Overcoming treatment inertia for patients with heart failure: how do we build systems that move us from rest to motion?

Abstract

In the 1990s, 5-year new-onset heart failure (HF) survival was as low as 25%. The standard treatment was fluid restriction, cardiac glycosides, and a combination of diuretics. Angiotensin-converting enzyme inhibitors were then approved with compelling evidence for improving outcomes, but prescribing and medication adherence rates remained low for many years.1 The costs and prevalence of HF are increasing worldwide, and we continue to struggle to implement evidence-based therapies for many reasons, collectively known as treatment inertia.2 Treatment inertia occurs when evidence-based therapies are not implemented or maximally titrated. This results in excess mortality, persistent quality of life impairments, and increased healthcare utilization. Moreover, patients may lose confidence in their care plan, leading to decreased adherence, trust, and satisfaction with care. Finally, healthcare systems may face increased costs and resource utilization due to preventable hospitalizations, emergency department visits, and readmissions. The roots of inertia permeate the healthcare system, harming patients and inflicting moral injury on clinicians (Figure 1). Providers may lack awareness of new guidelines, evidence-based therapies, or emerging evidence and may not feel confident in applying them to individual patients. Furthermore, clinicians may perceive the risks excessively while underappreciating the benefits of therapies or prioritizing attention to other comorbidities over HF management, leading to suboptimal treatment decisions. Patients may be unable to receive medications because of the preference against pill burden and limited payer coverage or drug availability in some nations. Furthermore, the healthcare system often incentivizes excess use of resources rather than prioritizing value-based care (VBC). Treatment inertia contributors. The inertia causes are typically categorized as the patient, clinician, and system factors. However, these are much more interconnected. There are few incentives to generate high-value processes. The implementation burden can heavily weigh on clinicians, lead to burnout and apathy, and engender a culture of inertia. Patients must be informed of treatment risks and procure resources to pay for medications, including out-of-pocket expenses, which can include transportation and time costs. Patients also tend to prefer minimizing pill burden and polypharmacy Ultimately, these circumstances increase the collective burden across all healthcare stakeholders, with a particularly detrimental burden and impact on clinicians and suffering patients.3 Consequently, burnout (including the domains of emotional exhaustion, depersonalization, and professional apathy) and depression are increasingly common among cardiologists.4 In the current paradigm, the clinician is ultimately responsible for implementing and intensifying treatment, implicitly forcing the clinician to repeatedly sacrifice excess time and mental energy. Under this system, translating validated treatments into clinical practice may take as long as 17 years.5 Building systems to address clinical inertia requires buy-in across a diverse spectrum of stakeholders and the use of implementation science. Implementation science has gained considerable traction in the last decade, with systematic approaches to identifying barriers and facilitators to inform implementation strategies designed to nudge clinicians, patients, and the healthcare system in the right direction. Results are sometimes mixed; however, some trials have demonstrated incremental progress (Table 1). Examples of implementation studies, findings, and take-home messages One innovative program example, developed at Saint Luke’s Health System of Kansas City and disseminated across several centers in the region, is a novel risk stratification program to better triage patients with HF in the emergency department, called Code-HF. Once patients are identified, a care pathway is recommended based on clinical variables within a risk model. If the predicted mortality rate is >1%, there is a rapid admission process, and if there is a failure to improve during the emergency department stay, they are also admitted. Otherwise, patients are discharged with prompt follow-up, including a phone call within 24 h and a clinic appointment within seven days. This process has improved the throughput of the emergency department stay, reduced unnecessary admissions, and increased follow-up.10 Further examples demonstrate the common effort to protect the patient from inert judgment regarding medication dosing by nudging the clinician to choose action and providing treatment pathways for patients (Table 1). Beyond this, some have utilized the healthcare system to implement guideline-based practices autonomously. Namely, the COACH-HF study meshed the rapid titration featured in STRONG-HF and the care pathways used in Code-HF. Ultimately, there is a benefit to systemizing the care pathway for HF patients to limit off-target variability in guideline implementation. As the leading cause of death, HF is a significant public health concern, and we have treatments that can dramatically improve patient outcomes. However, novel strategies to maximize medical treatment adoption and dissemination are urgently needed. Guidelines are clear, but the path forward is often difficult for patients and clinicians as they navigate a system with numerous barriers to optimal treatment. A growing body of work shows that if we can nudge clinicians while informing patients, we can improve the appropriate use of medical therapy. However, instituting these programs requires clinical champions and the use of implementation science. Through constructive disruption and advancing implementation science, we can improve the healthcare value for patients suffering from HF and lighten the load on overstretched clinicians suffering from burnout and falling prey to professional apathy.

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