Cardiac Outpatient Care in a Digital Age: Remote Cardiology Clinic Visits in the Era of COVID-19

Bridging the Gap: Remote Evaluation and Programming of Cardiac Implantable Devices in Medically Underserved Areas

BACKGROUND

Delivering care in medically underserved areas (MUA) is a public health challenge.

OBJECTIVES

The purpose of this study was to evaluate the advantages of a noncommercial multivendor solution for remote interrogation and programming of cardiac implantable electronic devices (CIEDs) among inhabitants of MUAs.

METHODS

This prospective comparative study evaluated benefits and safety of remote CIEDs evaluation in patients living >100 km from the Bordeaux University Hospital. A conventional in-person evaluation at the Bordeaux hospital was compared with a remote evaluation performed 6 months later at a nurse office close to the patient home. The technical solution consisted of remote controlling CIED programmers from the 5 main manufacturers allowing evaluation of all kinds of CIEDs.

RESULTS

A majority of the 34 included patients (94%) were satisfied with the remote evaluation strategy. To attend the in-person evaluation at the Bordeaux Hospital, the patients covered a median distance of 253 km (ICR: 221-258 km) compared with 9 km (ICR: 6-19 km) (P < 0.001) to get to the nurse's office. The use of a medical vehicle was reduced by a factor 7 (44% vs 6%; P = 0.001) with the remote evaluation, which translated into a reduction in the total traveling cost per patient by a factor 32 (96 Euros [87-268 Euros] vs 3 Euros [2-8 Euros]; P < 0.001). The travel carbon footprint was 14 times lower (28 Kg CO2-eq [24-28 Kg CO2-eq] vs 2 Kg CO2-eq [1-5 Kg CO2-eq]; P < 0.001) with the remote evaluation strategy.

CONCLUSIONS

Remote evaluation of CIEDS in patients living MUA is feasible and safe. This approach is associated with a high level of satisfaction, lower economic and ecological costs compared with the in-person assessment in this population. (Remote Programming of Cardiac Implantable Electronic Devices 2 [REACT 2]; NCT06272344).

Cardiovascular Precision Medicine and Remote Intervention Trial Rationale and Design

Background: It has recently been shown that excessive fluctuation in blood pressure readings for an individual over time is closely associated with poor outcomes, including increased risk of cardiovascular mortality, coronary heart disease and stroke. Fluctuations may be associated with inconsistent adherence to medical recommendations. This new marker of risk has not yet been incorporated into a monitoring and intervention strategy that seeks to reduce cardiovascular risk by identifying patients through an algorithm tied to their electronic health record (EHR). Methods: We describe the methods used in an innovative "proof of concept" trial using CP&R (Cardiovascular Precision Medicine and Remote Intervention). A blood pressure variability index is calculated for clinic patients via an EHR review. Consenting patients with excessive variability are offered a remote intervention aimed at improving adherence to medical recommendations. The outcomes include the ability to identify and engage the identified patients and the effects of the intervention on blood pressure variability using a pre-post comparison design without parallel controls. Conclusions: Our innovative approach uses a recently identified marker based on reviewing and manipulating EHR data tied to a remote intervention. This design reduces patient burden and supports equitable and targeted resource allocation, utilizing an objective criterion for behavioral risk. This study is registered under ClinicalTrials.gov Identifier: NCT05814562.

Technological Interventions to Implement Prevention and Health Promotion in Cardiovascular Patients

Background/Objectives: The aim of the narrative review is to identify information on the impact of technological interventions (such as telehealth and mobile health) on the health promotion of cardiac patients from diverse populations. Methods: The online databases of PubMed and the Cochrane Library were searched for articles in the English language regarding technological interventions for health promotion in cardiac patients. In addition, a methodological quality control process was conducted. Exclusion was based on first reading the abstract, and then the full manuscript was scanned to confirm that the content was not related to cardiac patients and technological interventions. Results: In all, 11 studies were included in this review after quality control analysis. The sample size reported in these studies ranged from 12 to 1424 subjects. In eight studies mobile phones, smartphones, and apps were used as mHealth interventions with tracking and texting components; two studies used videoconferencing as a digital intervention program, while three studies focused on using physical activity trackers. Conclusions: This review highlights the positive aspects of patient satisfaction with the technological interventions including, but not limited to, accessibility to health care providers, sense of security, and well-being. The digital divide becomes apparent in the articles reviewed, as individuals with limited eHealth literacy and lack of technological knowledge are not motivated or able participate in these interventions. Finding methods to overcome these barriers is important and can be solved to some extent by providing the technology and technical support.

