Dashboard Activated Services and Tele-Health for Heart Failure (DASH-HF)

The Dashboard Activated Services and tele-Health for Heart Failure (DASH-HF) study is a pragmatic randomized controlled trial of a quality improvement (QI) intervention of a prospective panel management intervention to optimize medical treatment for Veterans with heart failure with reduced ejection fraction (HFrEF) compared to the receipt of usual VA health care services over a 6-month period of observation. The study will incorporate the existing VA Academic Detailing Heart Failure Dashboard (ADHFD) to target actionable patients with gaps in performance measures for guideline-directed medical therapies (GDMT). Patients with HFrEF are optimally managed by cardiovascular specialty clinics. Typically, patients are referred to cardiology or heart failure (HF) clinics from primary care, emergency department, or post-hospitalization clinicians and scheduled into clinic grids. These patients may be lost to follow-up or clinicians may miss opportunities to optimize GDMT for HFrEF. GDMT includes Class I indicated medications from the following classes: beta blockers (BB), angiotensin-converting enzyme inhibitor (ACE), angiotensin II receptor blockers (ARB), angiotensin receptor neprilysin inhibitor (ARNI), mineralocorticoid receptor antagonist (MRA), sodium-glucose cotransporter-2 inhibitor (SGLT2i). The intervention is designed around a novel prospective panel management clinic led by clinicians or clinical pharmacists using impromptu patient telephone calls or electronic communications with existing responsible clinicians.

Study Overview

• Status: Completed
• Conditions: Heart Failure With Reduced Ejection Fraction
• Intervention / Treatment: Other: Proactive Panel Management Clinics for HFrEF

Detailed Description

This is a randomized, pragmatic QI study designed to evaluate the effectiveness of proactive panel management to close gaps in evidence-based care for patients with HFrEF. The investigators will use the VA's ADHFD to generate a list of actionable patients with HFrEF and left ventricular ejection fraction (LVEF) ≤ 35%. After identifying a cohort of HFrEF patients from the ADHFD, the investigators will randomize individual patients on the actionable list to usual VA care or a novel proactive panel management clinic. Clinicians will be trained on how to use the dashboard information to identify opportunities for optimization based on detailed chart review. The proactive panel management intervention will use clinicians to perform an electronic chart review and call patients impromptu at their discretion to evaluate HFrEF management and opportunities to optimize GDMT. Each panel management clinic is staffed by a single cardiovascular clinician or trainee with cardiology (PI) supervision. All patients will receive chart review or telehealth notes brought to the attention of primary care and cardiology clinicians. Patients randomized to the intervention will only receive one chart review during a half-day panel management clinic with follow-up of any laboratory results or diagnostic tests as required and referral to HF or general cardiology clinic as deemed appropriate. The control arm consists of the usual delivery of health services with routine scheduled appointments for primary care or cardiology.

Outcomes will be assessed at 6-months from the last patient to receive the intervention. The study is powered to detect superiority of the intervention compared to usual care in optimizing GDMT for HFrEF. Treatment assignment is based on 1:1 randomization using fixed blocks (size=6) to assure an equivalent number of patients randomized to the intervention and usual care. Patients are randomized after a list of 300 actionable patients are generated from the ADHFD. Study participant numbers will be assigned to the list of patients sorted by optimization scores in Excel. The supervising statistician (AA) will generate concealed randomization assignments by participant identification numbers. The randomization assignments will be merged with baseline study dataset and exported as password protected Excel and PDF documents. Study investigators will divide the intervention arm into lists of 10 to 15 per half-day clinic. Patients not receiving chart review or phone call attempts will be reassigned to future panel management clinics until all patients receive the intervention. Patients that did not answer phone calls will receive chart review notes for primary care and cardiology clinicians and not be reassigned to future panel management clinics.

Study participants do not require informed consent as determined by the VA IRB review. Patients will receive all accepted standards of care and medications approved by the Food and Drug Administration for HFrEF indications. The VA Subcommittee for Research and Safety found an absence of any declared research-laboratory-based biohazards and granted exemption from continued review. The study will evaluate the effectiveness of the QI intervention, telephone/telemedicine panel management clinics, to more rapidly implement evidence-based care for patients with HFrEF. Patients in the usual care arm will be unaware they are part of the control group for the RCT. Intervention patients nor study staff are blinded to usual care or intervention assignments. Patients that receive the intervention will be informed this is a pilot quality improvement effort with informal consent before proceeding to the clinical interventions. Intervention patients may refuse to participate after being contacted by phone in the intervention.

