heart failure: optimizing medical therapy and patient … · 2020. 7. 14. · heart failure:...

Heart Failure: Optimizing Medical Therapy and Patient Communication

Final Live Activities Outcomes Report

Clinical Updates for Nurse Practitioners and Physician Assistants: 2018

January 22, 2019Novartis Pharmaceuticals Corporation Grant ID: NGC34028

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Impact

Pre to Post Test Results By Learning Objective (LO)v LO1: 22% Improvement in recognizing the role of laboratory testing and

imaging in the evaluation and management of HF

v LO2: 45% Decrease in reliably assessing symptom burden in patients with HF

v LO3: 152% Improvement in implementing ACC/AHA/HFSA guideline directed medical therapy in the management of chronic heart failure

v LO4: 60% Improvement in recognizing strategies to reduce hospitalization and readmission for HF

v 2,365 attendees were reached via both online and live formats, with significant gains observed across profession and specialty cohorts, and modalities, all from Pre-Test to Post-Test.

v Despite their improvements, learners remain challenged in the selection of treatment for patients with a HFrEFdiagnosis, patient characteristics that indicate increased risk for hospital readmission for HF, and the identification of NYHA functional class for HF patients.

v Despite net gains in Competence, Confidence, and practice strategy, learners failed to retain an increased understanding of HF management as measured by the Post Curriculum 4-week Assessment, where low scores were observed in the Knowledge, Competence, and Performance domains.

Executive Summary2,365*Total Attendees

9 Cities

1,288*On Site

1,077*Simulcast / Virtual Symposium

0%20%40%60%80%

100%

LO 1 LO 2 LO 3 LO 4

Pre-Test Post-Test-45.14%*+22.25%* +151.57%*

(N = 473–569)

v This curriculum focused on the management of patients with Heart Failure (HF), including risk factors for hospitalization and treatment selection.

v Substantial improvements were measured in learners’ understanding of ACC/AHA/HFSA guidelines on medical therapy and strategies to reduce hospitalization.

*These numbers represent the total number of attendees, irrespective of assessment participation

+59.79%*


Curriculum Patient Impact

15,136–19,866 patients on a weekly basis

The findings reveal that this education has the potential to impact

910,052patients on an annual basis.

15,136–19,866

In the evaluation, learners (N = 2,365) were asked to report how many patients with HF they see in any clinical setting per week. The resulting distribution of learner responses was then extrapolated to reflect the total number of learners who attended the onsite and online meetings.


Faculty

Activity Planning CommitteeGregg Sherman, MD

Michelle Frisch, MPH, CCMEP

Stephen Webber

Sandy Bihlmeyer M.Ed

Alan Goodstat, LCSW

Debora Paschal, CRNP

Daniela Hiedra

Jan Basile, MDProfessor of Medicine

Seinsheimer Cardiovascular Health Program

Medical University of South Carolina

Ralph H Johnson VA Medical Center

Charleston, SC

Maria Galvao, NPCenter for Advanced Cardiac Therapy

Montefiore Medical Center

Bronx, NY

Robert L. Gillespie, MD, FACC, FASE, FASNCImmediate Past Chairman of the Board

Association of Black Cardiologists, Inc.

Director of Nuclear Imaging

Sharp Rees-Stealy Medical Group

San Diego, CA

Barbara Hutchinson, MD, PhD, FACCImmediate Past President, Association of

Black Cardiologists

President, Chesapeake Cardiac Care

Annapolis, MD

Eldrin F. Lewis, MD, MPHAssociate Professor of Medicine

Harvard Medical School

Brigham and Women’s Hospital

Director, Cardiovascular Clerkship Program

Boston, MA

Alanna A. Morris, MD, MSc, FHFSAAssistant Professor of Medicine

Division of Cardiology

Emory University School of Medicine

Atlanta, GA

Course Director

Eldrin F. Lewis, MD, MPH

Alanna A. Morris, MD, MSc, FHFSA

Faculty


Commercial SupportThe Clinical Updates for Nurse Practitioners and Physician Assistants: 2018 series of CME activities were supported through educational grants or donations from the following companies:

vActelion Pharmaceuticals US, Inc

vSanofi US

vGrifols

vNovartis Pharmaceuticals Corporation

vGlaxoSmithKline

vFerring Pharmaceuticals, Inc.

vMerck Sharp & Dohme Corp.