Physical Activity in Cancer Rehabilitation and Technology Acceptance: Results From the "Oncology in Motion" Project

Aims

The international literature underlines that physical activity has a role in preventing cancer and is beneficial for cancer recovery and rehabilitation. Therefore, patient education is essential to stimulate training. Telemedicine and e-health tools like apps and wearables can support patients' education and the monitoring of their health condition and progress.

Methods

The article reports the results of the Oncology in Motion telemedicine program of the National Cancer Institute of Aviano, Italy, to provide breast cancer patients with a personalized fitness path and telemonitoring.

Results

144 women took part in the program. Low adherence was recorded, performing the customized training schedule and, for those women sticking to the plan, using the technological devices and submitting the training data to the Institute.

Conclusion

Low technology acceptance and literacy, laziness, and lack of collaboration between cancer centers stood among the causes of low adherence, calling for more comprehensive and effective educational programs and support to stimulate physical activity and the use of new devices to get personalized counseling and contribute to the creation of knowledge.

Advancing telemedicine in cardiology: A comprehensive review of evolving practices and outcomes in a postpandemic context

Telemedicine, telehealth, e-Health, and other related terms refer to the exchange of medical information or medical care from one site to another through electronic communication between a patient and a health care provider. As telemedicine infrastructure has changed since the coronavirus disease 2019 (COVID-19) pandemic, this review provides an overview of telemedicine use and effectiveness in cardiology, with emphasis on coronary artery disease in the postpandemic context. Prepandemic studies tend to report statistically insignificant or modest improvements in cardiovascular disease outcome from telemedicine use to usual care. In contrast, postpandemic studies tend to report positive outcomes or comparable acceptance of telemedicine use to usual care. Today, telemedicine can effectively replace in person follow-up visits to produce comparable (but not necessarily superior) outcomes in cardiovascular disease management. A benefit of telemedicine is the potential reduction in follow-up time or time to intervention, which may lead to earlier detection and prevention of adverse events. Nonetheless, barriers remain to effective telemedicine implementation in the postpandemic context. Ensuring accessible and user-friendly telemedicine devices, maintaining adherence to remote rehabilitation procedures, and normalizing use of telemedicine in routine follow-up visits are examples. Current knowledge gaps include the true economic cost of telemedicine infrastructure, feasibility of use in specific cardiology contexts, and sex/gender differences in telemedicine use. Future telemedicine developments will need to address these concerns before acceptance of telemedicine as the new standard of care.

Disparities in Video-Based Primary Care Use Among Veterans with Cardiovascular Disease

BACKGROUND

Cardiovascular disease (CVD) is prevalent among Veterans, and video care enhances access to CVD care. However, it is unknown which patients with CVD conditions receive video care in primary care clinics, where a large proportion of CVD services is delivered.

OBJECTIVE

Characterize use of VA video primary care for Veterans with two common CVDs, heart failure and hypertension.

DESIGN

Retrospective cohort study.

PATIENTS

Veterans seen in VA primary care with diagnoses of heart failure and/or hypertension in the year prior to the COVID-19 pandemic and for the first two pandemic-years.

MAIN MEASURES

The primary outcome was use of any video-based primary care visits. Using multilevel regressions, we examined the association between video care use and patient sociodemographic and clinical characteristics, controlling for time and adjusting for patient- and site-level clustering.

