PhD Candidate University of British Columbia, Canada
Background: Heart failure (HF) medications are underutilized despite high-quality evidence of benefits. Non-physician-led models of care may improve access to and utilization of medical therapy. Characterizing these models may help guide their effective implementation.
METHODS AND RESULTS: We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature for studies published between January 2005 and October 2024. We included studies evaluating non-physician-led models of HF medication management conducted at least partially in the outpatient setting. We excluded studies that focused only on the management of a single medication class or where physicians were the most responsible clinician for HF medication optimization.
From 5,330 records, we included 39 reports describing 31 studies with a total of 17,216 patients. All 31 studies included patients with reduced ejection fraction, while 17 included those with ejection fraction >40%. Two studies were randomized controlled trials and 29 were observational. Seventeen were published after 2020 and 21 were conducted in the United States.
HF medication optimization was performed by pharmacists (N=20 studies), nurse practitioners or nurse clinicians (N=3), and multiple healthcare professions (N=8). Medication management was conducted in-person (N=19 studies), remotely (N=6), and through a hybrid approach (N=6). Median appointment frequency and duration were every 2 weeks (range: every 1–4 weeks) and 30 minutes (range: 15–60 minutes), respectively. Of the four studies reporting follow-up duration by time, the median follow-up was three months (range: 3–6 months). Among the 9 studies reporting number of follow-up visits, the median was 2 (range: 1–6 visits). The non-physician-led models of care were associated with increased HF medication use compared to baseline across all classes, particularly for sacubitril-valsartan, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors, resulting in a net increase in optimal guideline-directed medical therapy use (+6% to +66% patients receiving optimal medical therapy; Figure 1).
Conclusion: Non-physician-led HF medication optimization models of care are associated with improved GDMT use compared to baseline; however there is substantial heterogeneity in implementation. Comparative studies are needed to identify the most effective and efficient implementation.