Overview


Curriculum Overview

Clinical Highlights eMonograph -

eMonograph containing key teaching points

from the CME Activity was distributed 1 week

after the meeting to all attendees.

9 Accredited Live Regional Symposia

September 8, 2018 – November 10, 2018

1 Accredited Live Virtual Symposium:

November 17, 2018

Online Interactive Enduring CME Activity :

vLaunch Date: October 31, 2018

vEnd Date: October 30, 2019

vHosted at: http://naceonline.com/CME-

Courses/course_info.php?course_id=1051

http://naceonline.com/CME-Courses/course_info.php?course_id=1051


Learning Objectives

v Recognize the role of laboratory testing and imaging in the evaluation and management of HF

v Reliably assess symptom burden in patients with HF

v Implement ACC/AHA/HFSA guideline-directed medical therapy in the management of chronic HF

v Recognize strategies to reduce hospitalization and readmission for HF


Learning outcomes were measured using matched Pre-Test and Post-Test scores for Knowledge, Competence, Confidence, practice strategy, and Performance, and across all of the curriculum’s Learning Objectives.

Outcomes Metric Definition Application

Percentage change This is how the score changes resulting from the education are measured. The change is analyzed as a relative percentage difference by taking into account the magnitude of the Pre-Test average.

Differences between Pre-Test, Post-Test, and PCA score averages

P value (p) This is the measure of the statistical significance of a difference in scores. It is calculated using dependent or independent samples t-tests to assess the difference between scores, taking into account sample size and score dispersion. Differences are considered significant for when p ≤ .05.

Significance of differences between Pre-Test, Post-Test, and PCA scores and among cohorts

Effect size (d) This is a measure of the strength/magnitude of the change in scores (irrespective of sample size). It is calculated using Cohen's d formula, with the most common ranges of d from 0-1: d < .2 is a small effect, d=.2-.8 is a medium effect, and d > .8 is a large effect.

Differences between Pre-Test and Post-Test score averages

Power This is the probability (from 0 to 1) that the “null hypothesis” (no change) will be appropriately rejected. It is the probability of detecting a difference (not seeing a false negative) when there is an effect that is dependent on the significance (p), effect size (d), and sample size (N).


Percentage non-overlap This is the percentage of data points at the end of an intervention that surpass the highest scores prior to the intervention. In this report, it will reflect the percentage of learners at Post-Test who exceed the highest Pre-Test scores.


Outcomes Methodology


2018 Clinical Updates Participation

2018 Symposium/Simulcast Date Attendees

White Plains, NY 9/8/18 189Orlando, FL 9/15/18 199Seattle, WA 9/22/18 103

Philadelphia, PA (King of Prussia) 10/6/18 79Anaheim, CA 10/13/18 98Charlotte, NC 10/20/18 115Phoenix, AZ 10/27/18 116

Phoenix, AZ simulcast 10/27/18 550Dallas, TX 11/3/18 260Miami, FL 11/10/18 129

Virtual 11/17/18 527Total 2,365


Level 1 Participation

Demographics Patient Reach

2,365*Total Attendees

9 Cities

1,288*On Site

1,077*Simulcast / Virtual Symposium

Participation

*These numbers represent the total number of attendees, irrespective of assessment participation


