- Far more heart patients have used telehealth appointments in the COVID-19 era than before the pandemic, but cardiologists ordered fewer diagnostic tests and medications for remote patients than for those who saw their doctors in person, research from the Smidt Heart Institute at Cedars-Sinai Medical Center has found.
- The data, published Monday in JAMA Network Open, also showed patients who tapped into remote visits were more likely to be Asian, Black or Hispanic, have private insurance and have cardiovascular conditions such as hypertension, coronary artery disease, atrial fibrillation and heart failure.
- Reduced access to electrocardiograms and other cardiac tests and less clarity in communication during virtual visits may partly explain the overall decrease in diagnostic testing during remote care, the researchers said, but further studies are needed to understand whether less frequent testing leads to missed diagnoses. GE Healthcare, Philips and Hill-Rom are among the companies that make ECG testing equipment.
As COVID-19 cases began to rise again in the last three months of 2020, outpatient visits to cardiologists lagged many other specialties, declining 20% from a baseline in March, before the start of the pandemic, according to a recent Commonwealth Fund analysis.
At the same time, heart specialists are participating in the virtual care boom. A survey from telehealth vendor Amwell, for example, has documented an expansion of virtual specialty care visits in high-volume fields such as cardiology during the pandemic, compared to mostly urgent care use beforehand.
Changes to CMS reimbursement policies have helped facilitate increased use of telemedicine services among Medicare beneficiaries. Support appears to be gaining in Congress for making coverage changes that expand access to telehealth permanent after the pandemic.
Noting that widespread adoption of telemedicine during the COVID-19 crisis has likely set the stage for remote visits to become a bigger part of future cardiovascular care, the Smidt Heart Institute researchers sought to assess the impact on patient utilization. The study examined EHR data for 176,781 cardiology visits.
The researchers found patients from underrepresented racial and ethnic minority groups were more likely to participate in remote care visits and surmised that essential workers from these populations may have found in-person medical appointments more difficult to attend.
Patients seen by telehealth visits also had more medical comorbidities, suggesting that the decrease in medication and diagnostic test ordering was not due to healthier patients opting for remote care, the researchers said.
The study noted prior concerns that telemedicine visits could lead to unnecessary testing and overprescription of medications, but the data showed the opposite: The frequency of all diagnostics testing decreased with video and telephone visits.
The most common cardiology diagnostic tests in the study included electrocardiograms, transthoracic echocardiograms, coronary computed tomography angiography, nuclear stress imaging, stress echocardiogram, exercise stress ECG, coronary artery calcium scan, cardiac magnetic resonance imaging and external ECG monitoring tests. Laboratory tests included B-type natriuretic peptide, lipid panel, complete blood count, metabolic panel, coagulation studies, erythrocyte sedimentation rate and C-reactive protein tests.
The researchers said that because there are few formal guidelines outlining best practices for remote cardiology visits, there may be unintended consequences from this new form of care that have yet to be identified.
"We were encouraged to learn that access to cardiovascular care was maintained for high-risk and underserved communities during the pandemic," Joseph Ebinger, director of clinical analytics at the Smidt Heart Institute and senior author of the study, said in a written statement. However, the data also revealed differences in care that need to be further studied to be understood, he said.
"We plan to next examine if the ordering of fewer tests, such as stress tests, might predispose to missed diagnoses," Ebinger said. "We are also investigating whether the fewer tests ordered might actually represent opportunities to streamline away from certain types of care that were not important contributors to health in the prior system of only in-person visits."