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Telehealth and Outpatient Management of Heart Failure During Pandemic
Quick Takes
- This article showed that utilizing telehealth to care for heart failure outpatients was not associated with subsequent increases in emergency department visits, hospital admissions, ICU admission, or mortality.
Study Questions:
Does rapid incorporation of telehealth affect outcomes for outpatients with heart failure (HF)?
Methods:
This was a retrospective study of patient visits to one of sixteen cardiology clinics at a Midwestern health care system from March 15–June 15, 2020 (n = 5,224) compared with the same time period in 2018 (n = 5,246) and 2019 (n = 4,951). Patients were included if they had an International Classification of Diseases-Tenth Revision code of primary or secondary HF diagnoses at the outpatient encounter and heart transplant or left ventricular assist device patients were excluded. Patients were seen by attending cardiologists or advanced practice providers (APPs) as an in-person or telehealth (telephone or video) visit. Study outcomes included all-cause mortality, emergency department (ED) visits, hospital admissions, and need for intensive care unit (ICU) at 30 and 90 days after the index in-person visit. A propensity score was used to match 1:1 in-person visits in 2018 and 2019 (n = 4,541) to telehealth visits in 2020 (n = 4,541).
Results:
A total of 8,263 unique patients with HF were identified, making up 15,421 clinic visits. Telehealth was not used in 2018 or 2019 compared to 88.5% of visits in 2020 during the study period (70% telephone and 30% video). The breakdown of type of provider encounter (physician vs. APP) and clinic visit with a specialist (HF physician or APP) compared to other cardiology providers was similar across years. Patients in the 2020 group were younger (mean age 70.5 vs. 71.4 years), less likely to be diagnosed with acute HF (6.8% vs. 10.2%), and visits were more likely to be scheduled within the prior 48 hours (15.9% vs. 8.1%) compared to 2018 or 2019 (p < 0.001 for all). In 2020, acute HF diagnoses were lower for telehealth visits compared to in-person visits (5.8% vs. 14%; p < 0.001). Only 0.4% of patients were known to have coronavirus disease 2019 (COVID-19) infection before or within 90 days of outpatient visit. There were no significant differences in baseline characteristics in the propensity-matched groups.
All-cause mortality was similar at 30 days, but higher at 90 days (3.1% vs. 2.4%; p = 0.009) in 2020 compared to 2018 and 2019. Fewer ED visits were seen in 2020 compared to 2018 and 2019 at 30 (3.1% vs. 4.2%; p = 0.001) and 90 days (8.8% vs. 11%; p = 0.00002). Hospital admissions were lower in 2020 at 30 (5% vs. 7.4%) and 90 days (13.7% vs. 17%) compared to 2018 and 2019 (p < 0.000001 for both). ICU admissions were no different at 30 days, but higher at 90 days (25.6% vs. 21.1%; p = 0.013) in 2020 compared to 2018 and 2019. In the propensity-matched analysis, there were fewer ED visits in the telehealth group compared to the in-person visit group at 30 and 90 days (p = 0.001 and p = 0.00001, respectively). The telehealth group had fewer hospital admissions at 30 and 90 days compared to in-person visits (p < 0.000001 for both). In the propensity analysis, there was no difference in all-cause mortality or ICU admission at 30 or 90 days between telehealth and in-person visits.
Conclusions:
Telehealth visits were not associated with an increase in subsequent ED visits, hospital admissions, ICU admission, or all-cause mortality, suggesting that telehealth visits can be safely implemented.
Perspective:
Despite unadjusted survival curves showing an increase in all-cause mortality at 30 and 90 days and ICU admissions at 90 days in 2020 compared to 2018 and 2019 clinic visits, the propensity analysis comparing in-person to telehealth visits showed no difference in ICU admission or all-cause mortality. This article provides reassuring data for practitioners who have also incorporated a primarily telehealth-based model in caring for HF outpatients. However, several limitations of this study should be noted: No information regarding guideline-directed medical therapy was provided, the propensity score did not account for provider type or method of telehealth, and there was a low overall percentage of known COVID-19 infection. Future research should report on guideline-directed medical therapy, include a longer enrollment time frame, account for provider type and telehealth visit type, and consider technological access issues.
Clinical Topics: COVID-19 Hub, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure
Keywords: Ambulatory Care, COVID-19, Emergency Service, Hospital, Geriatrics, Heart Failure, Intensive Care Units, Pandemics, Patient Care Team, Outpatients, Patient Admission, Secondary Prevention, Telemedicine
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