COVID-era telephone visits confer higher 90-day mortality risk for HF patients

Remote visits for heart failure (HF) were tied to lower diagnostic testing and guideline-directed medical therapy prescription (GDMT), while teleconsults were associated with elevated 90-day mortality, according to new data published in Circulation: Heart Failure.

To gain a better understanding of the shift to remote HF outpatient care during the COVID-19 pandemic, the authors examined whether remote visits (video or telephone) were linked with different patient usage, clinician practice patterns and outcomes.

“We observed that during remote visits, clinicians ordered fewer tests and guideline-directed medical therapies when compared with in-person visits during the same COVID era, with the largest reductions occurring during telephone visits,” wrote lead author Neal Yuan , MD, with the Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, and colleagues. “Compared with COVID-era in-person visits, telephone but not video visits were associated with higher rates of 90-day mortality and trends towards higher rates of 90-day heart failure emergency department visits and hospital admissions.”

Researchers analyzed 11,106 outpatient cardiology visits for HF in the COVID-era study period between April 2020 to December 2020. Seventy percent of the visits were conducted in person, 9.1% by video, and 20.9% by telephone.

In the pre-COVID era, all visits were conducted in person between April 2019 to December 2019.

The team found that when comparing remote to in-person visits during the COVID era, video and telephone visits were more inclined to be with non-white patients (35.8% video, 37.0% telephone versus 33.2% in-person). In contrast, those patients seen via video tended to be younger (64.7 years old versus 74.2 in-person), male (68.3% versus 61.4%) and privately insured (45.9% versus 28.9%). In addition, those patients who were seen by telephone were more likely to be female (42.4% telephone versus 38.6% in-person).

The authors found that overall, remote visits were with patients with similar comorbidity profiles versus in-person visits.

The team also found that during remote visits, clinicians ordered less diagnostic tests, GDMT and loop diuretics, with the reduction in ordering being more noticeable during telephone visits compared with video visits.

The authors observed that when comparing video to in-person visits during the COVID era, clinicians did not prescribe as many beta blockers, nitrates, hydralazine and loop diuretics. And when comparing telephone to in-person visits during the COVID era, clinicians were much less likely to prescribe any GDMT including β-blockers, angiotensin-converting enzyme inhibitor (ACE) angiotensin receptor blockers (ARB), angiotensin receptor-neprilysin inhibitors (ARNI), mineralocorticoid receptor antagonist (MRAs), digoxin and loop diuretics.

When examining outcomes, the authors observed that patients had similar rates of 90-day HF-related emergency department visits, hospitalizations and mortality when comparing COVID-era to pre-COVID visits.

Patients hospitalized in the COVID era had longer hospital stays and an increased chance of requiring ICU care.

During the COVID era, patients seen by video compared with those seen in person did not have meaningfully different rates of 90-day ED visits, hospitalization or mortality, however, the overall number of events was low.

Meanwhile, patients seen via telephone compared with those seen in person had higher hazard rates for mortality and trended toward higher hazard rates for HF-related ED visits as well as hospitalizations.

Also, the chance of ICU admission was higher after a video visit or a telephone visit.

The authors also found that the frequency of 90-day HF-related ED visits, hospitalizations and mortality was the same or lower for COVID-era clinic visits from April to August compared with pre-COVID visits during the same months.

Nevertheless, from September through December, COVID-era telephone visits led to higher rates of ED use, hospitalizations and mortality

Remote visits will likely continue to play a large role in outpatient heart failure care for many patients," Yuan et al. predicted. "Clinicians should be aware that there may be barriers unique to remote visits, such as decreased communication clarity and inability to perform comprehensive physical examinations, that can influence care practice patterns, including the ordering of appropriate tests and medications. This, in turn, may affect patient outcomes.”

Read the full study here.

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