Practice Patterns and Patient Outcomes After Widespread Adoption of Remote Heart Failure Care

Neal Yuan; Patrick Botting; Y. Elad; Shaun Miller; Susan Cheng; Joseph E. Ebinger; M. Kittleson

doi:10.1161/circheartfailure.121.008573

September 30, 2021Circulation Heart FailureOpen Access

Practice Patterns and Patient Outcomes After Widespread Adoption of Remote Heart Failure Care

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Why the study?

Following an unprecedented shift to remote heart failure outpatient care during the COVID-19 pandemic, it was unknown whether remote visits (video or telephone) were associated with different patient usage, clinician practice patterns, and outcomes.

Do remote visits (video or telephone) affect clinician practice patterns and patient outcomes in ambulatory heart failure patients compared to in-person visits?

Structured PICO

Do remote visits (video or telephone) affect clinician practice patterns and patient outcomes in ambulatory heart failure patients compared to in-person visits?

P

Population

21,697 ambulatory cardiology visits for heart failure at a multisite health system (10,591 pre-COVID in-person, 7,775 COVID-era in-person, 1,009 COVID-era video, and 2,322 COVID-era telephone visits).

I

Intervention

Remote visits (video or telephone) for heart failure care during the COVID-19 pandemic (April 1, 2020, to December 31, 2020)

C

Comparator

In-person visits for heart failure care (pre-COVID and COVID-era)

O

Outcome

Clinician practice patterns (diagnostic testing, guideline-directed medical therapy prescription) and 90-day clinical outcomes (mortality, heart failure emergency department visits, and hospitalizations)hard clinical

Implication

Remote HF visits may warrant cautious integration into practice; leaves open optimal telehealth role versus in-person care.

Abstract

BACKGROUND: An unprecedented shift to remote heart failure outpatient care occurred during the coronavirus disease 2019 (COVID-19) pandemic. Given challenges inherent to remote care, we studied whether remote visits (video or telephone) were associated with different patient usage, clinician practice patterns, and outcomes. METHODS: We included all ambulatory cardiology visits for heart failure at a multisite health system from April 1, 2019, to December 31, 2019 (pre-COVID) or April 1, 2020, to December 31, 2020 (COVID era), resulting in 10 591 pre-COVID in-person, 7775 COVID-era in-person, 1009 COVID-era video, and 2322 COVID-era telephone visits. We used multivariable logistic and Cox proportional hazards regressions with propensity weighting and patient clustering to study ordering practices and outcomes. RESULTS: <0.05 for all). Remote visits were more frequently used by non-White patients (35.8% video, 37.0% telephone versus 33.2% in-person). During remote visits, clinicians were less likely to order diagnostic testing (odds ratio, 0.20 [0.18-0.22] video versus in-person, 0.18 [0.17-0.19] telephone versus in-person) or prescribe β-blockers (0.82 [0.68-0.99], 0.35 [0.26-0.47]), mineralocorticoid receptor antagonists (0.69 [0.50-0.96], 0.48 [0.35-0.66]), or loop diuretics (0.67 [0.53-0.85], 0.45 [0.37-0.55]). During telephone visits, clinicians were less likely to prescribe ACE (angiotensin-converting enzyme) inhibitor/ARB (angiotensin receptor blockers)/ARNIs (angiotensin receptor-neprilysin inhibitors; 0.54 [0.40-0.72]). Telephone visits but not video visits were associated with higher rates of 90-day mortality (1.82 [1.14-2.90]) and nonsignificant trends towards higher rates of 90-day heart failure emergency department visits (1.34 [0.97-1.86]) and hospitalizations (1.36 [0.98-1.89]). CONCLUSIONS: Remote visits for heart failure care were associated with reduced diagnostic testing and guideline-directed medical therapy prescription. Telephone but not video visits were associated with increased 90-day mortality.