Study enrollment is based on the inclusion and exclusion criteria used to filter the ADHFD list. A list of actionable patients with HFrEF will be exported for randomization. The GDMT optimization score will be automated for each patient on the extracted list (Table 1). A sample of 300 patients will be selected with the lowest GDMT composite scores. Once the final sample of the study is determined, patients will be randomized to usual care or the intervention. Intervention patients will be divided into smaller lists of 10 to 15 patients. These smaller lists will be assigned to proactive panel management clinics. Clinicians staffing the intervention clinics will review ADHFD data, review the electronic health record (EHR) and decide whether to proceed to evaluate and recommend treatment over the phone to patients directly. If clinicians did not have sufficient time to review all patients on their clinic list, they will be redistributed to future intervention clinics. Intervention clinics will be held until each patient assigned the intervention has a chart review or attempted telephone contact. A failure to contact a patient will trigger a letter to a patient or electronic communication to their primary care or cardiology clinician.

Prior to each ADHFD telehealth clinic (half-day clinic lasting 4 to 4.5 hours), clinicians will be sent a secure email that will include a password-protected Excel document of 15 patients with exported clinical summary data from the ADHFD. Clinicians will be instructed to chart-review patients and decide if an opportunity exists to further optimize the receipt of GDMT. Clinicians will also be given a document providing guidance on the sequence of GDMT optimization based on latest guidelines and VA policies (Supplement S1 GDMT Guidance Document). If a patient does not qualify for further optimization (i.e. chart documentation of prior intolerance, patient preference), a short note in the electronic health record (EHR) will document the chart review and inform the primary care clinician that based on chart review, no opportunity currently exists but they may consider further GDMT titration in the future. If a patient appears to have an opportunity for further titration, the clinician is encouraged to call the patient to see if they are available to discuss their HF care. If the patient agrees, a telehealth visit will take place over phone or switch to video. A formal telehealth cardiology visit will occur at the time of care. If the patient is interested but does not have time for a visit, a brief telephone note will be placed and a request for a future cardiology clinic visit will be requested. If a formal telehealth visit occurs, clinicians will be asked to inquire about key details around medication titration (Supplement S2 Interview Guide). The data from chart review and interviews will be documented on a password-protected Excel document (Supplement S3 Clinician Documentation Form). Any medication addition or titration will have indicated laboratory labs ordered per usual care. Lastly, clinicians will also be asked to administer a short survey with each participant based on a template at the end of the call proactive phone call (Supplement S2 Interview guide). Primary care and regular cardiology clinicians will be notified of any changes in medication management in the EHR. The study's lead (BZ, AV) will be available by phone to answer questions or problems that arise during the clinic. Supervision of patient encounters by clinical pharmacists, medical trainees, or advanced practice nurse practitioners and study protocols will be BZ as the licensed and boarded general cardiologist.

• Study Type: Interventional
• Enrollment (Actual): 300
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • California
    • Los Angeles, California, United States, 90048
      • VA West Los Angeles

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Facility: Greater Los Angeles, CA
• Division: West LA VAMC
• Patient is eighteen years of age or older
• Patients has a primary diagnosis of HFrEF (last documented LVEF ≤35% per ADHFD algorithms)
• Patient has an estimated GFR greater than or equal to 30 mL/min
• Patient has a last documented potassium less than 5
• Patient has a last documented systolic blood pressure over 90 mm Hg
• Patient lacks at least one active prescription of a beta-blocker, ACE/ARB/ARNI, MRA, or SGLT2i
• There are no upcoming heart failure or primary care appointments in the upcoming 2 weeks.

Exclusion Criteria:

● Patient is currently hospitalized at WLA

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Intervention; Patients with perceived gaps in performance measures for guideline-directed medical therapies for heart failure with reduced ejection fraction will be chart-reviewed and called impromptu to receive point of care medication titration or reintegration into routine heart failure clinic. Patients lost to follow-up may be better identified using the HFrEF panel management tools.	Other: Proactive Panel Management Clinics for HFrEF; Novel clinic based on review of panel HFrEF data and impromptu telephone or video patient contacts/visits.
No Intervention: Usual Care; A control group of patients with HFrEF will receive routine primary and cardiology care as currently indicated in routine scheduled clinic grids. Patients are at the discretion of their primary care and cardiology clinicians regarding whether further HFrEF optimization is warranted. While panel management data is available to all clinicians, clinical workflows and responsibilities do not encourage the use of panel data or response to performance measurement for HFrEF.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Optimization Potential Score	Change in composite score created for reaching target doses of guideline-directed medical therapies for HFrEF compared between treatment arms at the end of the study. Optimization Potential Scores ranges from 0 (least optimized) to 10 (full-optimized).	6-months after all patients receive the intervention

