Fine-Tuning Medications for Stronger Veteran Hearts
Cardiologists have learned over the past 30 years that patients with heart failure benefit the most from taking four classes of medications at the optimal dosages. Despite this, a third or more of patients living with this disease are not prescribed these evidence-based therapies at all, and many others receive prescriptions at suboptimal dosages. It’s a huge problem, even among the heart failure patients seen at the Veterans Affairs (VA) Palo Alto Health Care System, where a minority of heart failure patients take the fully recommended doses of these medications known to improve health and lengthen lives.
To try to turn that around, a collaboration between Stanford and the Palo Alto VA beginning in late 2019 tested a new approach to have pharmacists upwardly adjust, or titrate, patients’ doses for maximum benefit. The population health project brings together an interdisciplinary team of cardiologists, primary care physicians (PCPs), nurses, heart failure researchers, and pharmacists. Veterans in the program work with clinical pharmacists over several visits and calls to get to their optimal dosages.
“We get to leverage Stanford researchers’ expertise on new, cutting-edge interventions to more quickly implement evidenced-based treatments” at the VA, says Rhonda Hamilton, MD, MPH, clinical assistant professor of primary care and population health and general medicine clinic section chief at the Palo Alto VA, who is overseeing the project’s expansion at the Palo Alto clinic site. Under the mentorship of Nazima Allaudeen, MD, clinical assistant professor and director of quality improvement for inpatient medicine at the Palo Alto VA, Justin Slade, MD, led the pilot project while he was a cardiology postresident at Stanford as well as the Physician Scholar for Quality and Safety at the Palo Alto VA. The pilot project focused on the Major General William H. Gourley VA-DoD Outpatient Clinic, typically known as the Monterey VA site.
Maryn Yamamoto, pharmacist; Rhonda Hamilton, MD; Jessica Tran, pharmacist; Lauren Hamilton, data analyst
After just five months of the pilot project, patients on average significantly increased their dosages of both beta-blockers, which slow heart rate, and ACE inhibitor–like drugs, which lower blood pressure. In addition, the numbers of patients at or above 50% of the recommended doses for both drugs have steadily increased since the program began at the VA’s Monterey site. Due to that success, the program was expanded to three more Palo Alto VA sites.
“In the VA system, we have a responsibility not just to fix patients up in the hospital and send them home, but also to keep them healthy for the rest of their lives,” says Slade.
Heart failure affects 6.2 million adults in the U.S. and nearly 2,000 people across the Palo Alto VA system.
One of the first lines of treatment is to put patients on four different classes of medications. Taken together, these drugs work to reverse the hormonal signals in response to heart failure that tell the heart to work harder, and they reduce pressures in the heart to allow heart function to stabilize and get stronger.
Slade explains that cardiologists have long known that the optimal dosages of the four recommended drug treatments help people live better and longer with heart failure. “But the real challenge is getting those treatments to people in a more consistent, reliable way,” says Allaudeen.
Alex Sandhu, MD, MS
There are many barriers to optimal dosing, including 30-minute clinic appointment windows, during which a cardiologist or PCP must cover previous and current health issues, physician concerns, patient concerns, and a review of the 10 or more medications that veterans on average take, says Hamilton.
Alex Sandhu, MD, MS, instructor of cardiovascular medicine and the heart failure researcher advising the project, says that physician inertia can be another barrier when a patient’s condition appears stable. “Even among stable patients, the risk of deteriorating and getting sicker is substantial,” he says.
By harnessing data from a new VA heart-failure patient dashboard, the team can identify which patients are taking less than the recommended doses of beta-blockers and ACE inhibitor–like drugs. “The dashboard is also an important tool in addressing health care disparities,” says Allaudeen, because it can identify patients who are not coming in as frequently by their data, rather than relying solely on physician referrals.
Among approximately 1,400 patients with heart failure, the team found that fewer than half were taking the drugs at a dosage that was at least 50% of the recommended dosage. (They use 50% or greater as the mark for the recommended dosage because not all patients can tolerate 100%.)
Because heart failure is progressive and the drugs’ effects are additive, getting patients to the highest tolerable doses is key: “The maximum tolerated dose is where these patients will get the most benefit,” says Slade.
To titrate to that maximum dose, however, normally requires visits to the doctor’s office every two weeks for several months. Very few physicians have the bandwidth to handle that many visits, and many VA patients live far away or lack transportation.
Instead, the team tested the new approach with clinic pharmacists handling these iterative visits, following a cardiologist’s protocol to titrate doses and do follow-up appointments by phone or video call. During the five months of the study, which concluded in April 2020, patients on average improved their beta-blocker doses from 19% to 35% of the recommended dose, and their ACE inhibitor–like doses increased from 52% to 81% of the recommended dose.
"We want our patients to be on the best medical therapy for heart failure. Every month or year that goes by that a patient isn’t, that’s a missed opportunity"
“The pilot was definitely a great success to demonstrate that pharmacists were able to successfully increase patients’ doses and safely improve treatment,” says Sandhu. Importantly, there were no safety events or emergency room visits associated with the dosage changes. Sandhu will continue to advise the expanded project on incorporating newer therapies and formally evaluating the program’s impact.
Allaudeen, who cares for patients at the end stages of heart failure in the hospital, says that projects like this are a big win for everyone—for the facility in lowering costs, for the care teams who can treat patients more effectively, and for the patients themselves. The next step is to expand the program to all eight VA clinic sites, with programs currently started in the San Jose, Livermore, and Palo Alto sites.
Allaudeen feels an urgency to get there: “We want our patients to be on the best medical therapy for heart failure. Every month or year that goes by that a patient isn’t, that’s a missed opportunity.”
Taking Racial Disparities to Heart
Rhonda Hamilton was looking for ways to make a real difference in Black and Latinx VA patients’ lives, and she saw an opportunity after the death of George Floyd and the national resurgence of the Black Lives Matter movement.
“I wanted to leverage my leadership position to help with the health care disparities facing Black and Latinx patients in our medical care,” says Hamilton. So she formed a VA committee, and with her teenage daughter Lauren as their research assistant, they found striking results for heart failure: In the United States, “Black patients with heart failure symptoms were far less likely to be on the recommended doses of medications compared to their white counterparts,” says Hamilton.
The new approach to optimizing heart failure medications brings the added bonus of addressing this large racial health care disparity.
“Studies like this one save lives” in tangible ways, says Hamilton. Through her research on health disparities, Hamilton’s daughter Lauren also came to a striking conclusion: Interventions that better meet the needs of Black patients help all patients. And that, Hamilton says, makes the program a win for all veterans and their doctors.