KEY RESULTS

Of 3.8M Veterans with 51.9M primary care visits, 456,901 Veterans had heart failure and hypertension, 50,753 had heart failure only, and 3,300,166 had hypertension only. Veterans with heart failure and hypertension had an average age of 71.6 years. 2.9% were female, and 34.8% lived in rural settings. Patients who were male, aged 75 or older, or rural-dwelling had lower odds of using video care than female patients, 18-44-year-olds, and urban-dwellers, respectively (male patients' adjusted odds ratio [AOR] 0.73, 95% confidence interval [CI] 0.72-0.74; 75 years or older, AOR 0.38, 95% CI 0.37-0.38; rural-dwellers, AOR 0.71, 95% CI 0.70-0.71). Veterans with heart failure had higher odds of video care use than those with hypertension only (AOR 1.05, 95% CI 1.04-1.06).

CONCLUSIONS

Given lower odds of video primary care use among some patient groups, continued expansion of video care could make CVD services increasingly inequitable. These insights can inform equitable triage of patients, for example by identifying patients who may benefit from additional support to use virtual care.

Pandemic-related practice changes and CVD risk management in community clinics

OBJECTIVES

Understanding how the COVID-19 pandemic affected cardiovascular disease (CVD) risk monitoring in primary care may inform new approaches for addressing modifiable CVD risks. This study examined how pandemic-driven changes in primary care delivery affected CVD risk management processes.

STUDY DESIGN

This retrospective study used electronic health record data from patients at 70 primary care community clinics with scheduled appointments from September 1, 2018, to September 30, 2021.

METHODS

Analyses examined associations between appointment type and select care process measures: appointment completion rates, time to appointment, and up-to-date documentation for blood pressure (BP) and hemoglobin A1c (HbA1c).

RESULTS

Of 1,179,542 eligible scheduled primary care appointments, completion rates were higher for virtual care (VC) vs in-person appointments (10.7 percentage points [PP]; 95% CI, 10.5-11.0; P < .001). Time to appointment was shorter for VC vs in-person appointments (-3.9 days; 95% CI, -4.1 to -3.7; P < .001). BP documentation was higher for appointments completed pre- vs post pandemic onset (16.2 PP; 95% CI, 16.0-16.5; P < .001) and for appointments completed in person vs VC (54.9 PP; 95% CI, 54.6-55.2; P < .001). HbA1c documentation was higher for completed appointments after pandemic onset vs before (5.9 PP; 95% CI, 5.1-6.7; P < .001) and for completed VC appointments vs in-person appointments (3.9 PP; 95% CI, 3.0-4.7; P < .001).

CONCLUSIONS

After pandemic onset, appointment completion rates were higher, time to appointment was shorter, HbA1c documentation increased, and BP documentation decreased. Future research should explore the advantages of using VC for CVD risk management while continuing to monitor for unintended consequences.

Cardiology in a Digital Age: Opportunities and Challenges for e-Health: A Literature Review

To date, mortality rates associated with heart diseases are dangerously increasing, making them the leading cause of death globally. From this point of view, digital technologies can provide health systems with the necessary support to increase prevention and monitoring, and improve care delivery. The present study proposes a review of the literature to understand the state of the art and the outcomes of international experiences. A reference framework is defined to develop reflections to optimize the use of resources and technologies, favoring the development of new organizational models and intervention strategies. Findings highlight the potential significance of e-health and telemedicine in supporting novel solutions and organizational models for cardiac illnesses as a response to the requirements and restrictions of patients and health systems. While privacy concerns and technology-acceptance-related issues arise, new avenues for research and clinical practice emerge, with the need to study ad hoc managerial models according to the type of patient and disease.

Reshaping care in the aftermath of the pandemic. Implications for cardiology health systems

In the last two years, the COVID-19 pandemic has undeniably changed everyday life and significantly reshaped the healthcare systems. Besides the direct effect on daily care leading to significant excess mortality, several collateral damages have been observed during the pandemic. The impact of the pandemic led to staff shortages, disrupted education, worse healthcare professional well-being, and a lack of proper clinical training and research. In this review we highlight the results of these important changes and how can the healthcare systems can adapt to prevent unprecedented events in case of future catastrophes.

