Stanford University School of Medicine, Stanford, CA.
Sutter Health, California Pacific Medical Center, San Francisco, CA.
J Card Fail. 2023 Jul;29(7):1000-1013. doi: 10.1016/j.cardfail.2023.03.012. Epub 2023 Mar 31.
Traditional approaches to guideline-directed medical therapy (GDMT) management often lead to delayed initiation and titration of therapies in patients with heart failure. This study sought to characterize alternative models of care involving nonphysician provider-led GDMT interventions and their associations with therapy use and clinical outcomes.
We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies comparing nonphysician provider-led GDMT initiation and/or uptitration interventions vs usual physician care (PROSPERO ID: CRD42022334661). We queried PubMed, Embase, the Cochrane Library, and the World Health Organization International Clinical Trial Registry Platform for peer-reviewed studies from database inception to July 31, 2022. In the meta-analysis, we used RCT data only and leveraged random-effects models to estimate pooled outcomes. Primary outcomes were GDMT initiation and titration to target dosages by therapeutic class. Secondary outcomes included all-cause mortality and HF hospitalizations.
We reviewed 33 studies, of which 17 (52%) were randomized controlled trials with median follow-ups of 6 months; 14 (82%) trials evaluated nurse interventions, and the remainder assessed pharmacists' interventions. The primary analysis pooled data from 16 RCTs, which enrolled 5268 patients. Pooled risk ratios (RR) for renin-angiotensin system inhibitor (RASI) and beta-blocker initiation were 2.09 (95% CI 1.05-4.16; I = 68%) and 1.91 (95% CI1.35-2.70; I = 37%), respectively. Outcomes were similar for uptitration of RASI (RR 1.99, 95% CI 1.24-3.20; I = 77%) and beta-blocker (RR 2.22, 95% CI 1.29-3.83; I = 66%). No association was found with mineralocorticoid receptor antagonist initiation (RR 1.01, 95% CI 0.47-2.19). There were lower rates of mortality (RR 0.82, 95% CI 0.67-1.04; I = 12%) and hospitalization due to HF (RR 0.80, 95% CI 0.63-1.01; I = 25%) across intervention arms, but these differences were small and not statistically significant. Prediction intervals were wide due to moderate-to-high heterogeneity across trial populations and interventions. Subgroup analyses by provider type did not show significant effect modification.
Pharmacist- and nurse-led interventions for GDMT initiation and/or uptitration improved guideline concordance. Further research evaluating newer therapies and titration strategies integrated with pharmacist- and/or nurse-based care may be valuable.
传统的指南指导下的医学治疗（GDMT）管理方法通常导致心力衰竭患者治疗的延迟启动和滴定。本研究旨在描述涉及非医师提供者主导的 GDMT 干预的替代护理模式，并探讨其与治疗使用和临床结局的关系。
我们对随机对照试验（RCT）和观察性研究进行了系统评价和荟萃分析，比较了非医师提供者主导的 GDMT 起始和/或滴定干预与常规医师治疗（PROSPERO 标识符：CRD42022334661）。我们从数据库开始到 2022 年 7 月 31 日，在 PubMed、Embase、Cochrane 图书馆和世界卫生组织国际临床试验注册平台上查询了同行评审研究。在荟萃分析中，我们仅使用 RCT 数据，并利用随机效应模型估计汇总结果。主要结局是根据治疗类别进行 GDMT 起始和滴定至目标剂量。次要结局包括全因死亡率和 HF 住院率。
我们共审查了 33 项研究，其中 17 项（52%）为随机对照试验，中位随访时间为 6 个月；14 项（82%）试验评估了护士干预，其余评估了药师的干预。主要分析汇总了来自 16 项 RCT 的数据，这些研究共纳入了 5268 名患者。肾素-血管紧张素系统抑制剂（RASI）和β受体阻滞剂起始的汇总风险比（RR）分别为 2.09（95%CI 1.05-4.16；I²=68%）和 1.91（95%CI 1.35-2.70；I²=37%）。RASI 和β受体阻滞剂的滴定结局相似（RR 分别为 1.99 和 2.22；95%CI 分别为 1.24-3.20 和 1.29-3.83；I²分别为 77%和 66%）。与起始使用盐皮质激素受体拮抗剂（RR 1.01；95%CI 0.47-2.19）无关。干预组的死亡率（RR 0.82；95%CI 0.67-1.04；I²=12%）和因 HF 住院率（RR 0.80；95%CI 0.63-1.01；I²=25%）较低，但这些差异较小，且无统计学意义。由于试验人群和干预措施存在中度至高度异质性，预测区间较宽。按提供者类型进行的亚组分析未显示出显著的效应修饰。
药师和护士主导的 GDMT 起始和/或滴定干预提高了指南的一致性。进一步评估新疗法和整合基于药师和/或护士的治疗的滴定策略可能具有价值。
