Who is Using Telehealth for Cardiology Care During COVID-19?

During the peak of the COVID-19 pandemic, patients who most frequently used telehealth for cardiovascular care tended to be younger and privately insured, to have more comorbidities, and to be from underrepresented racial groups, according to data from Los Angeles. Additionally, both diagnostic testing and medication prescribing decreased for remote visits following the start of the pandemic.

Video and telephone appointments were not a new phenomenon in 2020, but by March, they became a lifeline for many patients who were unable or hesitant to access in-person care.

“The pandemic really jump-started the shift to telemedicine, but I think a lot of people found that they really liked the convenience of those visits and I think that there's a good chance that telehealth is definitely going to be here to stay even as the pandemic wanes,” lead author Neal Yuan, MD (Cedars-Sinai Medical Center, Los Angeles, CA), told TCTMD. “It's a really important topic and definitely an exciting area of research for potential ways that we can expand our reach to patients and improve the quality of care we can provide.”

Even though the data from this study come from a single institution, Ankitkumar Patel, MD (Hackensack University Medical Center, NJ), commented to TCTMD that it “definitely helps allay some concerns about disparities of care. . . . This provides practical data showing that telemedicine and remote visits can be done. And I think it sets in place data and research that we're going to get over the next couple of years really looking at outcomes, which I think will be the most important element.”

Patient, Visit Features

For the study, published online April 5, 2021, in JAMA Network Open, Yuan and colleagues compared 87,182 pre-COVID-19 in-person visits (April to December 2019) at 31 Los Angeles-area cardiology clinics with 74,498 in-person, 4,720 video, and 10,381 telephone COVID-19-era visits (April to December 2020).

Patients accessing remote visits during the pandemic were younger on average and more likely to be Asian, Black, or Hispanic; to have private insurance; and to have comorbidities including hypertension and heart failure compared with 2019 visits.

Patient Characteristics: Remote and In-person Visits

After adjustment for patient and visit characteristics, clinicians were less likely to order medications or ECGs in 2020 for all types of interactions as compared with 2019 in-person visits, with the drops being the most marked for video, followed by telephone visits. The only tests to see an increase were echocardiograms—following in-person consults in 2020—but echo referrals during the pandemic were significantly lower than 2019 for both video and telephone visits.

Of note, overall rates of ordering tests and medications increased during the pandemic in months where there were lower daily COVID-19 case numbers and vice versa.

“The rapid and large-scale transition from in-person to remote cardiovascular care during the COVID-19 pandemic has important implications for patient access to care as well as clinician practice patterns,” Yuan and colleagues write. “As a substantial proportion of future cardiology ambulatory care will likely continue to be delivered through remote visits, these changes in care access and practice patterns will have substantial ramifications with regards to both the efficacy and cost of future cardiovascular care.”

Fundamental Change in Practice

Historically, Yuan explained, the “digital divide” was thought to be a barrier to offering widespread telemedicine since many older, rural, and less-affluent patients might not have easy access to remote visit platforms. “While some of those demographics I think did track with access in the way that we might have expected, . . . there were other trends that I think were unexpected,” he said.

For instance, while the researchers were initially surprised that Asian, Hispanic, and Black patients were more likely to use remote visits during the pandemic, “when we thought about it more, I think there are good reasons for why that may have been the case. During the pandemic, it was pretty heavily publicized that individuals from these groups were at higher risk for COVID infection and severe COVID disease, which I think would have made a remote visit a lot more appealing to these patients than having to come in and potentially be at risk for exposure.”

Telehealth visits are also more convenient in terms of both scheduling and transportation, Yuan continued. “During a pandemic where we know that minority individuals made up a disproportionate amount of the essential worker workforce, that that may have been something that was especially appealing to those individuals who may not have been able to get to in-person visits,” he said.

Their results should serve as a baseline to “get a sense of where we are in terms of which patients we're able to reach,” Yuan said. “It is an interesting start for future studies that might be able to better get at the motivations and the reasons.”

It’s obvious that telehealth visits are fundamentally different from in-person visits, “both in terms of who we're able to reach as well as the way that we practice medicine,” he added. “What that means is that telehealth visits require specific attention in terms of understanding how we can improve the way we're providing care through this mechanism and what are the best practices. While telehealth has been around for a while, it's never been implemented at this scale, and like any new technology, there's always going to be a learning curve and it just speaks to the importance of having processes in place where we're able to continually study what are the effects of this new technology in our clinical practice.”

Patel said he was not surprised to see a dip in medication and test ordering during the pandemic. “That makes sense for two reasons,” he explained. “One, I think physicians at that time were hesitant to make significant changes in patients’ care if they were stable because doing follow-up testing and so forth was challenging. And, two, I think a lot of it was driven by patients who didn't want to come into medical environments, especially in the northeast and the New York metropolitan area where I practice. Patients were very hesitant.”

He agreed with Yuan that the results provide a solid baseline for future research, but said he’d like to see more widespread findings throughout other geographies and also outcomes research.

“The COVID-19 pandemic provided an opportunity that I don't think that many of us who were early adopters had thought would ever come at this massive scale,” Patel said. “That really has changed the way that we're able to provide care for patients. I think it really is a good complement to in-person visits. You're not going to replace in-person visits, nor should you, but I think this has really changed the way that you can provide care. People don't have to take off half a day of work to go to their own doctor's appointment. Family members can be across the country and participate. These are things that are all going to be studied and I think will be interesting.”

Reasons for Continued Reimbursement

The question of reimbursement for telehealth remains in limbo. The Centers for Medicare & Medicaid Services (CMS) had included telehealth as a temporary category in its Medicare Physician Fee Schedule (PFS) rule for 2021, but no updates have been released with regard to a more-permanent change.

 “In order for telemedicine to provide the increase in accessibility for patients, ideally reimbursement should remain the same because I think you don't want to disincentivize something that is providing more healthcare access to patients,” Patel said. “I imagine healthcare payers will look at ways of cost-savings, like anything else. Telemedicine still does require office support to prep the patient's chart, coordinate the appointments, email links, troubleshoot, so it's not completely free of resources that an in-person appointment has.”

But on the other hand, “telemedicine will allow you to reduce readmissions—I think that will be a key opportunity, he continued. “Whereas you may have an increase in visits, you're able to see patients a little bit more freely, the downstream effect will be less-costly care as you'll be able to prevent patients from having decompensations, being admitted to the hospital, requiring more aggressive therapies, and so forth.”

Yuan agreed. “There were a lot of changes that were implemented during the pandemic which allowed for reimbursement for telehealth visits, and I think that did go a long way in terms of really making telehealth a more-viable option,” he said. “I would support continuing to have reimbursement for telehealth visits. I think it is a really important part of clinical care. We saw a ton of patients accessing remote care from all sorts of different demographic backgrounds with a lot of different cardiovascular comorbidities, and we saw that it could expand potentially access to certain patient groups.”