Patients' Experiences With the Fit of Virtual Atrial Fibrillation Care During the Pandemic: Qualitative Descriptive Study

BACKGROUND

In-person health care has been the standard model of care delivery for patients with atrial fibrillation (AF). Despite the growing use of remote technology, virtual health care has received limited formal study in populations with AF. Understanding the virtual care experiences of patients in specialized AF clinics is essential to inform future planning of AF clinic care.

OBJECTIVE

This qualitative descriptive study aimed to understand patients' virtual AF clinic care experiences during the COVID-19 pandemic.

METHODS

Participants were recruited from a pool of patients who were receiving care from an AF clinic and who were enrolled in a larger survey study. A total of 8 virtual focus groups (n=30) were conducted in 2 waves between March 2021 and May 2021. Facilitators used a semistructured discussion guide to ask participants questions about their experiences of virtual care and the perceived quality of virtual care and technology support. Three team members initially open coded group data to create a preliminary coding framework. As the analysis progressed, with subsequent focus groups, the code clusters were refined.

RESULTS

The participants were primarily male (21/30, 70%), aged ≥65 years (20/30, 67%), and college graduates (22/30, 73%). Patients found virtual care to be highly beneficial. Central to their experiences of virtual care was its fit or lack of fit with their health needs, which was integrally connected to communication effectiveness and their preferred virtual care future. Practical benefits included flexibility, convenience, and time and cost savings of virtual care. Virtual care fit occurred for small, quick, and mundane issues (eg, medication refills) but was suboptimal for new and more complex issues that patients thought warranted an in-person visit. Fit often reflected the effectiveness of communication between patient and provider and that of in-clinic follow-up. There was near-complete agreement among participants on the acceptability of virtual communication with their providers in addressing their needs, but this depended on adequate reciprocal communication. Without the benefit of in-person physical assessments, patients were uncertain and lacked confidence in communicating the needed, correct, and comprehensive information. Finally, participants described concerns related to ongoing virtual care with recommendations for their preferred future using a hybrid model of care and integrating patient-reported data (ie, blood pressure measurements) in virtual care delivery.

CONCLUSIONS

Virtual care from a specialty AF clinic provides practical benefits for patients, but they must be weighed against the need for virtual care's fit with patients' needs and problems. The stability and complexity of patients' health needs, their management, and their perceptions of communication effectiveness with providers and clinics must be considered in decisions about appointment modality. Patients' recommendations for future virtual care through use of hybrid models together with systems for data sharing have the potential to optimize fit.

An electronic consultation program impacts on heart failure patients' prognosis: implications for heart failure care

AIMS

e-consults are asynchronous, clinician-to-clinician exchanges that answer focused, non-urgent, patient-specific questions using the electronic medical record. We instituted an e-consultation programme (2013-2019) for all general practitioners (GPs) referrals to cardiologists that preceded patients' in-person consultations when considered. In our study, we aimed to analyse the clinical characteristics, 1 year prognosis and the prognostic determinants of patients with a previous diagnosis of HF referred for an e-consult, categorized by their previous HF-related hospitalization status (recent hospitalization, <1 year before; remote hospitalization, >1 year before or never been hospitalized because of HF), and to analyse the impact of reducing the time elapsed between e-consultation and response by the cardiologist in terms of prognosis.

METHODS AND RESULTS

Epidemiological and clinical data were obtained from 4851 HF patients referred by GPs to the cardiology department for an e-consultation 2013 and 2020. The delay of time to e-consults were solved was 8.6 + 8.6 days with 84.3% solved in <14 days. For the 1 year prognosis evaluation after the e-consult were assessed the cardiovascular hospitalizations, HF-related hospitalizations, HF-related mortality, cardiovascular mortality, and all-cause mortality. Compared with the group without a previous hospitalization, patients with recent and remote HF hospitalization were at higher risk of a new HF-related hospitalization (OR: 19.41 [95% CI: 12.95-29.11]; OR: 8.44 [95% CI: 5.14-13.87], respectively), HF-related mortality (OR: 2.47 [95% CI: 1.43-4.27]; OR: 1.25 [95% CI: 0.51-3.06], respectively), as well as cardiovascular hospitalizations and mortality and all-cause mortality. Reduction in the time elapsed because e-consultation was solved was associated with lower risk of HF-related mortality (OR: 0.94 [95% CI: 0.89-0.99]), cardiovascular mortality (OR: 0.96 [95% CI: 0.93-0.98]), and all-cause mortality (OR: 0.98 [95% CI: 0.97-1.00]).

