Brief Report
Outpatient Management of Guideline-Directed Medical Therapy for Heart Failure Using Telehealth: A Comparison of In-Office, Video, and Telephone Visits

https://doi.org/10.1016/j.cardfail.2022.02.016Get rights and content

Abstract

Background

There are limited data regarding the management of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) with virtual visits in comparison with in-office visits. We sought to compare the changes in GDMT (angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, angiotensin receptor neprilysin inhibitors, mineralocorticoid receptor antagonists, and sodium glucose cotransporter-2 inhibitors) and loop diuretics across visit types.

Methods and Results

This study included 13,481 outpatient visits performed for 5439 unique patients with HFrEF between March 16, 2020, and March 15, 2021. The rates of initiation and discontinuation of GDMT were documented, and multivariable logistic regression was performed to test associations with outcomes between modes of visit. The rates of medication initiation were higher in office (11.7%) compared with video (9.6%) or telephone (7.2%) visits. In multivariable adjusted analysis, the initiation of at least 1 GDMT class was similar between in-office visits and video visits (adjusted odds ratio [OR] 0.97, 95% confidence interval [CI] 0.82–1.14, P = .703). Telephone visits were associated with less frequent initiation of at least 1 class of GDMT in comparison with in-office visits (adjusted OR 0.64, 95% CI 0.55–0.75; P < .001) and video visits (adjusted OR 0.67, 95% CI 0.55–0.81, P < .001). Despite similar rates of baseline loop diuretic use, patients seen with both video visits (adjusted OR 0.70, 95% CI 0.52–0.94, P = .018) and telephone visits (adjusted OR 0.64, 95% CI 0.49-0.83, P < .001) were less likely to have a loop diuretic initiated when compared with in-office visits.

Conclusions

The initiation of GDMT for HFrEF was similar between in-office and video visits and lower with telephone visits, whereas the initiation of a loop diuretic was less frequent in both types of virtual visits. These data suggest that video streaming capabilities should be encouraged for virtual visits.

Section snippets

Methods

We conducted a retrospective study of patients with HFrEF who were seen at Saint Luke's Health System cardiology clinics between March 16, 2020 through March 15, 2021. The electronic medical record (EPIC, Verona, WI) was queried to include patients with international classification of diseases, tenth-revision (International Classification of Diseases, 10th edition) HFrEF diagnosis codes (I50.2, I50.20–23, I50.4, I50.40–43, I42.0, and I25.5). Patients with a HFrEF diagnosis were included

Results

We identified 13,481 outpatient encounters performed for 5439 unique patients with HFrEF. Of these visits, 7045 were in-office (52.3%), 2610 were video (19.4%), and 3826 were telephone visits (28.4%). Overall, 65% of in-office, 59% of video, and 54% of telephone visits were conducted by physicians; the rest were conducted by advanced practice providers. Vital signs including blood pressure were recorded in 100% of in-office, 78.9% of video, and 72.7% of telephone visits (P < .001). Baseline

Discussion

Our study highlights several important findings with respect to GDMT use for HFrEF across outpatient visit types. Video visits were similar to in-office visits with respect to initiation of GDMT. However, adding GDMT during telephone visits was less common than in either in-office or video visits. Loop diuretics were initiated more frequently during in-office visits when compared with both forms of telehealth visits. These data have important implications when considering incorporating

Conclusions

Video visits provided similar performance to in-office visits regarding GDMT optimization in HFrEF, though loop diuretic initiation was less common in all telehealth visits. Telephone visits were associated with lower rates of GDMT initiation compared with in-office and video visits. Health systems should encourage remote visits to include video streaming.

Source of funding

No financial support was received.

Declaration of Competing Interest

The authors declare no conflict of interest relevant to this article.

Acknowledgments

The authors acknowledge Ty Terrell from Saint Luke's Health System for his work on behalf of this article.

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