DASH-HF 研究：射血分数降低的心力衰竭患者的实用质量改进随机实施试验。
DASH-HF Study: A Pragmatic Quality Improvement Randomized Implementation Trial for Patients With Heart Failure With Reduced Ejection Fraction.
机构信息
Department of Medicine (A.V., A.N.), David Geffen School of Medicine at the University of California, Los Angeles.
Division of Cardiology (G.C.F., J.J.H., O.A., D.U., K.T., K.B., B.Z.), David Geffen School of Medicine at the University of California, Los Angeles.
出版信息
Circ Heart Fail. 2023 Sep;16(9):e010278. doi: 10.1161/CIRCHEARTFAILURE.122.010278. Epub 2023 Jul 26.
BACKGROUND
Heart failure is a prevailing diagnosis of hospitalization and readmission within 6 months, and nearly a quarter of these patients die within a year. Guideline-directed medication therapies reduce risk of mortality by 73% over 2 years; however, the implementation of these therapies to their target dose in clinical practice continues to be challenging. In 2020, the Veterans Affairs (VA) Health Care System developed a HF dashboard to monitor and improve outpatient HF management. The DASH-HF (Dashboard Activated Services and Telehealth for Heart Failure) study is a randomized, pragmatic clinical trial to evaluate proactive dashboard-directed telehealth clinics to improve the use and dosing of guideline-directed medication therapy for patients with heart failure with reduced ejection fraction not on optimal guideline-directed medication therapy within the VA.
METHODS
Three hundred veterans with heart failure with reduced ejection fraction met inclusion criteria with an optimization potential score (OPS) of 5 or less out of 10, representing nonoptimal guideline-directed medication therapy. The primary outcome was a composite score of guideline-directed medical therapy, the OPS, 6 months after the end of the intervention. Secondary outcomes included active prescriptions for each individual guideline-directed medical therapy class, HF-related hospitalizations, deaths, and clinician time per patient during the intervention clinics.
RESULTS
There was no significant difference between the intervention arm and usual care group in the primary outcome (OPS, 2.9; SD=2.1 versus OPS, 2.6, SD=2.1); adjusted mean difference 0.3 (95% CI, -0.1 to 0.7) or in the prespecified secondary outcomes for hospitalization and all-cause mortality for the intervention of proactive dashboard-based clinics.
CONCLUSIONS
A dashboard-based clinic intervention did not improve the OPS or secondary outcomes of hospitalization and all-cause mortality. There remains a larger opportunity to better target patients and provide more intensive follow-up to further evaluate the utility of proactive dashboard-based clinics for HF management and quality improvement.
REGISTRATION
URL: https://www.
CLINICALTRIALS
gov; Unique identifier: NCT05001165.
背景
心力衰竭是住院和 6 个月内再次入院的常见诊断，其中近四分之一的患者在一年内死亡。指南指导的药物治疗可将 2 年内的死亡率降低 73%；然而，在临床实践中，将这些治疗方法应用于目标剂量仍然具有挑战性。2020 年，退伍军人事务部（VA）医疗保健系统开发了一个心力衰竭仪表盘，以监测和改善门诊心力衰竭管理。DASH-HF（基于仪表盘的服务和心力衰竭远程医疗）研究是一项随机、实用的临床试验，旨在评估积极的基于仪表盘的远程医疗诊所，以改善退伍军人事务部心力衰竭射血分数降低的心力衰竭患者的指南指导药物治疗的使用和剂量，这些患者不在最佳指南指导药物治疗范围内。
方法
300 名心力衰竭射血分数降低的退伍军人符合纳入标准，优化潜力评分（OPS）为 10 分中的 5 分或以下，代表非最佳指南指导的药物治疗。主要结局是干预结束后 6 个月时指南指导的药物治疗综合评分和 OPS。次要结局包括每一种指南指导的药物治疗类别的活性处方、心力衰竭相关住院、死亡以及干预期间每位患者的临床医生时间。
结果
干预组与常规护理组在主要结局（OPS，2.9；SD=2.1 与 OPS，2.6，SD=2.1）、住院和全因死亡率的干预（主动基于仪表盘的诊所）方面无显著差异。调整后的平均差异为 0.3（95%CI，-0.1 至 0.7）或预设的次要结局。
结论
基于仪表盘的诊所干预并不能提高 OPS 或住院和全因死亡率的次要结局。仍有更大的机会更好地针对患者，并提供更密集的随访，以进一步评估积极的基于仪表盘的诊所在心力衰竭管理和质量改进方面的实用性。
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