73.60%

9.97% 9.79%3.32% 2.80% 0.52%

NP PA MD RN Other DO

Profession Years in Practice

Patient Care Focus: 95%

36.99%

21.79% 19.59% 21.62%

< 5 5–10 11–20 > 20

Level 1: Demographics and Patient Reach

74.66%

6.90% 6.03% 4.31% 8.10%

Primary Care-Family Practice,Internal Medicine

Other Cardiology EmergencyMedicine/ Critical

Care

Specialty above

Specialists:Hospitalist 3.62%Endocrinology 2.41%Psychiatry/Neurology 0.69%Pulmonology 0.69%Gastroenterology 0.52%Rheumatology 0.17%

Patients with HF seen each week, in any clinical setting:

6.12%2.75%

6.62%9.99%

18.35%36.20%

19.98%

0% 10% 20% 30% 40%

> 25

21–25

16–20

11–15

6–10

1–5

None

Specialty

Average number of patients seen each week with HF per clinician: 7.4


Level 2-5:Outcomes Metrics


71.94%(44.93%)

30.44%(46.02%)

27.94%(44.87%)

39.87%(48.96%)

87.95%(32.55%)

16.70%(37.30%)

70.30%(45.69%) 63.71%

(48.08%)

Recognize the role of laboratory testingand imaging in the evaluation and

management of HF

Reliably assess symptom burden inpatients with HF

Implement ACC/AHA/HFSA guidelinedirected medical therapy in the

management of chronic heart failure

Recognize strategies to reducehospitalization and readmission for HF

Learning Objectives AnalysisLearning Objective 1 Learning Objective 2 Learning Objective 3 Learning Objective 4

v Substantial and significant gains (ranging from 22% to 152%) were achieved on three of the four Learning Objectives.

• A question about identification of NYHA functional class was the only item included in the remaining Learning Objective, about the assessment of symptom burden in patients with HF. Across all participants, there was a decrease of 45% on this question, but with a high degree of variability across venues (-80% to +125% changes). Some venues had substantial increases (100% and 125% increase in Charlotte and Anaheim, respectively), others remained quite low (8% to 45% at Post-Test, for all venues). This demonstrates that identification of NYHA functional class is a particularly challenging subject, which can be addressed with effective education.

(N = 473–569)

Pre-Test Post-Test

+22.25%* -45.14%* +151.57%* +59.79%*

*significant at the p ≤ 0.05 level


Learning Domain Analysis(N = 485–785)

Pre-Test Post-Test

v Significant gains (ranging from 11% to 101%) were achieved in all learning domains.

v The strong decrease in score on a single Performance item about identification of NYHA functional class lessened the increase in measured learner Performance (11%).

v Learners improved their Knowledge scores from 72% at Pre-Test to 88% at Post-Test. Notably, due to mastery on a question about non-invasive tests recommended for patients with HF.

v The substantial increases on the Confidence and practice strategy ratings reflect the increases in reported Confidence to incorporate new HF therapies into clinical practice and the intent to use objective measurements of functional class to determine symptom burden in patients with HF.

v Though score increases were significant in all learning domains, Post-Test scores remained low, especially in the Competence and Performance domains, indicating a need for further practical and case-based education on the management of HF.

71.94%(44.93%)

33.15%(41.10%)

59.15%(35.20%)

87.95%(32.55%)

66.71%(41.75%)

65.45%(32.36%)

Knowledge Competence Performance

*significant at the p ≤ 0.05 level, matched data

+22.25%* +101.27%*

2.17(0.99)

2.70(1.16)

3.07(0.93)

3.87(0.97)

Confidence Practice

+10.64%* +41.46%* +43.39%*


Curriculum/Activity Intervention Effect

Learning Domain Effect Size* % Non-OverlapKnowledge 0.408 27.60%

Competence 0.810 51.36%

Performance 0.186 17.65%

Effect Size Definition: This is a standardized measure of the strength/magnitude of the change in scores, irrespective of sample size. This metric quantifies the association between outcome and exposure to education, in a way which makes meta-analysis possible. There exist many types of effect size measures, each appropriate in different situations. We select Cohen’s d for this analysis, which is a standardized difference in mean. Most commonly, d ranges from 0–1: d < 0.2 is a small effect, d = 0.2–0.8 is a medium effect, and d > 0.8 is a large effect.


