Virtual Doctor Visits Reduce Missed Appointments After HF Hospitalizations: ViV-HF

PHILADELPHIA, PA—With data suggesting that more than half of patients with heart failure (HF) may skip their first outpatient visit after transitioning from a hospital stay to home, a small study suggests that a virtual visit option as a substitute for an in-office exam can increase the likelihood that the encounter will take place.

Missed clinic appointments after a recent hospitalization may be partially related to inconvenience or difficulty in getting to the appointment, said Eiran Z. Gorodeski, MD, MPH (University Hospitals Cleveland Medical Center, Ohio), last week at the Heart Failure Society of America (HFSA) 2019 meeting.

“In this trial we saw that there was no difference in the rate of hospital readmissions, ER visits, or death, so even though it was not powered for clinical outcomes . . . there was a comforting signal of safety for virtual visits that I think needs to be investigated further,” he told TCTMD.

But panelist Bertram Pitt, MD (University of Michigan School of Medicine, Ann Arbor), noted that while the technology has "important implications," the need to “visualize” congestion in patients with a recent HF admission could be a potential drawback of only seeing them on camera. “The evidence is that a lot people who are going out [of the hospital] look euvolemic but are not euvolemic, so . . . the concept is great, but I think I would be looking to evaluate congestion . . . ."

"Certainly, when you do a virtual visit you can't do a physical exam,” Gorodeski acknowledged. But such things as complexion and how patients are breathing can be visualized, he stressed. "The way we view virtual visits at 7 days postdischarge is in many ways [as] a screening platform. If someone seems to be doing poorly you can always invite them to come in, but most patients postdischarge are not congested, they are doing quite well. Probably more relevant issues are things like do they have their medications, do they understand what their follow-up appointments are, how to take care of themselves . . . ."

To TCTMD, Gorodeski said a future direction could involve hybridizing virtual visits with other devices that can detect congestion, such as a wearable vest or an implantable device in the pulmonary artery.

“Some patients already have an implantable device that can give you information about congestion metrics, so maybe that could be combined with a virtual visit,” he said. “But the truth is that we already know that in the majority of patients who are hospitalized for heart failure and who get readmitted, the readmission has nothing to do with heart failure. Medication errors are very common, patients being confused about medications is common . . . and with the virtual visits we’ve implemented as much as possible having patients hold up their pill bottles to the camera, so you’re doing medication reconciliation by video. A lot of times patients don’t remember to bring their pill bottles to clinic but in the virtual visit they are at home and have it there to show you, and I can tell you we do catch errors.”

Safe and Convenient

In the ViV-HF study, Gorodeski and colleagues compared outcomes in patients from the Cleveland Clinic who were discharged from a hospital stay and had either a 7-day postdischarge in-person office visit (n = 56) or a virtual visit via a secure video connection that they accessed from home (n = 52).

There were no significant differences between groups in terms of age, gender, racial profile, or education level. There also were no differences in insurance, living arrangement, distance from the hospital, or impairments in cognition or hearing. The majority of patients (about 60% in each group) had HF with reduced ejection fraction (HFrEF). Similar numbers of patients in each group were newly diagnosed, and similar numbers had been hospitalized for any cause in the 30 days prior to the HF admission.

In the in-person arm, the no-show rate was 50%, which was lower than the pretrial estimate of 76%, based on their institution’s experience. By contrast, the no-show rate for the virtual group was 34.6%, and this, too, was lower than the pretrial estimate of 51%. Although the difference between the arms in observed no-show rates amounted to a 31% lower relative risk for virtual visits, the reduction was not statistically significant (P = 0.12). Gorodeski said this was likely due to the study being underpowered, with lower-than-anticipated event rates in the control arm. For the clinical outcomes of hospital readmission, emergency room visit, and death, there were no significant differences at 45 days postdischarge in the combined or individual components.

According to Gorodeski, the platform that was used in the study allows patients to connect using any device they have at home, including smartphones, laptops, and desktops. Only 10% of patients approached for the study were unable to be randomized due to not having adequate equipment to participate.

"They log in to a virtual visit waiting room . . . and then the clinicians get a text message and log into the virtual visit room. I think that one way to overcome barriers is to use a platform like this that is both medically secure and makes things easier," Gorodeski said. Although the trial did not look at time spent with patients, he said virtual visits have the potential to be shorter and more convenient, allowing family members from out of state, for example, to join the call.

One potential barrier that does exist is that there is currently no way to bill for this type of visit. At the Cleveland Clinic, where virtual visits have been in use for a while for a variety of medical specialties, patients typically pay out of their own pocket. For the trial, Gorodeski said the investigators determined what an individual patient’s copay would be and told them they would pay only that amount regardless of whether they were randomized to the in-office or virtual visit.

According to Gorodeski, the findings may change the minds of some who initially thought that virtual visits for this patient population were dangerous and would lead to increased readmissions.

“We did not see that in this trial,” he observed. “It was quite the opposite.”