Experiences and Perceptions of Patients and Providers Participating in Remote Titration of Heart Failure Medication Facilitated by Telemonitoring: A Qualitative Study (Preprint)

BACKGROUND Guideline-directed medical therapy (GDMT), optimized to target doses, improves health outcomes in patients with heart failure (HF). However, GDMT remains underutilized, with less than 25% of patients receiving target doses in clinical practice. A randomized controlled trial (RCT) was conducted at the Peter Munk Cardiac Centre in Toronto to compare a remote GDMT titration intervention with standard in-office titration. This RCT found that remote titration increased the proportion of patients that achieved optimal GDMT doses, decreased the time to dose optimization, and reduced the number of necessary clinic visits. This paper presents findings from the qualitative component of the mixed-methods study, which evaluated the implementation of the remote titration intervention. OBJECTIVE The objective of the qualitative component was to assess the perceptions and experiences of clinicians and HF patients who participated in the remote titration intervention to identify factors that impacted the implementation of the intervention. METHODS We conducted semi-structured interviews with clinicians (n=5) and patients (n=11) that participated in the remote titration intervention. Questions probed the experiences of the participants to identify factors that can serve as barriers and facilitators to its implementation. Conventional content analysis was first used to analyze the interviews and gain direct information based on the participants’ unique perspectives. Subsequently, the generated themes were delineated and mapped following a multi-level framework outlined by Chaudoir et al. RESULTS Patients and clinicians indicated that the intervention was easy to use, was integrated well into their routines and removed practical barriers to titration. Key implementation facilitators from the patients’ perspective included the reduction in clinic visits and daily monitoring of their condition, while clinicians emphasized the benefits of rapid drug titration and efficient patient management. Key implementation barriers included the resources necessary to support the intervention and lack of physician remuneration. CONCLUSIONS This study presents results from a real-world implementation assessment of remote titration facilitated by telemonitoring. It is among the first to provide insight into the perception of the remote titration process by clinicians and patients. Our findings indicate that the relative advantages that remote titration presents over standard care strongly appeal to both clinicians and patients. However, to ensure uptake and adherence, it is important to make sure that suitable patients are enrolled, and impact on the physicians’ workload is minimized. The implementation of remote titration is now more critical than ever as it can help provide access to care for patients during times when physical distancing is required. CLINICALTRIAL ClinicalTrials.gov NCT04205513; https://clinicaltrials.gov/ct2/show/NCT04205513 INTERNATIONAL REGISTERED REPORT RR2-10.2196/19705