This transcript has been edited for clarity. For more episodes, download the Medscape app or subscribe to the podcast on Apple Podcasts, Spotify, or your preferred podcast provider.
Nihar R. Desai, MD, MPH: Hello. I'm Dr Nihar Desai from the Yale School of Medicine. Welcome to season 1 of the Medscape InDiscussion Cardiorenal Metabolic Syndrome Podcast series. Today we're discussing implementation science in the context of cardiorenal metabolic (CRM) syndrome. I want to welcome our expert guests, two close friends and colleagues, Drs Tariq Ahmad and Ankeet Bhatt. Dr Ahmad is an associate professor of medicine and chief of the heart failure program at the Yale School of Medicine in New Haven, Connecticut. Dr Bhatt currently serves as an associate physician at the Kaiser San Francisco Medical Center, a research scientist in the sections of cardiovascular and metabolic conditions and healthcare delivery and policy at the Kaiser Division of Research, and on the faculty in the Department of Health System Science at the Kaiser Permanente Bernard J. Tyson School of Medicine. Welcome, Tariq and Ankeet. Thanks so much for being with us today.
Ankeet S. Bhatt, MD: Nihar, thanks for having us.
Tariq Ahmad, MD, MPH: It's a great honor to be here. It is good to have this discussion with friends and colleagues.
Desai: I couldn't be more excited to have this discussion with both of you. I know implementation science is a topic that we are very passionate about. How do we make progress? How do we deliver everything that the healthcare system needs to deliver, for our patients and the communities we serve? In this podcast series, we've had a wide-ranging discussion. Please check out all the other topics as well. You'll hear things from the American Heart Association presidential statement on cardiovascular-kidney-metabolic health, a discussion on epidemiology, social determinants of health, and a very comprehensive review of evidence-based and emerging novel therapies to manage CRM syndrome. But in many ways, our topic today, implementation science is the linchpin. If we don't get this part of the story right, if we aren't able to bring all of these therapies to the patients who need and deserve them, then I'm fearful that most of the other discussions are for naught and become moot. With that, we're lucky to have two experts in the field to walk through this topic.
What is implementation science? What does it seek to study and accomplish? Ankeet, we'll start with you, with a definition so that all of us are on the same page.
Bhatt: Broadly speaking, it's the scientific study of methods and strategies that facilitate the uptake of both evidence-based practice and research into regular use by practitioners, care providers, and policymakers. It's strategies that help close the gap between what we know and what we do.
As you alluded to, I think it is this final common pathway. It's the body of research that's aligned most closely with clinical care because it intersects with clinical care innately. It's the area in which we can take all of the scientific discoveries and all the work that's been put into developing those discoveries and bring them to patients at scale.
Desai: Tariq, can you give some introductory comments? How do you think about implementation science? What's the work that we're going to spend the rest of our program today talking about?
Ahmad: From my perspective, I see this time as the golden era of biomedical research. We have therapies now that humankind could never even have dreamt of. We have highly effective treatments that save lives, that keep people out of the hospital. There's been a dramatic growth in those therapies over the past 20 years. When Nihar and I were training together as housestaff not too long ago, we had only a fraction of these therapies for heart failure, for example. Now we have these riches of therapies, but it does not make much of a difference to the individual patient unless they get those therapies. That's what's driven me, and that's what implementation science means to me: How do we get those life-saving therapies to the patients who need them? What has guided us has been the dramatic difference between the science and the use of these therapies at the bedside. For me, implementation science is all the different things we can do to bridge this large gap in heart failure.
Desai: I appreciate the way both of you laid this out and it is important for all of us to understand, and certainly for the audience to appreciate, that implementation science is a deep science. There's a rigor, there's a set of methods, a set of frameworks and principles. But I also think that both of you rightfully pointed out that it's exquisitely focused on what we are doing for the patients that we serve. How are we going to fill this very conspicuous gap between evidence and practice? We have all these therapies, we have all these guidelines, we have all of this literature. And yet, what happens in routine clinical care is oftentimes something that's very, very different from what evidence would suggest we do or what guidelines suggest we do. I think implementation science really says hey, let's figure out what works, how do we fill these care gaps, and how do we spread and scale those things to other places so that all patients in all communities can benefit.
Let's very quickly highlight some of the key care gaps in the CRM syndrome space. I want to focus on two elements of this specifically. One aspect is underdiagnosis. Where are we in terms of basic routine understanding to guide which patients are at risk for or already have CRM syndrome? Specifically, the example of urine albumin-to-creatinine ratio (UACR) testing. I think we can talk about all the under evaluation of that important element of this clinical syndrome. Then we'll switch gears and talk about the underuse of evidence-based therapies, whether that's sodium-glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide 1 (GLP-1) receptor agonists, or other therapies.
