Amrita Mukhopadhyay

Background: Most eligible patients are not prescribed guideline‐directed medical therapy for heart failure with reduced ejection fraction (EF). Increased time pressures for providers in the ambulatory setting may contribute to these shortfalls. We assessed the association between cardiologist ambulatory workload and guideline‐directed medical therapy prescription for patients with heart failure with reduced EF. Methods: This was a cross‐sectional study of patients with heart failure with reduced EF (EF ≤40%) seen by a cardiologist from October 1, 2022, to September 30, 2023, using deidentified administrative and electronic health record data from Optum Labs Data Warehouse, which includes data from multiple health systems across the United States. The primary exposure was ambulatory workload, measured as the average number of visits per day, categorized into quartiles. The primary outcome was “comprehensive quadruple therapy,” defined as prescription for all 4 guideline‐directed medical therapies: β‐blocker; angiotensin receptor–neprilysin inhibitor; mineralocorticoid receptor antagonist; and sodium‐glucose cotransporter 2 inhibitor. Analyses were conducted using generalized estimating equations, adjusted for demographic and clinical variables. Results: Overall, 40 173 patients were seen by 881 cardiologists (median ambulatory workload, 9.1 patients per day; interquartile range=5.1–13.0). The percentage of patients prescribed comprehensive quadruple therapy was higher among patients in lower quartiles (quartile 1: 14%; quartile 2: 9.7%; quartile 3: 8.9%; quartile 4: 7.4%; P P value=quartile 1: 1.35 [1.09–1.66], 0.008; quartile 2: 1.20 [1.00–1.43], 0.050; quartile 3: 1.11 [0.93–1.32], 0.28; quartile 4 [reference]). Conclusions: Seeing a cardiologist with lower ambulatory workload was associated with increased prescribing of guideline‐recommended, life‐saving therapy in patients with heart failure with reduced EF. Current models that incentivize more visits per day may negatively impact care in the ambulatory setting.

Background: There is no gold standard for measuring adherence to a complex medication regimen. Heart failure is a chronic disease state that requires multiple medications for optimal control, known as guideline-directed-medical therapy (GDMT), and can be used a model to explore approaches to assessing multi-medication adherence. We aimed to compare seven proportion of days covered (PDC) measures for assessing adherence to multiple GDMT medications and to evaluate their association with clinical outcomes. Methods: We conducted a large, single center, retrospective cohort study of 34,603 patients with heart failure who filled a GDMT prescription between April 2021 and July 2022. The primary outcomes were the seven PDC-based adherence measures derived from electronic health record and pharmacy data. PDC was defined as the proportion of days in which patients had possession of GDMT medications. Our secondary outcome was the combined clinical outcome of ED visits, hospitalizations, and death. Results: The seven measures provided a wide range of measured PDC adherence. Using the strictest measure, ‘each’ (>= 80% of days with each drug available) 54% of patients were considered adherent, compared with 73% measured adherence for the least restrictive measure, ‘at least one’. Variability increased with increasing number of medications across all non-average based measures. For example, using the ‘all’ measure (a more restrictive PDC measure) adherence ranged from 0.53 to 0.41 with increasing number of GDMT prescriptions. Higher PDC for each of the seven measures was associated with increased number of ED, visits, hospitalizations, and death. There was no association with the combined outcome in patients with heart failure with reduced ejection fraction. Conclusions and Relevance: There was a wide variability in adherence measures for assessing adherence to GDMT depending on the measure used. This variability has significant implications for the policy, clinical, and intervention context to which the measure is applied.