CONCLUSIONS

A clinician-to-clinician e-consultation programme between GPs and cardiologists in patients with HF allows to solve the demand of care in around 25% e-consults without an in-person consultation; the patients with a previous history of HF-related hospitalization showed a worse 1 year outcome. A reduction in the time elapsed because e-consultation was solved was associated with a mortality reduction.

Developing a contemporary community clinic for patients with heart failure with preserved ejection fraction within the current National Health Service model

Introduction

The diagnostic and therapeutic arsenal for heart failure with preserved ejection (HFpEF) has expanded. With novel therapies (eg, sodium-glucose co-transporter 2 inhibitors) and firmer recommendations to optimise non-cardiac comorbidities, it is unclear if outpatient HFpEF models can adequately deliver this. We; therefore, evaluated the efficacy of an existing dedicated HFpEF clinic to find innovative ways to design a more comprehensive model tailored to the modern era of HFpEF.

Methods

A single-centre retrospective analysis of 202 HFpEF outpatients was performed over 12 months before the COVID-19 pandemic. Baseline characteristics, clinic activities (eg, medication changes, lifestyle modifications, management of comorbidities) and follow-up arrangements were compared between a HFpEF and general cardiology clinic to assess their impact on mortality and morbidity at 6 and 12 months.

Results

Between the two clinic groups, the sample population was evenly matched with a typical HFpEF profile (mean age 79±9.6 years, 55% female and a high prevalence of cardiometabolic comorbidities). While follow-up practices were similar, the HFpEF clinic delivered significantly more interventions on lifestyle changes, blood pressure and heart rate control (p<0.0001) compared with the general clinic. Despite this, no significant differences in all-cause hospitalisation and mortality were observed. This may be attributed to the fact that clinic activities were primarily cardiology-focused. Importantly, non-cardiovascular admissions accounted for >60% of hospitalisation, including causes of recurrent admissions.

Conclusion

This study suggests that existing general and emerging dedicated HFpEF clinics may not be adequate in addressing the multifaceted aspects of HFpEF as clinic activities concentrated primarily on cardiological measures. Although the small cohort and short follow-up period are important limitations, this study reminds clinicians that HFpEF patients are more at risk of non-cardiac than HF-related events. We have therefore proposed a pragmatic framework that can comprehensively deliver the modern guideline-directed recommendations and management of non-cardiac comorbidities through a multidisciplinary approach.

Telemedicine in pediatric cardiology: pros and cons

PURPOSE OF REVIEW

The aim of this article is to review recent uses of telemedicine in pediatric cardiology, highlighting merits, challenges, and future directions.

RECENT FINDINGS

The COVID-19 pandemic accelerated telemedicine use, which has had a positive impact with respect to providers, patients, and their caregivers. Recent data have demonstrated the feasibility and effectiveness of telemedicine through expediting needed care and reducing healthcare utilization, including unnecessary emergency department visits, transports, and hospitalizations. With increasing complexity of cardiac care, telecardiology allows for establishing a medical home, improving access, and continuity of care. Great potential also exists for telecardiology to permit more consistent preventive care, possibly resulting in improved health equity, reduced morbidity and mortality, and associated costs. Challenges to optimal implementation of telecardiology, which are all surmountable, include the currently unaccounted additional workload and administrative burden, licensing restrictions, disparities in access to care, insurance reimbursement, and potential fraud and abuse.

SUMMARY

Telecardiology allows for efficient, quality, effective, collaborative care and is foundational to creating innovative, high-value care models. Through integration with accelerating technology and in-person visits, a sustainable hybrid model of optimal care can be achieved. Addressing barriers to progress in telecardiology is critical.