Patient Use and Clinical Practice Patterns of Remote Cardiology Clinic Visits in the Era of COVID-19

Importance: The COVID-19 pandemic has led to an unprecedented shift in ambulatory cardiovascular care from in-person to remote visits. Objective: To understand whether the transition to remote visits is associated with disparities in patient use of care, diagnostic test ordering, and medication prescribing. Design, Setting, and Participants: This cross-sectional study used electronic health records data for all ambulatory cardiology visits at an urban, multisite health system in Los Angeles County, California, during 2 periods: April 1, 2019, to December 31, 2019 (pre-COVID) and April 1 to December 31, 2020 (COVID-era). Statistical analysis was performed from January to February 2021. Exposure: In-person or remote ambulatory cardiology clinic visit at one of 31 during the pre-COVID period or COVID-era period. Main Outcomes and Measures: Comparison of patient characteristics and frequencies of medication ordering and cardiology-specific testing across 4 visit types (pre-COVID in-person (reference), COVID-era in-person, COVID-era video, COVID-era telephone). Results: This study analyzed data from 87 182 pre-COVID in-person, 74 498 COVID-era in-person, 4720 COVID-era video, and 10 381 COVID-era telephone visits. Across visits, 79 572 patients were female (45.0%), 127 080 patients were non-Hispanic White (71.9%), and the mean (SD) age was 68.1 (17.0) years. Patients accessing COVID-era remote visits were more likely to be Asian, Black, or Hispanic individuals (24 934 pre-COVID in-person visits 28.6% vs 19 742 COVID-era in-person visits 26.5% vs 3633 COVID-era video visits 30.4% vs 1435 COVID-era telephone visits 35.0%; P < .001 for all comparisons), have private insurance (34 063 pre-COVID in-person visits 39.1% vs 25 474 COVID-era in-person visits 34.2% vs 2562 COVID-era video visits 54.3% vs 4264 COVID-era telephone visits 41.1%; P < .001 for COVID-era in-person vs video and COVID-era in-person vs telephone), and have cardiovascular comorbidities (eg, hypertension: 37 166 pre-COVID in-person visits 42.6% vs 31 359 COVID-era in-person visits 42.1% vs 2006 COVID-era video visits 42.5% vs 5181 COVID-era telephone visits 49.9%; P < .001 for COVID-era in-person vs telephone; and heart failure: 14 319 pre-COVID in-person visits 16.4% vs 10 488 COVID-era in-person visits 14.1% vs 1172 COVID-era video visits 24.8% vs 2674 COVID-era telephone visits 25.8%; P < .001 for COVID-era in-person vs video and COVID-era in-person vs telephone). After adjusting for patient and visit characteristics and in comparison with pre-COVID in-person visits, during video and telephone visits, clinicians had lower odds of ordering any medication (COVID-era in-person: odds ratio OR, 0.62 95% CI, 0.60-0.64, COVID-era video: OR, 0.22 95% CI, 0.20-0.24; COVID-era telephone: OR, 0.14 95% CI, 0.13-0.15) or tests, such as electrocardiograms (COVID-era in-person: OR, 0.60 95% CI, 0.58-0.62; COVID-era video: OR, 0.03 95% CI, 0.02-0.04; COVID-era telephone: OR, 0.02 95% CI, 0.01-0.03) or echocardiograms (COVID-era in-person: OR, 1.21 95% CI, 1.18-1.24; COVID-era video: OR, 0.47 95% CI, 0.42-0.52; COVID-era telephone: OR, 0.28 95% CI, 0.25-0.31). Conclusions and Relevance: Patients who were Asian, Black, or Hispanic, had private insurance, and had at least one of several cardiovascular comorbidities used remote cardiovascular care more frequently in the COVID-era period. Clinician ordering of diagnostic testing and medications consistently decreased when comparing pre-COVID vs COVID-era and in-person vs remote visits. Further studies are needed to clarify whether these decreases represent a reduction in the overuse of tests and medications vs an underuse of indicated testing and prescribing.