Remote monitoring titration clinic to implement guideline-directed therapy for heart failure patients with reduced ejection fraction: a pilot quality-improvement intervention.

Introduction: Guideline-directed medical therapy (GDMT) is the recommended treatment for heart failure with reduced ejection fraction (HFrEF). However, the implementation remains limited, with suboptimal use and dosing. The study aimed to assess the feasibility and effect of a remote monitoring titration program on GDMT implementation. Methods: HFrEF patients were randomly assigned to receive either usual care or a quality-improvement remote titration with remote monitoring intervention. The intervention group used wireless devices to transmit heart rate, blood pressure, and weight data daily, which were reviewed by physicians and nurses every 2-4 weeks. Medication tolerance was assessed via phone, and dosage instructions were given. This workflow was repeated until target doses were reached or further adjustments were not tolerated. A 4-GDMT score measured use and target dosage, with the primary endpoint being the score at 6 months follow-up. Results: Baseline characteristics were similar (n = 55). A median of 85% of patients complied with transmitting device data every week. At the 6-month follow-up, the intervention group had a 4-GDMT score of 64.6% compared to 56.5% in the usual care group (p = 0.01), with a difference of 8.1% (95% CI: 1.7%-14.5%). Similar results were seen at the 12-month follow-up [difference 12.8% (CI: 5.0%-20.6%)]. The intervention group showed a positive trend in ejection fraction and natriuretic peptides, with no significant difference between groups. Conclusions: The study suggests that a full-scale trial is feasible and that utilizing a remote titration clinic with remote monitoring has the potential to enhance the implementation of guideline-directed therapy for HFrEF.

Pharmacy Resident Perspectives on the Layered Learning Practice Model.

Objective: To describe pharmacy resident perspectives on the layered learning practice model (LLPM) at large academic medical centers in the United States and identify the types of training residents receive to prepare for the LLPM. Methods: This was a cross-sectional, mixed methods study that surveyed pharmacy residents completing training at large, academic medical centers on their perspectives of the LLPM. Residents with at least 4 weeks of precepting experience were eligible to complete an online survey. Descriptive statistics were generated for demographic and Likert data while themes were identified from narrative free responses. Results: Twenty-seven resident responses from 10 institutions were included. Likert data showed generally positive perspectives toward overall experience with the LLPM and perceived LLPM impact on clinical knowledge and professional practice, with 100.0% of respondents agreeing they enjoyed precepting under the LLPM. However, 44.4% also agreed that precepting was stressful. LLPM impact on resident behavior received positive to neutral responses; 63.0% neither agreed nor disagreed that the LLPM changed their approach to patient care. Written comments revealed themes such as sources of stress within the LLPM, increased depth of learning, improved comprehensive patient care, and improved professional growth. The most common forms of LLPM training occurred through preceptor and student evaluations (73.1% and 61.5%, respectively) and orientation (50.0%). Conclusion: These findings identified a variety of resident perspectives on the LLPM ranging from positive to negative and revealed possible areas of improvement related to LLPM implementation. Residency programs may consider exploring stressors on the resident role in the LLPM to better structure resident precepting training and maximize their clinical learning experience.

Pharmacy multidisciplinary stewardship program for high-risk patients prescribed opioids in an academic clinic.

OBJECTIVE: To assess observation of the Centers for Disease Control (CDC) Guideline for prescribing opioids for chronic pain within a Pharmacy Controlled Substance Clinic (PCSC) compared to usual care by resident physicians in a Primary Care Internal Medicine (IM) clinic. DESIGN: Single-center, retrospective cohort. SETTING: IM clinic within a large, academic medical center. PARTICIPANTS: Patients receiving stable opioid prescriptions for management of chronic nonmalignant pain (CNCP) were screened. Exclusions included age < 18 years old, aberrant opioid use behaviors, or malignancy-related pain. Both cohorts included 100 eligible patients. INTERVENTIONS: Within the PCSC, a pharmacy team provided assistance to resident physicians monitoring patients receiving opioid medications. MAIN OUTCOME MEASURES: The primary outcome was application of CDC guidelines: creation of an annual patient provider agreement (PPA); annual urine drug screen (UDS); quarterly review of a prescription drug monitoring program (CURES); and documentation of quarterly evaluation of opioid use. Secondary outcomes included risk factors for opioid-related harms. RESULTS: Respective measures from the control versus the intervention group demonstrated: PPA creation in 28 percent (n = 28) versus 100 percent (n = 100) (p < 0.001); UDS obtained in 59.2 percent (n = 58) versus 90.6 percent (n = 87) (p < 0.001); quarterly CURES review in 26 percent (n = 26) versus 70 percent (n = 70) (p < 0.001); and quarterly evaluation of opioid use in 26 percent (n = 26) versus 37 percent (n = 37) (p = 0.10). CONCLUSIONS: Pharmacy-led monitoring of patients prescribed opioids for CNCP in an academic resident clinic improves implementation of CDC guidelines. Similar multidisciplinary team integration may improve opioid prescribing safety in academic primary care settings.