There are so many examples of that, but we'll quickly touch quickly on both of those. I'll turn to Ankeet again underuse or undertesting of UACR as a prime example of the evidence-practice gap that we're trying to fill.
Bhatt: Thanks, Nihar. The fun, and what makes implementation science such an exciting field for research, is that it follows the patient and provider journey. Zooming out, there are implementation science initiatives aimed at diagnosing conditions. You talked about one, which is UACR and proteinuria testing in patients with kidney disease. Another example is the recognition of certain forms of heart failure. For example, heart failure with preserved ejection fraction. There's a diagnosis piece where implementation science can play a role. There's an area in which we can learn how to implement effective therapies across the CRM spectrum. That is an exciting area because the number of therapies has grown, as Tariq has alluded to, but there are particular therapies that are at the nexus of these CRM comorbidities and are effective across multiple domains.
The way I view it, there's sort of a final pathway. Once you have patients on effective therapies, they need to stay on them to get the population benefit that these therapies would otherwise provide. There's a whole piece around implementation science that promotes adherence and equity in both the initial prescription and the adherence to those medications.
That's the broad framework in which I think about this. When we think specifically about UACR testing, we have a nice case example of the first pillar that I discussed, which was around underdiagnosis. We know that chronic kidney disease affects a large percent of the population, but in many cases, we've defaulted to a measure of estimated glomerular filtration rate (eGFR) as an indicator that someone has chronic kidney disease. What we know from the epidemiology is that proteinuria irrespective of a patient's creatinine or eGFR can be an important prognostic marker for the progression of kidney disease. However, we're not testing for this in routine clinical practice, in a way that mirrors our guidelines.
It's an important area of further study. I'll pause there and see if you and Tariq have any thoughts about that.
Desai: I think that's a great framework that you put forward for us. I couldn't agree with you more on the UACR front. I think we continue to see undertesting of something as simple as the UACR. It can be done by every healthcare provider, and it brings so much complementary adjunctive information in terms of profiling patients with CRM syndrome. And yet we see, time and again, that testing rates are less than 1 in 5 or maybe even 1 in 4 patients, who get and receive what the guidelines recommend. I'll have Tariq comment on the underuse of CRM therapies. Again, not getting into an in-depth discussion, but Tariq, are there data or something that you might share with the audience about just how big of a problem underuse of CRM therapies is?
Ahmad: I would say that this is one of the greatest challenges facing US medicine right now. I think every clinician and patient would tell you that the best thing to do is prevent disease. We see a lot of patients in the hospital with heart failure, end-stage kidney disease, who need dialysis or who need transplants. It's one aspect of our practice. But the most important thing, I would argue, that we do is to prevent those outcomes — to prevent patients from progressing to the end stage of any disease. And for the first time in history, we have therapies that we know will prevent the progression to advanced disease. The most important thing becomes being able to diagnose patients at an earlier stage of the disease. We have biomarkers like the one that you mentioned before for kidney disease. We have one for heart failure.
I routinely check natriuretic peptide levels to pick up patients who have earlier stages of heart failure. We know that once we can diagnose early-stage heart failure, as the case example that you brought up, then we can use guideline-directed medical therapy to dramatically reduce the progression in disease. Unfortunately, both the diagnosis of heart failure and the use of guideline-directed medical therapy are incredibly low. We know from national registries that only a small percentage of patients are on appropriate doses of the four pillars of guideline-directed medical therapy: beta-blockers, an angiotensin receptor-neprilysin inhibitor (ARNI), mineralocorticoid receptor antagonists (MRAs), and SGLT2 inhibitors. Unfortunately, this has major negative population health impacts because these are the patients who end up getting hospitalized for heart failure, who have progression in their disease to a point where the medications stop working. With these new therapies that we have, most of which were not available 20 years back, we can start to think about preventing heart failure and end-stage renal disease. And that starts with an appropriate diagnosis.
Desai: It's a pretty sobering statistic, right? When we look at the proportion of patients who might be candidates or eligible for some of these therapies, we stack that up against the proportion of patients who receive them. Are there numbers that either of you want to share regarding how big this evidence and practice gap is? And maybe not just overall, but have we learned anything in terms of race, ethnicity, socioeconomics, or social determinants of health that might also underlie some of the disparities in the use of these therapies?
Bhatt: What I find troubling, but maybe highlights where implementation science can play an important role, is that we know for each of these conditions, there are large evidence gaps. If we take heart failure, for example, we know that less than 5%, and some registries say less than 1%, of patients are on multidrug disease-modifying guideline-directed medical therapy at appropriate doses.