Background: Patients with heart failure (HF) often have difficulty obtaining life‐saving medications due to coverage barriers, such as prior authorizations and high out‐of‐pocket costs. To promote better coverage for high value therapies and inform policymakers about cost effectiveness, the American Heart Association/American College of Cardiology/Heart Failure Society of America added Value Statements to HF guidelines. We assessed whether these guidelines influenced Medicare drug coverage policies for 2 life‐saving, costly HF medications: angiotensin receptor neprilysin inhibitors (ARNI–guideline “high value”) and sodium glucose cotransporter‐2 inhibitors (SGLT2i–guideline “intermediate value”). Methods: We performed an observational study using Medicare prescription drug plan formulary files from April 2020 to April 2023 to separately assess for changes in coverage barriers to ARNI and SGLT2i after Value Statement publication (April 2022), and subsequent Medicare plan online update (October 2022). The primary outcome was the percentage of plans each month with any barrier to drug coverage (prior authorizations, tier ≥3 out‐of‐pocket cost‐sharing, step therapy, or no coverage). Analyses used interrupted time series and difference‐in‐differences approaches. Difference‐in‐differences analyses used direct oral anticoagulants as a control due to their comparable cost and use as ARNI and SGLT2i, but without a Value Statement. Results: Among 7396 Medicare drug plans, monthly rates of any coverage barrier ranged from 94.3% to 97.4% for ARNI and 93.2% to 96.6% for SGLT2i. Most barriers were due to tier ≥3 out‐of‐pocket cost‐sharing requirements (ARNI: 94.3%–95.8%; SGLT2i: 93.2%–95.6%). Coverage barriers remained stable in April 2022 and declined slightly in October 2022. In difference‐in‐differences analyses, the presence of a Value Statement was associated with a ~1 percentage point decline in coverage barriers for both ARNI (difference‐in‐differences estimate, −1.07% [95% CI, −1.44% to −0.70%]) and SGLT2i (−1.32% [95% CI, −1.63% to −1.00%]). Conclusions: Coverage barriers to ARNI and SGLT2i were common and changed only slightly after publication of Value Statements in HF guidelines. There is a critical need for robust strategies to improve access to life‐saving HF medications.

Importance Patients with poor glycaemic control have a high risk for major cardiovascular events. Improving glycaemic monitoring in patients with diabetes can improve morbidity and mortality. Objective To assess the effectiveness of a patient portal message in prompting patients with poorly controlled diabetes without a recent glycated haemoglobin (HbA1c) result to have their HbA1c repeated. Design A pragmatic, randomised clinical trial. Setting A large academic health system consisting of over 350 ambulatory practices. Participants Patients who had an HbA1c greater than 10% who had not had a repeat HbA1c in the prior 6 months. Exposures A single electronic health record (EHR)-based patient portal message to prompt patients to have a repeat HbA1c test versus usual care. Main outcomes The primary outcome was a follow-up HbA1c test result within 90 days of randomisation. Results The study included 2573 patients with a mean (SD) HbA1c of 11.2%. Among 1317 patients in the intervention group, 24.2% had follow-up HbA1c tests completed within 90 days, versus 21.1% of 1256 patients in the control group (p=0.07). Patients in the intervention group were more likely to log into the patient portal within 60 days as compared with the control group (61.2% vs 52.3%, pConclusions Among patients with poorly controlled diabetes and no recent HbA1c result, a brief patient portal message did not significantly increase follow-up testing but did increase patient engagement with the patient portal. Automated patient messages could be considered as a part of multipronged efforts to involve patients in their diabetes care.

