ImportanceImplementation of guideline-directed medical therapy (GDMT) in real-world practice remains suboptimal. It is unclear which interventions are most effective at addressing current barriers to GDMT in patients with heart failure with reduced ejection fraction (HFrEF).ObjectiveTo perform a systematic review to identify which types of system-level initiatives are most effective at improving GDMT use among patients with HFrEF.Evidence ReviewPubMed, Embase, Cochrane, CINAHL, and Web of Science databases were queried from January 2010 to November 2023 for randomized clinical trials that implemented a quality improvement intervention with GDMT use as a primary or secondary outcome. References from related review articles were also included for screening. Quality of studies and bias assessment were graded based on the Cochrane Risk of Bias tool and Oxford Centre for Evidence-Based Medicine.FindingsTwenty-eight randomized clinical trials were included with an aggregate sample size of 19 840 patients. Studies were broadly categorized as interdisciplinary interventions (n = 15), clinician education (n = 5), electronic health record initiatives (n = 6), or patient education (n = 2). Overall, interdisciplinary titration clinics were associated with significant increases in the proportion of patients on target doses of GDMT with a 10% to 60% and 2% to 53% greater proportion of patients on target doses of β-blockers and renin-angiotensin-aldosterone system inhibitors, respectively, in intervention groups compared with usual care. Other interventions, such as audits, clinician and patient education, or electronic health record alerts, were also associated with some improvements in GDMT utilization, though these findings were inconsistent across studies.Conclusions and RelevanceThis review summarizes interventions aimed at optimization of GDMT in clinical practice. Initiatives that used interdisciplinary teams, largely comprised of nurses and pharmacists, most consistently led to improvements in GDMT. Additional large, randomized studies are necessary to better understand other types of interventions, as well as their long-term efficacy and sustainability.

中文翻译：

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优化指南指导的医疗治疗的干预措施

重要性在现实世界实践中，指南指导的药物治疗 (GDMT) 的实施仍然不够理想。目前尚不清楚哪些干预措施最有效地解决射血分数降低的心力衰竭 (HFrEF) 患者目前的 GDMT 障碍。目的进行系统评价，以确定哪些类型的系统级举措最有效地改善患者中 GDMT 的使用从 2010 年 1 月到 2023 年 11 月，对 HFrEF.Evidence ReviewPubMed、Embase、Cochrane、CINAHL 和 Web of Science 数据库进行了随机临床试验的查询，这些试验实施了以 GDMT 作为主要或次要结局的质量改进干预措施。相关评论文章的参考文献也包括在内以供筛选。研究质量和偏倚评估根据 Cochrane 偏倚风险工具和牛津循证医学中心进行分级。研究结果纳入了 28 项随机临床试验，总样本量为 19 840 名患者。研究大致分为跨学科干预措施 (n = 15)、临床医生教育 (n = 5)、电子健康记录举措 (n = 6) 或患者教育 (n = 2)。总体而言，跨学科滴定诊所与接受目标剂量 GDMT 的患者比例显着增加相关，其中接受目标剂量 β 受体阻滞剂和肾素-血管紧张素-醛固酮的患者比例分别增加 10% 至 60% 和 2% 至 53%与常规护理相比，干预组分别使用系统抑制剂。其他干预措施，例如审计、临床医生和患者教育或电子健康记录警报，也与 GDMT 利用率的一些改善相关，尽管这些研究结果在不同研究中不一致。结论和相关性本综述总结了旨在优化临床实践中 GDMT 的干预措施。使用跨学科团队（主要由护士和药剂师组成）的举措最能持续改善 GDMT。为了更好地了解其他类型的干预措施及其长期疗效和可持续性，需要进行更多的大型随机研究。