Learning DomainNurse Practitioner Physician

N Pre-Test Post-Test % Change N Pre-Test Post-Test % Change

Knowledge 196 75.00%(43.30%)

90.82%(28.88%) +21.09%* 22 77.27%

(41.91%)100.00%(0.00%) +29.41%*

Competence 230 33.04%(39.50%)

69.35%(41.25%) +109.87%* 28 53.57%

(39.93%)73.21%

(36.55%) +36.67%

Confidence 171 2.06(1.00)

2.92(0.91) +42.05%* 20 2.70

(0.64)3.45

(0.80) +27.78%*

Practice 158 2.75(1.11)

3.80(0.88) +38.25%* 20 3.20

(0.75)4.40

(0.49) +37.50%*

Performance 243 57.96%(32.78%)

64.88%(28.65%) +11.95%* 30 60.83%

(28.48%)64.72%

(26.67%) +6.39%

Learning Domain by Professional Cohort

v Nurse practitioners (NPs) demonstrated statistically significant gains in all learning domains. Physicians also demonstrated increases in all learning domains, which were significant in Knowledge, Confidence, and practice strategy.

v In all learning domains physicians demonstrated higher Post-Test scores than NPs; however, in Performance, their scores were comparable.

v Results for physicians should be interpreted with some caution due to the small sample size (N=20-30).



*significant at the p ≤ 0.05 level; unmatched data

At follow-up:

v Statistically significant net gains were measured from Pre-Test to the Post Curriculum Assessment (PCA) in Competence, Confidence, and practice strategy. Modest score decreases were measured in Knowledge and Performance.

v The lowest PCA score was observed in the Competence domain, where comparably low averages were shown on both questions.

v The low PCA score in the Performance domain was largely impacted by the item about identifying NYHA functional class, where Pre- and Post-Test scores varied widely by city.

4-Week Retention Analysis

71.94%(44.93%)

33.15%(41.10%)

59.15%(35.20%)

87.95%(32.56%)

66.71%(41.75%)

65.45%(32.36%)

65.91%(47.45%)

34.60%(47.59%)

58.47%(49.29%)

0%20%40%60%80%

100%

Knowledge Competence PerformancePre-Test Post-Test PCA

+4.37%*

2.17(0.99)

2.70(1.16)

3.07(0.93)

3.87(0.97)

2.64(0.93)

3.46(1.10)

1.00

2.00

3.00

4.00

Confidence PracticePre-Test Post-Test

-8.38%* +21.66%* +28.15%*

(N = 503)

-1.15%


Pharmacotherapy Patient education Disease state awareness

Diagnostic evaluation Screening protocols

(4-week Post Assessment)

72% 74% 78%

51%62%

Sample Size: N = 503

Please select the specific areas of skills, or practice behaviors, you have improved regarding the treatment of patients with CHF since this CME activity. (Select all that apply)


Medication costs Insurance/financial issues Patient adherence/

compliance

Formulary restrictions Time constraints

What specific barriers have you encountered that may have prevented you from successfully implementing strategies for patients with CHF since this CME activity? (Select all that apply) (4-week Post Assessment)

56% 47% 44%

61%46%

Sample Size: N = 503


The majority of learners also incorrectly answered Performance items about the use of ivabradine, lisinopril, and sacubitril/valsartan for patients with HFrEF.

69-y/o man p/w progressive dyspnea on exertion, fatigue, and peripheral edema. C/O dyspnea when he walks uphill or carries heavy items. PMHX: hypertension, dyslipidemia, and NSTEMI 2 years ago. Exam: BP 104/70, HR 66 bpm, jugular venous distension, lungs CTA, moderate edema. CXR shows cardiomegaly. Meds: lisinopril/hydrochlorothiazide 20/25 mg qd, atorvastatin 80 mg qd, metoprolol succinate 100 mg qd, and aspirin 81 mg qd.

