More patients, particularly those with medical risk factors or from underserved communities, opted into telehealth appointments for their cardiovascular care during the COVID-19 pandemic, a cross-sectional study of more than 176,000 ambulatory cardiology visits in Los Angeles County, USA, has shown. The data also suggests these telehealth patients underwent fewer diagnostic tests and received fewer medications than patients who saw their doctors in person.
The findings, published in JAMA Network Open, point to a “digital shift” in cardiovascular care amid the ongoing COVID-19 pandemic—which the authors say will likely lay the foundation for more remote clinic visits as a more permanent and substantial part of future cardiovascular care.
“We were encouraged to learn that access to cardiovascular care was maintained for high-risk and underserved communities during the pandemic,” said Joseph Ebinger, director of Clinical Analytics at the Cedars-Sinai Smidt Heart Institute, Los Angeles, USA, and senior author of the study. “This same study, however, identified some differences in care that we need to delve into further to better understand.”
The researchers examined data collected from 87,182 pre-COVID in-person visits, 74,498 COVID-era in-person visits, 4,720 COVID-era telehealth video visits and 10,381 COVID-era telephone visits.
The researchers found that patients seen by in-person and telephone visits were of similar age, whereas those seen by video visit had a significantly younger mean (SD) age (pre-COVID in-person: 67.7 (17.3) years; COVID-era in-person: 69.0 (16.7) years; COVID-era video: 61.1 (16.5) years, COVID-era telephone: 68.4 (16.0) years; P < .001 for COVID-era in-person vs video and COVID-era in-person vs. telephone).
Furthermore, the researchers noted that patients from underrepresented racial and ethnic groups were seen at similar or slightly lower rates in the COVID-era period, they constituted a larger proportion of remote visits, while a larger proportion of remote visits were also with patients who had private insurance
Patients seen by remote visit had more cardiovascular comorbidities, including hypertension, coronary artery disease, atrial fibrillation or flutter, heart failure, and chronic kidney disease. Despite having more comorbidities, patients seen by remote visit had fewer mean (SD) visits overall during the study period (2.33 [2.11] pre-COVID in-person visits vs 2.47 [2.69] COVID-era in-person visits vs. COVID-era video visits 1.48 [0.97] vs COVID-era telephone visits 1.51 [1.09]; p<0.001 for COVID-era in-person vs video and COVID-era in-person vs telephone).
“Our data reveal a reduced rate of testing and prescribing, likely due to a number of factors,” said Ebinger. “We see these results as being not obviously negative or positive but a trend that is important to understand. For instance, lower rates of testing and prescribing may-in many instances-reflect reductions in the types of care that are not really needed to achieve good health outcomes while adding costs to the system.”
One of the key benefits to telehealth visits, researchers say, is access to a cardiologist at a distance, which is vital for individuals who cannot—or do not want to—travel for care due to concerns over virus exposure, lack of transportation, increased family demands or inability to take time off of work. Without telehealth visits, Ebinger said, many of these patients may well not have received any healthcare at all.
But researchers also note the importance of recognising potential pitfalls of telehealth services, many of which disproportionately affect communities of colour.
“Being a relatively new platform for patients and providers alike, there is a learning curve with telehealth, both technically and with respect to comfort and confidence,” said Susan Cheng, associate professor, Cedars-Sinai Department of Cardiology, director of the Institute for Research on Healthy Aging in the Department of Cardiology at the Smidt Heart Institute, and an author on the study.
As an example, Cheng notes that patients must have access to a device that allows them to connect with their provider. Similarly, patients must be comfortable with the telehealth platform and feel confident around how to access and use it effectively.
Notwithstanding the challenges of telehealth, there are also conveniences. Researchers say past reports have indicated that racial and ethnic minority populations make up a disproportionate size of the essential job market. Essential worker schedules have been even busier during the pandemic, making it more difficult to fit in an in-person medical appointment during regular business hours. This factor could have contributed to the higher rates of telehealth use among racial and ethnic minority patients.
As a next step, researchers plan to determine whether the changes in clinician practices during the pandemic will lead to changes in patient outcomes.
“We plan to next examine if the ordering of fewer tests, such as stress tests, might predispose to missed diagnoses,” said Ebinger. “To understand the balance of risks and benefits, we are also investigating whether the fewer tests ordered might actually represent opportunities to streamline away from certain types of care that were not important contributors to health in the prior system of only in-person visits.”
