Outpatient Management of Heart Failure During the COVID-19 Public Health Emergency After Adoption of a Telehealth Model

Abstract

The COVID-19 pandemic led to a dramatic change in the process of delivering outpatient care for patients with heart failure, including more reliance on telehealth to maintain care delivery. Excess mortality has been reported during the COVID-19 era. Heart failure patients represent a vulnerable patient population. Whether the increased use of telehealth was associated with a difference in outcomes for outpatients with heart failure is unclear. Further, there are multiple demographic and socioeconomic factors that are associated with reduced access to telehealth. I sought to describe the transition to telehealth in a cohort of heart failure patients and its association with outcomes during 2020 and to compare this with similar periods in 2018 and 2019, prior to the emergence of COVID-19. I also assessed disparities in access to video telehealth visits and compared outcomes between patients treated with video and telehealth visits. In March 2020, a large Midwestern healthcare system, encompassing 16 cardiology clinics, 16 emergency departments, and 12 hospitals, initiated a predominantly telehealth-based model for outpatient care in the setting of the COVID-19 pandemic. A propensity-matched analysis was performed to compare outcomes between outpatients seen in-person in 2018-2019 and via telemedicine in 2020. Adjusted multivariable analyses were used to determine predictors of access to video telehealth visits and compare outcomes between video versus telephone telehealth visits that were conducted in 2020. Among 8,263 unique heart failure patients with 15,421 clinic visits seen from March 15-June 15 in the years 2018, 2019 and 2020, telehealth was employed in 88.5% of 2020 visits but none in 2018 or 2019. Despite the pandemic, more outpatients were seen in 2020 (n=5,224) as compared with 2018 and 2019 (n=5,099/year). Using propensity matching, 4,541 telehealth visits in 2020 were compared with 4,541 in-person visits in 2018-2019. The comparison groups were well matched. Mortality was similar for telehealth compared with in-person visits at both 30 (0.8% vs 0.7%) and 90 days (2.9% vs 2.4%). Similarly, there was no excess in hospital encounters or need for intensive care associated with telehealth visits. In a sub-analysis, older age, African American race, lack of spouse or significant other, lack of college education, and lower median household income were associated with less use of video telehealth visits. Additionally, video visits were associated with fewer subsequent emergency department visits and hospitalization in comparison with telephone visits with no difference in mortality. The data suggested that telehealth outpatient visits in patients with heart failure can be safely incorporated into clinical practice without increases in subsequent acute care or mortality. There are certain demographic and socioeconomic factors that associated with reduced access to video visits and sensitivity to these issues may be needed to support equity in the use of telehealth care strategies.