,” Jennifer said. “We don’t let that deter us from talking to patients.”

Since APPs staff the clinic alongside pharmacists and cardiologists, dose adjustments due to side effects are just a phone call away. “Having APPs staff the clinic allows us to make quick provider judgements and reduces back and forth about medication changes,” Jennifer said.

Collaboration with referring physicians is an integral aspect of the Medication Optimization Clinic as well. The team partners with experts from the UPMC Center for Heart Valve Disease, UPMC Adult Congenital Heart Disease, and other programs to ensure patients receive holistic, individualized care.

For more information or to refer a patient to the UPMC Heart and Vascular Institute, please email HVIReferral@upmc.edu.

Reference

1. Schwann, N. Alexandra; Riello, Ralph; Ahman, Tariq. American College of Cardiology. 2022. https://www.acc.org/latest-in-cardiology/articles/2022/06/01/12/11/inpatient-initiation-of-hfref-therapies. Accessed on 2 September 2022.