Remote Cardiovascular Care Reached Underserved Populations During COVID-19

Neal Yuan, MD

The transitional use from in-person to remote ambulatory cardiovascular care led to a significant increase in remote visits during the COVID-19 pandemic, according to a recent study.

Investigators conducted a cross-section study of 176,781 ambulatory cardiology visits, finding that remote-use patients during the COVID-19 era were more likely to be Asian, Black or Hispanic individuals, traditionally underserved patient groups, as well as those with private insurance.

However, clinicians had significantly lower rates of ordering medication and tests during video and telephone visits compared to pre-pandemic in-person visits.

The study, headed by Neal Yuan, MD, of the Smidt Heart Institute at Cedars-Sinai Medical Center, stated it is the first to investigate how the “dramatic increase in the use of telehealth is associated with changes in cardiovascular patient care in a real-world setting.”

The data did not measure differences in care access, but they were able to characterize overall differences in care usage.

“The promise of telemedicine has always been tempered by concerns about disparities in access driven by the digital divide,” investigators wrote.

These disparities in access are generally thought to affect those who are older, have lower income and less education, as well as underrepresented minority groups, patients in rural areas and patients with chronic conditions. These communities are known to have less access to the internet and thus telemedicine services, making technology literacy and use a concern for telemedicine access

Trends in the data were consistent with certain expectations. Patients with private insurance and higher socioeconomic status made up a large percentage of remote visits compared to low-income individuals without access to technology.

However, disparities not expected included those in underrepresented racial communities using video and telephone care more than White individuals. Data also showed patients using remote visits were more likely to have documented cardiovascular comorbidities.

The investigators identified visits from 31 different cardiology clinics in the Los Angeles area between the COVID-19 period of April 1 – December 31, 2020, when remote visits increased. This data was compared to a pre-COVID cohort from April 1 – December 31, 2019 to minimize fluctuations in patient composition and ordering.

Data analysis of the study included the following:

• 87,182 pre-COVID in-person visits
• 74,498 COVID-era in-person visits
• 4,720 COVID-era video visits
• 10,381 COVID-era telephone visits

Information available from the electronic health record (EHR) was used to determine visit type (in-person, video, or telephone) and ordering frequency of the most common cardiology-specific diagnosis test (ECGs. TTEs, etc.) Ordering frequencies of tests and medications by visit type were categorized by month and compared against daily COVID-19 case rates as reported by the Los Angeles County Department of Public Health.

Investigators stratified the visit data by time period, pre-COVID and COVID era. All 2019 visits were held in person, creating 4 visit types pre-Covid in-person, COVID-era in-person, COVID-era video, and COVID-era telephone. In the data, the differences in discrete variables between groups were evaluated by the χ2 test and continuous variables evaluated using the t test.

Multivariable linear regression studied the association between visit type and the number of diagnostic tests ordered per visit. Multivariable logistic regression studied the association between visit type and the odds of ordering at least 1 medical test or medication.

All analyses adjusted for these patient demographics and visit characteristics that may affect ordering patterns, including age, sex, race and insurance status, as well as adjusting for 155 individual clinicians practice patterns.

A minority of patients (45%) were female, while 71.9% were non-Hispanic White, and the mean age was 68.1 years.

Patients accessing remote visits in the COVID-era were more likely to be Asian, Black or Hispanic individuals. These minority communities Pre-COVID in-person visits were 24,934 (28.6%) versus 19,742 (26.5%) for COVID-era in-person visits. COVID-era video visits were 3,633 (30.4%) versus 1,435 (35%) for COVID-era telephone visits.

Investigators believe the gradual increase of telehealth in previous decades and the now-widespread use during the pandemic will result in a permanent and significant future for remote cardiovascular care.

“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,” they concluded.

The study, “Patient Use and Clinical Practice Patterns of Remote Cardiology Clinic Visits in the Era of COVID-19,” was published online in JAMA Network Open.