What we also know is that as patients gain CRM comorbidities, the likelihood that they're on these effective therapies goes down. There's this paradox between being at higher clinical risk and having less implementation of disease-modifying therapies. It's troublesome because these are the people that are going to progress, as Tariq said, to end-stage forms of CRM conditions, whether that's heart failure or kidney disease or otherwise.
But we're treating them the least aggressively. And then you compound that. The socioeconomic and sociodemographic inequities that we see in the implementation of guideline-directed medical therapy show that the most disadvantaged groups are the ones who potentially have the most to gain from these therapies, but are receiving them with the least prevalence.
That is quite concerning for our field, in which there's a risk-based paradox with getting guideline-directed medical therapy and a socioeconomic paradox with the patients that need it most potentially having the least uptake of those therapies.
Desai: Those are critical points. We've teed up the discussion and the importance of this notion of implementation science really well.
Ahmad: I would add, there appears to be this interesting behavior among clinicians where there is a long delay in starting newer therapies. Beta-blocker uptake is good. ARNI uptake took several years. And then with MRAs and SGLT2 inhibitors, as you might imagine, people are quite slow in adopting. There is this concerning learning that we're getting from implementation science that a lot of this is from therapeutic inertia. There is clear evidence that we could do a lot better with use of these medications.
The other thing is, on a patient level, it is quite dramatic when you see patients in clinic and you add these therapies, and you can watch both the heart function and the biomarkers get better. I think that's something that we need to drive home because if you start seeing these illnesses as things that we can treat and reverse the course of, that message needs to get back to individual clinicians who may not completely understand the massive impact of these therapies in modifying disease.
Desai: It's such a such a great point. I'm so appreciative that you raised that as we think about, where do we go from here? How are we going to make progress? It seems like such a huge, monumental challenge before us. Maybe I'll get both of you to share some of the key barriers that are impeding progress.
Why is there this evidence-practice gap? Tariq, you already started some discussion around this notion of clinical inertia and what goes on in the exam room or in the hospital. I'll have you continue on this notion of clinical inertia. What are some of the other barriers that you think are important for us to tackle?
Ahmad: First of all, there is clinical inertia because you're seeing that patient in follow-up. It's a 20-minute visit. It's a lot of work to add medication. That certainly can disincentivize clinicians from doing that extra legwork.
The other thing, and this is very important for patients, is cost. You've written key landmark papers about how we need to make sure that we're able to tackle the financial toxicity of certain things.
We work very closely with patients to get them on the right therapies. It's also informational. We'll get into this later, but we've designed interventions that use the electronic health record to get beyond informational gaps that individual clinicians might have and nudge them to get people on the right therapies.
And then, as with anything, it's health system incentives. If the entire health system is aligned and agrees that this aspect of quality is important, then they can put a lot of resources both on the macro and the micro level to get their patient population on the right therapies.
Bhatt: I think Tariq put that nicely: the facets and the barriers to implementation across the way the health system and care delivery currently operate. I do agree that there is clinical inertia at the nexus of the provider–patient interaction. Our visits are infrequent; they're brief, they're filled with lots of things to talk about, and it becomes very challenging to start a new therapy, educate a patient on a new therapy, and promote adherence all within the context of a short visit.
Where that takes us is that systems need to start thinking about this more holistically and rather than just at the patient-provider level. Thinking about population health initiatives, if the ethos of a healthcare delivery system is that we should be studying these strategies in the context of quality improvement, in the context of the way we deliver care.
As Tariq nicely put it, then there's the incentive, both in terms of effort and financially to be able to study these strategies at scale. To keep the ones that work and integrate them into usual care very quickly, and to not implement the strategies that don't seem to be effective, that's going to take a redesign from a healthcare system perspective.
But I think it's where we need to go because this is the right thing to do for patients, and it translates all of the discovery and the upfront cost and time that researchers, clinical trial participants, and others have put into developing and bringing these therapies to the market and takes that last mile toward implementation.
Desai: I want to get into the final piece of our discussion today. What are you most excited about? What's happening in terms of implementation science? We've identified the barriers. What are the solutions? What are institutions and groups doing to solve some of these problems? What might they also engage in? What are some tactics and tools that they might be able to leverage to make progress within their local environment? Is it the electronic health records (EHR)? I know Tariq already raised that. We've done some work in that space. I know Ankeet has also been very active in that space also with digital technologies. Will we rely on novel tools, remote monitoring, and other devices?
