Telemedicine May Adversely Impact Care Quality for HF Patients

Heart failure (HF) patients whose physicians tend toward greater use of telemedicine are less likely to undergo diagnostic testing, according to observational data from Stanford Medicine.

Additionally, remotely managed patients—even those with reduced ejection fraction (HFrEF), for whom there are clear recommendations around guideline-directed medical therapy (GDMT)—are less likely to be started on the ideal drug regimen.

Many studies have shown an underuse of GDMT in HF, “possibly related to clinical inertia and all the barriers patients face in getting care,” said senior author Neil Kalwani, MD (Stanford University and VA Palo Alto Health Care System, CA). With telemedicine, these obstacles might be augmented when clinicians lack key pieces of information at the time of the visit, he explained.

“As a clinician prescribing [drug therapy] that may reduce blood pressure, that may reduce heart rate, that could affect kidney function, electrolytes—if you don’t have that data ready at the time of the appointment, you may not feel comfortable prescribing some of these medications,” Kalwani told TCTMD. “Then, the can sort of gets kicked down the road and patients may not get these really important therapies that we know can reduce mortality, prevent hospitalizations, and improve quality of life.”

The differences in care “underscore the need to be intentional and strategic” when using telemedicine in the heart failure setting, he added.

While prior studies have been done on remote care delivery for HF patients, these came with limitations. “A lot of them were very much focused on the early phase of the COVID-19 pandemic when we know that care delivery was not routine, and [they] also compared patients who got telemedicine to those who got in-person care,” he explained. With the latter, “oftentimes the concern is that those patients may not really be comparable.”

For this study, Kalwani continued, “what we wanted to do was to take a different approach to the same question to try to see if we could get a better sense of the actual causal effect of telemedicine on the care patterns for patients with heart failure.”

The researchers tracked patterns in clinicians’ use of telehealth and how those tied to the care they offered their patients over nearly 4 years.

Kalwani said the decrease in diagnostic testing they saw made sense, in that when patients aren’t physically there, it’s simply less convenient to do tests and the decision in fact could be justified. More worrisome is the decrease in GDMT for patients with HFrEF, who are known to “really benefit from these medications,” he said.

Led by Mugdha Joshi, MD (Duke University School of Medicine, Durham, NC), the study was published recently in Circulation: Population Health and Outcomes.

The COVID-19 pandemic was when telehealth became an “indispensable” tool for maintaining care continuity, not just a means of reducing costs and improving access, according to the authors of an accompanying editorial. Today, say Gabriella V. Rubick, MD, Michael P. Thompson, PhD, and Jessica R. Golbus, MD (all from University of Michigan, Ann Arbor), these virtual encounters continue despite no longer being a necessity.

“As telemedicine shifts from innovation to infrastructure, questions persist about its impact on care quality, particularly for patients with HF, whose complex management relies on an integrated assessment incorporating physical examination, symptoms, vital signs, and diagnostic studies,” the editorialists write. The new results, they add, raise a question: “Is telemedicine conserving resources or sacrificing quality?”

Diagnostic Testing and GDMT

Joshi et al analyzed data for 7,741 HF patients (mean age 65 years; 41% female; 48.1% white) treated through Stanford Medicine by 44 clinicians between March 2019 and May 2023. They divided this study period into eight discrete 6-month intervals, excluding the height of the COVID-19 pandemic (March-May 2020). Patients were grouped according to the cardiologist who provided more than half of their visits for HF.

The patients whose clinicians were more apt to use telemedicine were less likely to have ECGs (incident rate ratio [IRR] 0.30 per 50-percentage-point increase in the proportion of visits; 95% CI 0.25-0.35), transthoracic echocardiograms (IRR 0.70; 95% CI 0.59-0.82), natriuretic peptide tests (IRR 0.66; 95% CI 0.49-0.88), and chemistry panels (IRR 0.66; 95% CI 0.56-0.76) ordered on their behalf. There was a nonsignificant trend toward fewer orders per patient for Holter monitors with higher telemedicine use.

Importantly, though, “we cannot determine whether the avoided tests represented high- or low-value care,” the investigators note.

Clinician telemedicine use also was tied to significant reductions in new medication orders for beta-blockers, renin-angiotensin-system (RAS) inhibitors, nitrates, diuretics, and total GDMT (beta-blocker, aldosterone antagonist, RAS inhibitor, hydralazine, and nitrate). The researchers did not assess SGLT2 inhibitor use because these drugs were not yet recommended by guidelines at the start of the study.

Among the 1,941 patients with HFrEF, seen by 28 cardiologists, those whose clinicians emphasized telehealth were less likely to be started on total GDMT (IRR 0.80 per 50-percentage-point increase in the proportion of visits; 95% CI 0.69-0.94) and on aldosterone antagonists (IRR 0.72; 95% CI 0.52-0.99).

“The reduction in GDMT prescribing is particularly concerning because these medications are known to reduce morbidity and mortality in this population,” the researchers write. This phenomenon “may have been due to decreased availability of objective data during telemedicine visits, including vitals and same-day labs, which may have led to increased clinician discomfort prescribing new medications with potential hemodynamic and renal effects.”

‘Unintended Consequences’

The researchers say the data point to the potential for “unintended consequences of substituting in-person visits with telemedicine in HF care delivery.” Some patients may be ill-suited to this form of delivery, they note, suggesting that hospitals “should implement improved clinic triage systems to preferentially direct these patients to in-person care in advance of their visits.” It may also be possible to leverage telemedicine in ways that augment rather than replace routine care.

Indeed, the editorialists conclude, “the message is not that telemedicine should be avoided, but rather that its implementation should be deliberate.” They add: “The pandemic demonstrated that telemedicine can expand access; the current challenge is to ensure it provides care that is not only accessible but also accountable, comprehensive, and of high quality.”

Joshi, Kalwani, and colleagues agree that, in HF care, remote management is challenging. On the flip side, telemedicine offers the opportunity to more regularly connect patients with their clinicians.

People with HF “often benefit from high-touch care, especially early [on] after their diagnosis and after hospitalization, when we know [they] are very vulnerable for readmission and bad outcomes,” Kalwani said. “Being able to add additional touchpoints with telemedicine or increase access for patients who may have a lot of difficulty coming for an in-person visit may significantly improve the quality of care.”

Next up, Kalwani and colleagues are trying to develop a virtual GDMT management pathway for HF patients admitted to the hospital, wherein pharmacists can assist with initiation and titration of drugs. Such an approach could then be tested in a randomized trial looking at quality measures and clinical outcomes.