Phone calls improve heart failure medical therapy for patients from Navajo Nation
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Key takeaways:
- A telehealth model improved uptake of guideline-directed medical therapy for rural Navajo Nation patients with heart failure.
- The low-cost strategy may be useful for other rural settings where care is limited.
ATLANTA — A phone-based telehealth model improved rates of guideline-directed classes of HF drugs filled at the pharmacy at 30 days among adults with HF with reduced ejection fraction in Navajo Nation, where access to care is limited.
“CV health inequities are pervasive among the American Indian population and for many American Indian patients receiving care through the Indian Health Service, access to care is limited, especially for heart care,” Lauren A. Eberly, MD, MPH, assistant professor of medicine in the division of cardiovascular medicine at the University of Pennsylvania and a staff cardiologist for the Indian Health Service at Gallup Indian Medical Center, said during a presentation at the American College of Cardiology Scientific Session. “Given this, with community and stakeholder input, we designed a telehealth model in rural Navajo Nation in which guideline-directed medical therapy is initiated and titrated over the phone with remote monitoring using a home BP cuff.”
Addressing significant health care barriers
Residents of Navajo Nation endure significant barriers to accessing health care, Eberly said, adding that the design of the trial required input from community stakeholders to consider limitations.
“Due to the enduring impacts of settler colonialism, one in three people living on the Navajo reservation lack running water and one-third lack electricity, and transportation [involves] unpaved roads,” Eberly said during a discussion after the presentation. “There are significant care access barriers. When we met with our patient stakeholders and community stakeholders, we felt that phone-based communication was the best modality for telehealth, given broadband limitations and lack of connectivity. Even with phone calls, there was some lack of connectivity on the reservation. It took multiple calls to get a hold of people when they were out of service.”
For the Heart Failure Optimization at Home to Improve Outcomes (Hózhó) trial, researchers analyzed data from 103 adults with HFrEF receiving care at two Indian Health Service facilities in rural Navajo Nation, defined as having a primary care physician with one clinical visit and one prescription filled in the last 12 months. The median age of participants was 65 years and 40.8% were women; mean left ventricular EF was 32%. At baseline, 94.2% of participants were prescribed a beta-blocker; 87.4% were prescribed ACE inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor (ARNI) therapy; 39.8% were prescribed mineralocorticoid receptor antagonist (MRA) therapy and 43.7% were prescribed SGLT2 inhibitor therapy.
For the phone-based intervention, participants received a home BP cuff and training on its use in their preferred language. A member of the telehealth team contacted participants by phone to discuss medication recommendations after an electronic health record review. The participants then received “check in” calls with a Navajo-speaking nurse to assess medication tolerability, collect BP, heart rate measurements, provide ongoing education and discuss care. Ongoing initiation and titration of guideline-directed medical therapy over the phone, based on home BP and heart rate measurements, took place every 1 to 2 weeks until optimized, Eberly said.
“The goal was to get all patients on quad therapy or all eligible therapies by 30 days at the latest,” Eberly said.
Researchers randomly assigned participants to the telehealth care model or usual care in a stepped-wedge fashion, with five predetermined time points in 30-day intervals until all patients crossed over into the intervention.
The primary outcome was an increase in the number of guideline-directed classes of drugs filled from the pharmacy at 30 days.
“What we counted as a success was any new addition of guideline-directed medical therapy added to the regimen, and we also counted a transition from an ARB or an ACE inhibitor to an ARNI, given its superior clinical benefit,” Eberly said.
The findings were simultaneously published in JAMA Internal Medicine.
Uptake of therapies improved
The primary outcome occurred more in the intervention group vs. controls (66.2% vs. 13.1%), increasing uptake of guideline-directed classes of drugs by 53% (OR = 12.99; 95% CI, 6.87-24.53; P < .001). The number of patients needed to receive the telehealth intervention to result in an increase of guideline-directed drug classes was 1.88.
At the end of the study, 97% of eligible patients were taking a beta-blocker; 98% were taking a renin-angiotensin-aldosterone system inhibitor; 84% were taking an SGLT2 inhibitor; and 78% were taking an MRA, with 81% eligible for all four medications receiving quadruple therapy.
“We know that racially marginalized patient groups are less likely to receive specialty cardiology care, and even when seen by a provider, they are less likely to receive recommended therapies,” Eberly told Healio. “Our strategy leveraged the EHR on a health-system level to identify patients not receiving appropriate therapy and subsequently optimize therapy without relying on in-person visits for specialty care. We believe that such models advance equity and combat structural racism.”
Eberly added that effective strategies to improve HF care must be community-designed and tailored to fit the local context.
"This strategy was designed with community stakeholder input to meet community needs and address unique Indigenous determinants of health,” Eberly told Healio. “Partnering with communities to design programs to center their perspectives and needs is critical to achieving equity in HF care.”
Eberly noted that the sample size for the study was small and from a single health care system, with medications provided at no cost to enrolled members and with a short follow-up time.
“We believe this is a low-cost strategy that can be expanded to other rural settings where access to care is limited,” Eberly said during the presentation, adding that the telehealth intervention will soon be expanded to an Indian Health Service site in Arizona.
“We have been performing ongoing qualitative studies with our stakeholders and patients to further understand barriers to cardiac care and how we can further optimize our model to meet the needs of the community,” Eberly told Healio. “We are next hoping to design a similar model with our stakeholders to optimize lipid management and guideline-directed care for coronary artery disease and peripheral artery disease. We hope to continue to partner with the community and our patients to design care delivery to advance equity in cardiac care and beyond.”
Reference:
For more information:
Lauren A. Eberly, MD, MPH, can be reached at lauren.eberly@ihs.gov; X (Twitter): @eberly_lauren.
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Eberly LA, et al. Clinical and investigative horizons. Presented at: American College of Cardiology Scientific Session; April 6-8, 2024; Atlanta.
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