Based on the clinical scenario, please rate this statement as consistent with or not consistent with your current clinical practice:

If the patient is diagnosed with HFrEF, consider adding ivabradine:

• At Post-Test, only 44% of learners correctly answered: “No, it is not consistent.”

If the patient is diagnosed with HFrEF, consider discontinuing lisinopril and starting sacubitril/valsartan:

• At Post-Test, only 56% of learners correctly answered: “Yes, it is consistent.”

Identified Learning Gaps: Treatment selection for patients with a history of HF

On a Competence question presenting a patient with a history of heart failure and who is taking a variety of medications, learners remained challenged on whether hydralazine/ISDN should also be considered.

62 y/o AA woman with 2 yr. history of HF with EF 30% presents for a checkup. Workup: BP 110/76 mmHg, HR 68 bpm, eGFR 50 mL/min/1.73m2, and mild edema. Other findings are WNL. She reports fatigue and shortness of breath when she does chores or walks. Meds: carvedilol, lisinopril, spironolactone, and aspirin. According to guidelines, the addition of which of the following agents could be considered for this patient?• At Post-Test, only 70% of learners correctly answered: “Hydralazine/ISDN.”


Learners also demonstrated a low Post-Test score on a Competence question that addressed patient characteristics that predict 30-day readmission for HF.

A 70-year-old African American woman with HFrEF (EF 30%), hypertension, dyslipidemia, and type 2 diabetes is discharged following treatment for acute HF. On discharge, her hemoglobin is 10 g/dL, sodium 135 mEq/L, heart rate 68 bpm, and respiratory rate 16 bpm. All of the following findings in this case have been demonstrated to predict 30-day readmission for HF, EXCEPT:

• At Post-Test, only 58% of learners correctly answered: “Respiratory rate.”

Identified Learning Gaps:

Patient characteristics that predict hospital readmission for HF


Identified Learning Gaps: Evaluation of NYHA functional class in HF patients

On the Performance item which presented the workup of a patient with a history of heart failure, most learners failed to accurately classify the patient as NYHA functional class III.

69-y/o man p/w progressive dyspnea on exertion, fatigue, and peripheral edema. C/O dyspnea when he walks uphill or carries heavy items. PMHX: hypertension, dyslipidemia, and NSTEMI 2 years ago. Exam: BP 104/70, HR 66 bpm, jugular venous distension, lungs CTA, moderate edema. CXR shows cardiomegaly. Meds: lisinopril/hydrochlorothiazide 20/25 mg qd, atorvastatin 80 mg qd, metoprolol succinate 100 mg qd, and aspirin 81 mg qd.

Based on the clinical scenario, please rate this statement as consistent with or not consistent with your current clinical practice:

Identify NYHA functional class III.

• At Post-Test, only 16% of learners correctly answered: “No, it is not consistent.”


Overall Educational Impactv Significant improvements (ranging from 11% – 101%) were seen across all learning domains.

• The cohort analysis of professions showed that physicians demonstrated higher Post-Test scores than NPs in all learning domains except Performance, in which scores were comparable (both 65%).

• Live onsite learners demonstrated higher Post-Test averages than live online participants in all learning domains.

• Analysis of learning retention in the PCA showed that net gains were measured in Competence, Confidence, and practice strategy (4% – 28%). The greatest net increases were measured in learners’ reported Confidence to integrate new HF therapies into clinical practice and their intent to use objective measurements of functional class/exercise capacity to determine symptom burden in patients with HF.

v Significant improvements (ranging from 22% – 152%) were measured across all Learning Objectives except for the Learning Objective related to the assessment of symptom burden in patients with HF.

v The Learning Objective on the assessment of symptom burden included only one Performance item, on which scores varied widely among cities and online activities, suggesting differences in content coverage and presentation among the faculty.

v Onsite learners achieved higher Post-Test averages and greater score increases than online learners on all Learning Objectives (except for the Learning Objective on the assessment of symptom burden where both onsite and online learners independently demonstrated strong score decreases).

v The analysis of the Knowledge, Competence, and Performance domains identified three persistent learning gaps related to treatment selection for patients with a history of HF, patient characteristics that demonstrate increase risk for hospital readmission, and the evaluation of NYHA functional class in HF patients.

