Creating A Cardiorenal Multidisciplinary Team for Management HF and CKD Patients

Study Summary

Several drugs have been labeled as guideline-directed-medical therapies (GDMT) to improve overall health outcomes and slow the progression of disease in patients with heart failure (HF). Although scientific trials have deemed these drugs to be successful, many HF patients have been unable to either get started on the appropriate drug regimens or be optimized on the doses required to show substantial benefit, particularly in those who also suffer from chronic kidney disease (CKD). This is largely due to the current health care delivery model that requires a primary care clinician or general internist to refer patients to heart failure specialists and nephrologists. The specialty care itself then requires even more coordination resulting in patients getting lost to follow-up, physicians losing track of recommendations from different clinics, and too many separate electronic medical documentations to consolidate prior to deciding on what medication is appropriate at one thirty-minute outpatient visit. This study plans to create a new, virtual cardio-renal multidisciplinary team including a heart failure specialist and nephrologist to ease the coordination of care and consequently show a better implementation of GDMT in patients with HF and CKD when comparing those rates to the traditional referral-based way that these medications get prescribed.

Primary Outcome

Given that increased SGLT2i is likely to be the major driver of improved clinical outcomes in patients with heart failure and chronic kidney disease, the primary outcome of interest is the difference in rate of SGLT2i use between multidisciplinary care model versus usual care model at 3 months and 6 months.

Interventions

• BEHAVIORAL Multidisciplinary Care Coordination Team