Heart failure clinic volumes have rebounded since the early days of the COVID-19 era with telehealth appointments, but the care delivered virtually was not the same as in-person, a Utah health system found.
At a tertiary care heart failure clinic, guideline-directed medical therapy (GDMT) titration overall decreased from in-person visits before COVID (Feb. 18 to March 13 this year) to virtual visits during the pandemic (March 16 to May 15), with a rate of 45.4% vs 35.9% (P=0.01).
While diuretic titration didn’t change significantly (14.5% vs 16.0%, P=0.61), it did when considered together with GDMT titration (54.2% vs 45.6%, P=0.03).
Barriers to medication titration in virtual visits included lack of blood pressure readings or recent laboratory results, according to researchers led by Sharon Ugolini, MSN, RN, of University of Utah Heath, Salt Lake City, who presented their work in a poster at this year’s virtual meeting of the Heart Failure Society of America.
Clinicians could have been wary of adjusting GDMT without enough information to ensure the safety of doing so, commented James Januzzi, MD, of Massachusetts General Hospital in Boston.
Other factors could have played a role, too, speculated Nancy Albert, PhD, of Cleveland Clinic, in an email to MedPage Today. “Were patients more symptomatic during the telemedicine visit and there was a desire to ‘wait’ before up-titrating?”
“Was the provider uncomfortable explaining the rationale for up-titration as a telemedicine visit versus an in-person visit? Were there ‘distraction factors’ during the telemedicine visit, lack of privacy or other issues that decreased the rate of up-titration? Or, was the person completing the telemedicine visit not the patient’s normal provider?” she posited.
“No matter the cause, solutions will need to be implemented, since we know that quality of life is improved and morbidity and possibly even mortality are reduced when medications are up-titrated toward optimum doses used in national trials,” Albert added.
The Utah clinic had cancelled all non-urgent in-person appointments on March 15 and transitioned patients to virtual appointments where possible. Outpatient volume decreased significantly after that date, but increased steadily to even exceed pre-COVID numbers by mid-May, driven by the fast rise of virtual visits.
“These results illustrate the important role that virtual care has taken on during the COVID-19 pandemic. It is to be expected that some amount of healthcare will continue to be virtual even after the pandemic is over, thus emphasizing how important it is to work out the limitations and address them as much as possible,” according to Januzzi.
He suggested greater use of more accurate in-home measurement of vital signs and heart rhythm, as well as point-of-care or at-home blood testing.
In total, there were 745 patients included in the study (average age 60.7 years, 65.2% men, 80.9% Caucasian).
All appointments pre-COVID were in person versus 18% during the pandemic period.
The observed drop in GDMT titration during virtual visits was consistent in the subgroup of people with heart failure with reduced ejection fraction — a population for whom initiating and optimizing GDMT dosing is crucial for better outcomes, stressed Gregg Fonarow, MD, of UCLA.
“These findings are concerning. They suggest that it will be critical to integrate more effective protocols and strategies into telehealth visits for heart failure to better ensure GDMT use and dosing is better optimized,” according to Fonarow.
“This opportunity should not be missed,” Januzzi urged.
Ugolini’s group had no disclosures.
Fonarow reported consulting for Abbott, Amgen, AstraZeneca, Janssen, Merck, and Novartis.
Januzzi disclosed research grants from Novartis and Janssen and consulting for Boehringer-Ingelheim.