I think both of you rightfully talked about some of the incentives and maybe some of the perverse incentives that we have in our current predominantly, fee-for-service, volume-based payment system. Do we need a new model for care delivery, a new model for how we finance healthcare — those are large policy-level changes? I'm curious to get both of your perspectives on what's out there that you're excited about. We've got to solve some of these challenges and barriers.
We'll start with Tariq and then go to Ankeet.
Ahmad: This is such an important question. The great thing about the space right now is that there's so many brilliant people who are starting to think about this. When you and I were training, we focused a lot on clinical trials, but then we would see clinically that there was less of an uptake at the bedside.
And now we're focusing on implementation. I'm super excited about it. Everyone's coming together and thinking about this. How do we get these therapies to the patients in the most efficient way possible?
For example, look at flu vaccines at CVS. I think the easiest step, would be — and I'm very biased here — to use the prompt heart failure intervention that we tested at Yale and other healthcare systems. We get contacted once a week by different healthcare systems to integrate the alert in their healthcare system, and we're already live at Inova in Colorado, at Columbia, and several healthcare systems. I think that there's still a gap that would require other interventions. For instance, integrating wearable technology and remote monitoring to be able to get these therapies to patients without them needing to come in for clinic visits.
Doing as much as possible remotely will be important. The question for the future is, do we move away from the current care delivery set up where we require patients to come into clinic to get care? Do we have some chronic care management done at other sites? I think that will have to be in the discussion as we start moving from, as you alluded to, a fee-for-service model to more of a quality-of-care model. It's only a matter of time, because I don't think that the healthcare system can sustain the current approach.
Desai: It is so exciting, and I will fully endorse everything Tariq has said. There are so many technologies and so many solutions. Is it the EHR? Is it freestanding? Is it something else that's a patient engagement tool? There are so many things happening there. How are we going to know what's working, and how are we going to scale it? What are you most excited about? What are you working on? How are we going to make sure that we scale up and make progress?
Bhatt: Thanks, Nihar. I share your and Tariq's excitement. I think it's a great time to be an implementation science researcher. The field is totally wide open. The gaps are pervasive. The therapies are abundant. There are many things that I'm excited about in the implementation science field and strategies.
More broadly speaking, I'm very excited about building a platform for what I'll call precision implementation. One strategy is not going to be the end-all and be-all for a system. The gaps are too large, and the therapies are too complex. I think we can start implementing the easy things. You and Tariq have led much of the seminal work on taking an existing tool, the EHR, and using it to improve care. You've shown that now in many respects, and I think the broad-scale adoption of successful tools in that space is an easy win.
And then there's the broader-scale initiatives, like the ones that use digital technology. We've seen an explosion in the availability of technology and capital, which has brought a lot of health platforms to the market. I think there needs to be a clearinghouse here because there's so many tools. Most of them have had no rigorous validation across health systems. I know, Nihar, you've been integrally involved in some of the initiatives to develop high-quality evidence there for those tools.
Finally, I think there needs to be an alignment between performance on implementation science initiatives. For example, looking at the provider or patient level to understand how providers prescribe evidence-based therapies and then tailoring implementation initiatives based on performance.
Desai: Thanks so much. I can't say how grateful I am to have had both of you join our discussion today and cap this podcast series. We said at the top that implementation, especially in this area of CRM syndrome, is the linchpin. It allows all the therapies and all the tools we have to have impact at an individual at a community level at the population level. There's such an immense opportunity for us. But if we don't get the implementation part of it right, I'm afraid what will happen to the health of our country and those that we serve.
This has been a terrific discussion. What you laid out for the audiences, in the compelling need for this kind of work, what excites you, what are some of the barriers, and the importance making sure we are focused on this. I want to thank both of you again for taking some time out of your schedules to join us. And so, Tariq and Ankeet, my deep appreciation to both of you.
Bhatt: Nihar, thanks for the invitation. This was a lot of fun.
Ahmad: This was great, and I hope you know we can impact all those patients out there. I think it's really exciting.
Desai: Thanks again. For our audience, please take a moment to download the Medscape app to listen and subscribe to this podcast series. Thank you again for joining us. This is Nihar Desai from the Yale School of Medicine, for the Medscape InDiscussion Cardiorenal Metabolic Syndrome Podcast.
Resources
Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association
A Global Health Tidal Wave? Cardiorenal Metabolic Syndrome
Social Determinants of Health in Cardiorenal Conditions
Epidemiology of Chronic Kidney Disease: An Update 2022
The Inflation Reduction Act and Patient Costs for Drugs to Treat Heart Failure
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Cite this: Bridging the Care Gap in Cardiorenal Metabolic Care - Medscape - Jan 22, 2025.
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