• On Competence and Performance items related to the selection of treatment for patients with a history of HF, learners remained challenged on the use of hydralazine/ISDN, ivabradine, lisinopril, and sacubitril/valsartan.

• On a Competence question which presented the discharge summary of a patient with HF, participants demonstrated a low score identifying which features suggest increased risk for readmission.

• On the Performance item, learners remained especially challenged (16% at Post-Test) classifying the statement “identify NYHA functional class III”. This item showed substantial variability across cities and among the lowest scores overall.

• There were substantial increases in learner intent to use objective measurements of functional class to determine symptom burden.


Appendix


Learning Objectives Analysis – Live Onsite vs. Live Online Audience• “Live onsite learners” include only those attending in-person meetings.

• ”Live online learners” include those from both the Simulcast and Virtual Symposium.


v Live onsite learners demonstrated higher Post-Test scores than live online learners, on all Learning Objectives.

v Onsite learners also demonstrated greater score increases on three of the four Learning Objectives.v On the Learning Objective on the assessment of symptom burden, live onsite and live online

learners demonstrated substantial score decreases. This Learning Objective included only one item, where scores were highly variable among cities, simulcast, and virtual symposium.

Learning ObjectiveLive Onsite Learners Live Online Learners


Recognize the role of laboratory testing and imaging in the evaluation and management of HF

348 74.43%(43.63%)

89.94%(30.08%) +20.85%* 208 67.79%

(46.73%)84.62%

(36.08%) +24.82%*

Reliably assess symptom burden in patients with HF 272 33.09%

(47.05%)21.32%

(40.96%) -35.56%* 201 26.87%(44.33%)

10.45%(30.59%) -61.11%*

Implement ACC/AHA/HFSA guideline-directed medical therapy in the management of chronic heart failure

350 24.86%(43.22%)

78.57%(41.03%) +216.09%* 219 32.88%

(46.98%)57.08%

(49.50%) +73.61%*

Recognize strategies to reduce hospitalization and readmission for HF 308 40.91%

(49.17%)65.26%

(47.61%) +59.52%* 166 37.95%(48.53%)

60.84%(48.81%) +60.32%*


Learning DomainLive Onsite Learners Live Online Learners


Knowledge 348 74.43%(43.63%)

89.94%(30.08%) +20.85%* 208 67.79%

(46.73%)84.62%

(36.08%) +24.82%*

Competence 472 32.20%(41.69%)

71.29%(40.87%) +121.38%* 240 35.00%

(39.84%)57.71%

(41.99%) +64.88%*

Confidence 315 2.14(1.00)

3.10(0.97) +45.32%* 189 2.23

(0.99)3.02

(0.86) +35.31%*

Practice 295 2.65(1.18)

3.88(1.05) +46.29%* 190 2.77

(1.11)3.86

(0.83) +39.09%*

Performance 536 59.92%(37.89%)

66.29%(35.75%) +10.64%* 249 57.50%

(28.51%)63.62%

(23.38%) +10.65%*


• “Live onsite learners” include only those attending in-person meetings.

• ”Live online learners” include those from both the Simulcast and Virtual Symposium.

Learning Domain Analysis – Live Onsite vs. Live Online Audience

v Live onsite and live online learners independently demonstrated significant score increases across all learning domains.

v Live onsite learners achieved higher Post-Test scores in all learning domains. Score differences were modest in Knowledge, Confidence, practice strategy, and Performance, with the greatest score difference in Competence (71% vs 58%).


