Telephone-Based Guideline-Directed Medical Therapy Optimization in Navajo Nation: The Hózhó Randomized Clinical Trial.

Autor:	Eberly LA; Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico.; Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia.; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia.; Penn Cardiovascular Center for Health Equity and Social Justice, University of Pennsylvania, Philadelphia.; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia., Tennison A; Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico., Mays D; Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico., Hsu CY; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee., Yang CT; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee., Benally E; Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico., Beyuka H; Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico., Feliciano B; Office of Quality, Division of Innovations and Improvement, Indian Health Service Headquarters, Rockville, Maryland., Norman CJ; Office of Quality, Division of Innovations and Improvement, Indian Health Service Headquarters, Rockville, Maryland., Brueckner MY; Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico., Bowannie C; Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico., Schwartz DR; Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia.; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania., Lindsey E; Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico., Friedman S; Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico., Ketner E; Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico., Detsoi-Smiley P; Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico., Shyr Y; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee., Shin S; Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico.; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts.; Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts., Merino M; Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico.
Jazyk:	angličtina
Zdroj:	JAMA internal medicine [JAMA Intern Med] 2024 Jun 01; Vol. 184 (6), pp. 681-690.
DOI:	10.1001/jamainternmed.2024.1523
Abstrakt:	Importance: Underutilization of guideline-directed medical therapy for heart failure with reduced ejection fraction is a major cause of poor outcomes. For many American Indian patients receiving care through the Indian Health Service, access to care, especially cardiology care, is limited, contributing to poor uptake of recommended therapy. Objective: To examine whether a telehealth model in which guideline-directed medical therapy is initiated and titrated over the phone with remote telemonitoring using a home blood pressure cuff improves guideline-directed medical therapy use (eg, drug classes and dosage) in patients with heart failure with reduced ejection fraction in Navajo Nation. Design, Setting, and Participants: The Heart Failure Optimization at Home to Improve Outcomes (Hózhó) randomized clinical trial was a stepped-wedge, pragmatic comparative effectiveness trial conducted from February to August 2023. Patients 18 years and older with a diagnosis of heart failure with reduced ejection fraction receiving care at 2 Indian Health Service facilities in rural Navajo Nation (defined as having primary care physician with 1 clinical visit and 1 prescription filled in the last 12 months) were enrolled. Patients were randomized to the telehealth care model or usual care in a stepped-wedge fashion, with 5 time points (30-day intervals) until all patients crossed over into the intervention. Data analyses were completed in January 2024. Intervention: A phone-based telehealth model in which guideline-directed medical therapy is initiated and titrated at home, using remote telemonitoring with a home blood pressure cuff. Main Outcomes and Measures: The primary outcome was an increase in the number of guideline-directed classes of drugs filled from the pharmacy at 30 days postrandomization. Results: Of 103 enrolled American Indian patients, 42 (40.8%) were female, and the median (IQR) age was 65 (53-77) years. The median (IQR) left ventricular ejection fraction was 32% (24%-36%). The primary outcome occurred significantly more in the intervention group (66.2% vs 13.1%), thus increasing uptake of guideline-directed classes of drugs by 53% (odds ratio, 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. Conclusions and Relevance: In this heart failure trial in Navajo Nation, a telephone-based strategy of remote initiation and titration for outpatients with heart failure with reduced ejection fraction led to improved rates of guideline-directed medical therapy at 30 days compared with usual care. This low-cost strategy could be expanded to other rural settings where access to care is limited. Trial Registration: ClinicalTrials.gov Identifier: NCT05792085.
Databáze:	MEDLINE
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