Background: Despite the exponential growth in telemedicine visits in clinical practice due to the COVID-19 pandemic, it remains unknown if telemedicine visits achieved similar adherence to prescribed medications as in-person office visits for patients with heart failure. Objective: Our study examined the association between telemedicine visits (vs in-person visits) and medication adherence in patients with heart failure. Methods: This was a retrospective cross-sectional study of adult patients with a diagnosis of heart failure or an ejection fraction of ≤40% using data between April 1 and October 1, 2020. This period was used because New York University approved telemedicine visits for both established and new patients by April 1, 2020. The time zero window was between April 1 and October 1, 2020, then each identified patient was monitored for up to 180 days. Medication adherence was measured by the mean proportion of days covered (PDC) within 180 days, and categorized as adherent if the PDC was ≥0.8. Patients were included in the telemedicine exposure group or in-person group if all encounters were video visits or in-person office visits, respectively. Poisson regression and logistic regression models were used for the analyses. Results: A total of 9521 individuals were included in this analysis (telemedicine visits only: n=830 in-person office visits only: n=8691). Overall, the mean age was 76.7 (SD 12.4) years. Most of the patients were White (n=6996, 73.5%), followed by Black (n=1060, 11.1%) and Asian (n=290, 3%). Over half of the patients were male (n=5383, 56.5%) and over half were married or living with partners (n=4914, 51.6%). Most patients’ health insurance was covered by Medicare (n=7163, 75.2%), followed by commercial insurance (n=1687, 17.7%) and Medicaid (n=639, 6.7%). Overall, the average PDC was 0.81 (SD 0.286) and 71.3% (6793/9521) of patients had a PDC≥0.8. There was no significant difference in mean PDC between the telemedicine and in-person office groups (mean 0.794, SD 0.294 vs mean 0.812, SD 0.285) with a rate ratio of 0.99 (95% CI 0.96-1.02; P=.09). Similarly, there was no significant difference in adherence rates between the telemedicine and in-person office groups (573/830, 69% vs 6220/8691, 71.6%), with an odds ratio of 0.94 (95% CI 0.81-1.11; P=.12). The conclusion remained the same after adjusting for covariates (eg, age, sex, race, marriage, language, and insurance). Conclusions: We found similar rates of medication adherence among patients with heart failure who were being seen via telemedicine or in-person visits. Our findings are important for clinical practice because we provide real-world evidence that telemedicine can be an approach for outpatient visits for patients with heart failure. As telemedicine is more convenient and avoids transportation issues, it may be an alternative way to maintain the same medication adherence as in-person visits for patients with heart failure.

Importance: Medication nonadherence is common among patients with heart failure with reduced ejection fraction (HFrEF) and can lead to increased hospitalization and mortality. Patients living in socioeconomically disadvantaged areas may be at greater risk for medication nonadherence due to barriers such as lower access to transportation or pharmacies.Objective: To examine the association between neighborhood-level socioeconomic status (nSES) and medication nonadherence among patients with HFrEF and to assess the mediating roles of access to transportation, walkability, and pharmacy density.Design, Setting, and Participants: This retrospective cohort study was conducted between June 30, 2020, and December 31, 2021, at a large health system based primarily in New York City and surrounding areas. Adult patients with a diagnosis of HF, reduced EF on echocardiogram, and a prescription of at least 1 guideline-directed medical therapy (GDMT) for HFrEF were included.Exposure: Patient addresses were geocoded, and nSES was calculated using the Agency for Healthcare Research and Quality SES index, which combines census-tract level measures of poverty, rent burden, unemployment, crowding, home value, and education, with higher values indicating higher nSES.Main Outcomes and Measures: Medication nonadherence was obtained through linkage of health record prescription data with pharmacy fill data and was defined as proportion of days covered (PDC) of less than 80% over 6 months, averaged across GDMT medications.Results: Among 6247 patients, the mean (SD) age was 73 (14) years, and majority were male (4340 [69.5%]). There were 1011 (16.2%) Black participants, 735 (11.8%) Hispanic/Latinx participants, and 3929 (62.9%) White participants. Patients in lower nSES areas had higher rates of nonadherence, ranging from 51.7% in the lowest quartile (731 of 1086 participants) to 40.0% in the highest quartile (563 of 1086 participants) (P < .001). In adjusted analysis, patients living in the lower 2 nSES quartiles had significantly higher odds of nonadherence when compared with patients living in the highest nSES quartile (quartile 1: odds ratio [OR], 1.57 [95% CI, 1.35-1.83]; quartile 2: OR, 1.35 [95% CI, 1.16-1.56]). No mediation by access to transportation and pharmacy density was found, but a small amount of mediation by neighborhood walkability was observed.Conclusions and Relevance: In this retrospective cohort study of patients with HFrEF, living in a lower nSES area was associated with higher rates of GDMT nonadherence. These findings highlight the importance of considering neighborhood-level disparities when developing approaches to improve medication adherence.