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Professor of Medicine
Division of Cardiovascular Medicine
Department of Medicine
Section Chief, Advanced Heart Failure and Cardiac Transplant
University of Pennsylvania
Lee R. Goldberg, MD, MPH, FACC, has disclosed that he has received funds for research support from Respircardia and consulting fees from Abbott, Respircardia, and Viscardia.
During the COVID-19 pandemic, many healthcare professionals pivoted from in-person office visits to virtual visits, including telephone and video. At the 2021 American Heart Association Virtual Scientific Sessions (AHA 2021), new data on the use of telehealth platforms demonstrated that video visits are a feasible approach to managing patients with heart failure. Here’s my synopsis.
GDMT Outcomes With Telehealth Platforms
Block and colleagues presented results from a study comparing initiation rates of guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF) who were seen in office visits vs video or telephone visits. This study was quite timely against the backdrop of the COVID-19 pandemic, with so many offices pivoting to telemedicine. The study found that both initiation and discontinuation rates for GDMT were comparable between patients with HFrEF who were seen in the office and via video. However, telephone visits were associated with significantly lower rates of initiating at least 1 GDMT class compared with both office and video visits. Compared with video visits, discontinuation rates were similar among patients who were engaged over the telephone, whereas telephone visits had fewer discontinuations vs office visits.
These data mirror the experience at my institution. What is fascinating—but not talked about in this abstract—is the characteristics of persons who tend to choose telephone vs video and office visits. In our experience, telephone visits were favored by our patients who were older, had more financial challenges, and/or were disabled, including cognitive, visual, or hearing trouble preventing them from navigating the video technology. There is also is a built-in confounder in access and equity. Some of our neighborhoods in Philadelphia are lacking reliable Wi-Fi and cellular signals, so people were unable to connect with us even if they knew how to use video platforms. This is a hot topic, especially in heart failure where we have frequent visits and assessments. We must answer the questions of where and how to leverage telemedicine going forward. We learned from the COVID-19 pandemic—and these new data confirm—that video visits are feasible. In my opinion, we can probably accomplish 80% of what we need to do via video and reduce the burden of people having to come into the office. However, patients who choose telephone visits should probably be seen in the office to ensure they are receiving the right care.
Moreover, we have been able to use telehealth platforms to host “hybrid visits,” where the patient is physically in the office but their support person/family member is on the video screen. This has been particularly helpful when trying to limit the number of people in the office and also provides convenience for family members who may be located in a different part of the city or country. The social workers at our institution have quickly concluded that we were underestimating the value of pulling in a wider circle, which can help provide emotional support. That check-in phone call or medication reminder phone call can come from out of state and be just as valuable. Even when families are physically distant, pulling them together to rally around a patient is incredibly impactful.
We also shifted our support groups to virtual meetings and were shocked at how much attendance increased. Prior to the pandemic, we would typically have between 30 and 50 patients and caregivers at in-person meetings. When COVID-19 safety concerns prompted us to offer the meetings online, we had more than 250 participants at the first meeting alone!
Although this abstract from Block and colleagues was limited to their institution’s experience with these 3 modalities, this study forms an important foundation as we consider what the future will look like. I think these type of data demonstrate that there is something magical about the connection of video that changes the physician–patient interaction vs telephone. To provide the highest level of care, video seems to add a comfort level for people. And in heart failure, we are constantly adjusting medications and adding agents to get to guideline‑directed therapy. If you are having multiple telephone visits without making any changes, you are losing a lot of time. As we roll out more widespread telehealth services, we probably want to focus on video technology.
Virtual Multidisciplinary Care for Heart Failure
In a second study from Block and colleagues, telehealth platforms were further evaluated in the context of using multidisciplinary care teams to achieve GDMT for patients with heart failure. They enrolled both inpatient and outpatient persons with HFrEF to participate in a 3-month program consisting of virtual visits with a kinesiologist for lifestyle optimization and, separately, a nurse for up-titration of guideline-based therapies (with oversight by a cardiologist). Among 297 participants, they achieved significant improvement in the proportion of patients receiving the prescribed optimal dosage of GDMTs at 3 months vs baseline. Moreover, there were no hospitalizations during the study period, and no participants reported drug-related adverse events.
I found this report particularly interesting, as this is an approach we are trying at my institution. They were leveraging the convenience of video visits to integrate a multidisciplinary care team into the management approach, and it was quite effective. I was glad to see that patients in this study reached optimal doses quickly. These data offer further evidence that telehealth platforms can help advance the care of our patients with heart failure, including when multidisciplinary care teams are brought on board.
How have you leveraged telehealth platforms when managing patients with heart failure? Answer the polling question and join the conversation by posting a comment. For more new data from AHA 2021, download and reuse the Capsule Summary slides in your own noncommercial presentations.