Barriers To ARNi Prescribing By Internal Medicine Residency Program Trainees Of A Single Academic Center

Background The 2017 update of the ACC/AHA/HFSA guideline for heart failure (HF) management recommends replacing ACEIs or ARBs with an ARNi (class I recommendation, moderate-quality evidence) in chronic, symptomatic, or New York Heart Association (NYHA) class II or III HFrEF to further reduce morbidity and mortality, provided there are no contraindications. Surprisingly, only 10% of 2.29 million eligible patients use ARNi. There are limited data on the perception of ARNi among Internal Medicine (IM) Residency Program trainees, who provide a majority of hospital care in academic centers in the US. Objective: We sought to identify among IM Residency Program trainees the barriers and opportunities to clinical implementation of ARNi after acute heart failure decompensation as part of transitional care prescribing. Methods Two IM Residency Programs across 3 campuses at an urban, academic medical center were identified. An online, anonymous, 8-question survey using a Likert scale was created and distributed via e-mail. Survey questions included frequency in initiating or titrating ARNi prior to discharge as well as comfort level in prescribing in patients with and without chronic kidney disease (CKD). Questions on barriers to prescribing, such as hypotension and hyperkalemia, as well as knowledge of patient resources were also included. Finally, quality improvement opportunities and interventions were also listed. The survey was administered over a 2-week period in January 2022. Results The survey was administered to 150 trainees and the response rate was 26.7%. Among respondents 62% stated that ARNi was initiated sometimes and 42% reported they were comfortable initiating ARNI during hospitalization. Conversely, 78% were slightly to not at all comfortable prescribing ARNi for patients with CKD. Perceived barriers to prescribing ARNi included cost to patient (87%), renal dysfunction (59%), hypotension (43%) and hyperkalemia (38%) and 82% were not at all familiar with patient resources such as the co-pay assistance program. To improve ARNi uptake, 58% of respondents suggested a consult to pharmacy and 47% thought a note in the electronic health record from would yield similar results. Conclusion Among IM trainees, CKD largely drives the low clinical implementation of ARNi in transitional care prescribing after acute HF exacerbation. Multidisciplinary initiatives with nephrology and pharmacy represent opportunities to improve provider adherence to guideline-directed medical therapy. The 2017 update of the ACC/AHA/HFSA guideline for heart failure (HF) management recommends replacing ACEIs or ARBs with an ARNi (class I recommendation, moderate-quality evidence) in chronic, symptomatic, or New York Heart Association (NYHA) class II or III HFrEF to further reduce morbidity and mortality, provided there are no contraindications. Surprisingly, only 10% of 2.29 million eligible patients use ARNi. There are limited data on the perception of ARNi among Internal Medicine (IM) Residency Program trainees, who provide a majority of hospital care in academic centers in the US. Objective: We sought to identify among IM Residency Program trainees the barriers and opportunities to clinical implementation of ARNi after acute heart failure decompensation as part of transitional care prescribing. Two IM Residency Programs across 3 campuses at an urban, academic medical center were identified. An online, anonymous, 8-question survey using a Likert scale was created and distributed via e-mail. Survey questions included frequency in initiating or titrating ARNi prior to discharge as well as comfort level in prescribing in patients with and without chronic kidney disease (CKD). Questions on barriers to prescribing, such as hypotension and hyperkalemia, as well as knowledge of patient resources were also included. Finally, quality improvement opportunities and interventions were also listed. The survey was administered over a 2-week period in January 2022. The survey was administered to 150 trainees and the response rate was 26.7%. Among respondents 62% stated that ARNi was initiated sometimes and 42% reported they were comfortable initiating ARNI during hospitalization. Conversely, 78% were slightly to not at all comfortable prescribing ARNi for patients with CKD. Perceived barriers to prescribing ARNi included cost to patient (87%), renal dysfunction (59%), hypotension (43%) and hyperkalemia (38%) and 82% were not at all familiar with patient resources such as the co-pay assistance program. To improve ARNi uptake, 58% of respondents suggested a consult to pharmacy and 47% thought a note in the electronic health record from would yield similar results. Among IM trainees, CKD largely drives the low clinical implementation of ARNi in transitional care prescribing after acute HF exacerbation. Multidisciplinary initiatives with nephrology and pharmacy represent opportunities to improve provider adherence to guideline-directed medical therapy.