Elsevier

American Heart Journal

Volume 200, June 2018, Pages 134-140
American Heart Journal

Clinical Investigation
Early impact of guideline publication on angiotensin-receptor neprilysin inhibitor use among patients hospitalized for heart failure

https://doi.org/10.1016/j.ahj.2018.01.009Get rights and content

Abstract

Background

On May 20, 2016, US professional organizations in cardiology published joint treatment guidelines recommending the use of angiotensin-receptor neprilysin inhibitor (ARNI) for eligible patients with heart failure with reduced ejection fraction (HFrEF). Using data from the Get With The Guidelines–Heart Failure registry, we evaluated the early impact of this update on temporal trends in ARNI prescription.

Methods

We analyzed patients with HFrEF who were eligible for ARNI prescription (EF ≤40%, no contraindications) and hospitalized from February 20, 2016, through August 19, 2016—allowing for 13 weeks before and after guideline publication. We quantified trends in ARNI use associated with guidelines publication with an interrupted time-series design using logistic regression and accounting for correlations within hospitals using general estimating equation methods.

Results

Of 7,200 eligible patient hospitalizations, 51.9% were discharged in the period directly preceding publication of the guidelines, and 48.1% were discharged after. Odds ratios of ARNI prescription at discharge were significantly higher in the postguideline period compared with the preguideline period in adjusted models (adjusted odds ratio 1.29, 95% CI 1.06-1.57, P = .01). However, there was no significant interaction between observed and expected ARNI use after guideline publication (Pinteraction = .14). Results were consistent using a 6-month before and after time frame.

Conclusions

The model suggested a small increase in ARNI use in HF patients being discharged from the hospital immediately after guideline release. However, the publication of national guidelines recommending ARNI use seemed to have little influence on the adoption of this evidence-based medication in the first 3 to 6 months.

Section snippets

Data sources

We used data from the Get With The Guidelines–Heart Failure (GWTG-HF) registry and the American Hospital Association survey. The details of the GWTG-HF registry have been previously described.9., 10. Briefly, GWTG-HF is a national quality improvement initiative sponsored by the American Heart Association and the American Stroke Association. Trained personnel at participating sites extract information on eligible patients hospitalized for HF and enter information into an online system. Registry

Results

Of 7,200 patients included in the primary analysis population (EF  40% and no recorded contraindication to ARNI use), 51.9% were discharged in the period directly preceding online publication of the guidelines (2/20/16-5/20/16), and 48.1% were discharged in the period directly after (5/21/16-8/19/16). Baseline characteristics of discharged patients by guideline period are shown in Table I. The distribution of age, race, gender, and insurance status was similar in both periods. Patients in the

Discussion

On May 20, 2016, the ACC/AHA published joint treatment guidelines recommending the use of ARNI for eligible patients with HFrEF. Based on the PARADIGM-HF trial, the ARNI sacubitril/valsartan reduced cardiovascular mortality or HF hospitalization in patients with HFrEF by 20%, and a prior analysis has shown that optimal implementation could have substantial benefits.17., 18. We evaluated the impact of this update on temporal trends in ARNI prescription among patients discharged from hospitals

Conclusions

Use of ARNI at hospitalization discharge is increasing over time but remains low.41 Publication of national guidelines recommending ARNI use in eligible patients did not appear to influence the rate of ARNI uptake among patients with HF discharged from the hospital in the first 3 to 6 months of release. Future studies are needed to identify barriers to guideline adherence in HF and accelerate diffusion of new evidence into practice.

Acknowledgements

The authors would like to thank the GWTG-HF staff and participants for their important contributions to this work.

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  • Sources of funding: This work was sponsored by Novartis Pharmaceuticals Corporation, East Hanover, NJ. Additionally, the Get With The Guidelines–Heart Failure (GWTG-HF) program is provided by the American Heart Association. GWTG-HF is sponsored, in part, by Amgen Cardiovascular and has been funded in the past through support from Medtronic, GlaxoSmithKline, Ortho-McNeil, and the American Heart Association Pharmaceutical Roundtable.

    Disclosures: E. C. O. receives research support from Janssen, Pfizer, GSK, Novartis, Sanofi, and Bristol Myers Squibb.

    L. H. C. receives research support from NIH, PCORI, Novartis, GlaxoSmithKline, Gilead, Boston Scientific, and St Jude.

    C. L. C. is an employee of Novartis Pharmaceuticals Corporation and owns stock in Novartis AG.

    A. F. H. receives research support from AstraZeneca, Bristol-Myers Squibb, GlaxoSmithKline, Luitpold Pharmaceuticals, Merck, and Novartis and honoraria from Bayer, Boston Scientific and Novartis.

    G. C. F. receives research funding from NIH and consulting funding from Amgen, Janssen, Medtronic, Novartis, and St Jude Medical.

    All other authors have no relevant disclosures.

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