8.00%

85.12%

2.46%

4.43%

6.65%

68.51%

8.03%

16.81%

4. Repeat measurement of ejection fraction

following significant change in clinical status

3. Routine repeat measurement of left

ventricular function

2. 2D echocardiography for initial evaluation

of HF

1. Chest X-ray for acute, suspected, or new-

onset HF

All of the following non-invasive tests are recommended for patients with HF, EXCEPT:

Knowledge Question:

+24.25%✓

N = (797–813)

Pre-Test Post-Test Note: Data is unmatched


11.66%

13.49%

69.87%

4.98%

20.68%

42.50%

27.99%

8.83%

4. Valsartan

3. Ivabradine

2. Hydralazine/ISDN

1. Eplerenone

62 y/o AA woman with 2 yr. history of HF with EF 30% presents for a checkup. Workup: BP 110/76 mmHg, HR 68 bpm, eGFR 50 mL/min/1.73m2, and mild edema. Other findings are WNL. She reports fatigue and shortness of breath when she does chores or walks. Meds: carvedilol, lisinopril, spironolactone, and aspirin. According to guidelines, the addition of which of the following agents could be considered for this patient?

Competence Questions

+149.57%

N = (662–835)

Note: Data is unmatched Pre-Test Post-Test

✓

A 70-year-old African American woman with HFrEF (EF 30%), hypertension, dyslipidemia, and type 2 diabetes is discharged following treatment for acute HF. On discharge, her hemoglobin is 10 g/dL, sodium 135 mEq/L, heart rate 68 bpm, and respiratory rate 16 bpm. All of the following findings in this case have been demonstrated to predict 30-day readmission for HF, EXCEPT:

18.80%

10.30%

58.32%

12.57%

24.32%

17.37%

37.46%

20.85%

4. Discharge sodium level

3. African American race

2. Respiratory rate

1. Hemoglobin

+55.69%✓


Confidence Question:Please rate your confidence in your ability to incorporate new therapies for heart failure into your clinical practice:

Confidence & Practice QuestionsN = (728–850)

Practice Question:How often do you use objective measurements of functional class/exercise capacity to determine symptom burden in patients with Heart Failure?

Pre-Test Post-TestNote: Data is unmatched

7.29%

20.71%

45.88%

24.00%

2.12%

2.85%

7.46%

24.02%

38.94%

26.73%

5. Very confident

4. Pretty much confident

3. Moderately confident

2. Slightly confident

1. Not at all confident

24.79%

46.76%

19.54%

6.47%

2.44%

5.08%

21.98%

27.88%

23.21%

21.84%

5. Always

4. Often

3. Sometimes

2. Rarely

1. Never


16.41%

83.59%

30.62%

69.38%

2. No, it is not consistent

1. Yes, it is consistent

3.83%

96.17%

18.38%

81.62%



69-y/o man p/w progressive dyspnea on exertion, fatigue, and peripheral edema. C/O dyspnea when he walks uphill or carries heavy items. PMHX: hypertension, dyslipidemia, and NSTEMI 2 years ago. Exam: BP 104/70, HR 66 bpm, jugular venous distension, lungs CTA, moderate edema. CXR shows cardiomegaly. Meds: lisinopril/hydrochlorothiazide 20/25 mg qd, atorvastatin 80 mg qd, metoprolol succinate 100 mg qd, and aspirin 81 mg qd. Based on the clinical scenario, please rate this statement as consistent with or not consistent with your current clinical practice:

• Order blood tests, including B-type natriuretic peptide:

Performance Questions

+17.83%

N = (662–835)

Note: Data is unmatchedPre-Test Post-Test

✓

• Identify NYHA functional class III:

-46.41%✓• If the patient is diagnosed with HFrEF, consider adding ivabradine:

44.47%

55.53%

49.09%

50.91%



-9.41%

• If the patient is diagnosed with HFrEF, consider discontinuing lisinopril and starting sacubitril/valsartan:

44.47%

55.53%

49.09%

50.91%


1. Yes, it is consistent +29.42%

✓

✓

heart failure: optimizing medical therapy and patient … · 2020. 7. 14. · heart failure:...

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