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Total Deaths	Total number of all-cause deaths compared between treatment arms at the end of the study.	6-months
Change in Number of Patient Receiving ACE/ARB/ARNI	Number of patients that receive an active prescription for angiotensin-converting enzyme inhibitor (ACE), angiotensin II receptor blockers (ARB), or angiotensin receptor neprilysin inhibitor (ARNI) compared between treatment arms at the end of the study.	6-months after all patients receive the intervention
Change in the Number of Patients Receiving Beta-blockers	Number of patients that receive an active prescription for beta-blockers compared between treatment arms at the end of the study.	6-months after all patients receive the intervention
Change in the Number of Patients Receiving MRA	Number of patients that receive an active prescription for mineralocorticoid receptor antagonist (MRA) compared between treatment arms at the end of the study.	6-months after all patients receive the intervention
Change in Number of Patients Receiving ARNI	Number of patients that receive an active prescription for angiotensin receptor neprilysin inhibitor (ARNI) compared between treatment arms at the end of the study. .	6-months after all patients receive the intervention
Change in Number of Patients Receiving SGLT2i	Number of patients that receive an active prescription for sodium-glucose cotransporter-2 inhibitor (SGLT2i) compared between treatment arms at the end of the study. .	6-months after all patients receive the intervention
Total Number of Hospitalizations	Total number of any cause hospitalizations compared between treatment arms at the end of the study.	6-months

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Qualitative Analysis of Patient Satisfaction	For only patients that received the intervention, we perform an informal survey of patient feelings about the telehealth intervention scaled from a range of 0 to 10 for satisfaction at the end of the visit. Zero represents no satisfaction with the intervention and 10 being complete satisfaction with the intervention. Control patients do not receive a survey question, since they did not receive the intervention.	At the end of the successful telehealth intervention. On average within one month of randomization.
Average Number of Patients Contacted Per Half-day Clinic	Average number of patients reviewed or contacted per half-day clinic to understand health services efficiency	After intervention is delivered (post-baseline) - on average within 1 month of randomization.
Clinician Time Per Patient	This is estimated only for the intervention arm. Control patients did not receive the intervention so no time was spent per patient to compare. Clinician time spent per patient from opening chart to end of patient-specific intervention and documentation.	After intervention delivery (post-baseline). Within 1 month of the intervention on average.
Average Number of Orders Placed Per Clinic	Average medication adjustments (stop, start, titration) per half-day clinic; Average laboratory tests ordered per half-day clinic; Average imaging/diagnostic procedures ordered per half-day clinic; Average of referrals for consults/device therapy per half-day clinic	After intervention clinic delivered - on average within one month of randomization.

Collaborators and Investigators

• Sponsor: VA Greater Los Angeles Healthcare System
• Investigators: Principal Investigator: Boback Ziaeian, MD PhD, VA Greater Los Angeles Healthcare System

Publications and helpful links

General Publications

• Verma A, Fonarow GC, Hsu JJ, Jackevicius CA, Mody FV, Amidi O, Goldberg S, Upparapalli D, Theodoropoulos K, Gregorio S, Chang DS, Bostrom K, Althouse AD, Ziaeian B. The design of the Dashboard Activated Services and Telehealth for Heart Failure (DASH-HF) study: A pragmatic quality improvement randomized implementation trial for patients with heart failure with reduced ejection fraction. Contemp Clin Trials. 2022 Sep;120:106895. doi: 10.1016/j.cct.2022.106895. Epub 2022 Aug 24.

Study record dates

Study Major Dates

• Study Start (Actual): September 17, 2021
• Primary Completion (Actual): June 16, 2022
• Study Completion (Actual): June 16, 2022

Study Registration Dates

• First Submitted: June 30, 2021
• First Submitted That Met QC Criteria: August 3, 2021
• First Posted (Actual): August 11, 2021

Study Record Updates

• Last Update Posted (Estimated): November 14, 2024
• Last Update Submitted That Met QC Criteria: October 18, 2024
• Last Verified: October 1, 2024

More Information

Terms related to this study

• Keywords: heart failure; proactive outpatient management; learning health system; panel management; medical optimization
• Additional Relevant MeSH Terms: Cardiovascular Diseases; Heart Diseases; Heart Failure
• Other Study ID Numbers: 2020-000311

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No