key: cord-0771362-u3zqickb
authors: Umapathi, Priya; Cuomo, Kimberly; Riley, Sarah; Hubbard, Abby; Menzel, Kathryn; Sauer, Erica; Gilotra, Nisha A.
title: Transforming ambulatory heart failure care in the COVID-19 era: initial experience from a heart failure disease management clinic
date: 2020-06-09
journal: J Card Fail
DOI: 10.1016/j.cardfail.2020.06.003
sha: 44d84a226efcc76f54d967ec2bf1fa2ff0d083a6
doc_id: 771362
cord_uid: u3zqickb

nan

Patients with heart failure (HF) require frequent medical contact and are at high risk of hospitalization (1) . Coronavirus disease 19's (COVID-19) rapid transmissibility, associated mortality and anticipated burden on the healthcare system forced dramatic changes in HF healthcare delivery (2, 3) . The immediate need to incorporate telemedicine prompted recent publication of a Heart Failure Society of America expert consensus statement on use of telehealth in HF(4). We thus describe our initial COVID-19 era experience of a telemedicinebased strategy to manage an at-risk ambulatory HF patient cohort in our HF disease management and ambulatory diuresis clinic.

Patients are referred to the Johns Hopkins Heart Failure Bridge Clinic after hospital discharge or by outpatient providers. Clinic services include assessment by HF certified nurse practitioners, HF medication optimization, intravenous (IV) diuretic administration, laboratories, education, and care coordination. Patients may be seen same day and as frequently as needed. In response to the first Maryland COVID-19 cases and state-issued "stay at home" orders, we implemented a COVID-specific clinic workflow incorporating telemedicine. In-person visits occurred per provider discretion. Weekly clinic volumes and hospital HF discharges (using all patient refined diagnosis related group [APR-DRG]) were tabulated. Patient and visit characteristics, and need for hospitalization were collected for the initial COVID-19 response study period: March 16 to April 24, 2020. All patients were screened for COVID-19 symptoms(5) and referred for testing as indicated. For comparison, clinic volumes and outcomes from March 18 to April 26, 2019 were tabulated. The study was approved by the Institutional Review Board.

There were 116 patients (61±14 years, 50% female, 70% Black, left ventricular ejection fraction 25±21%) seen 164 times (Supplementary Table) . Visit characteristics, including visit type, referral reason, diuretic interventions and disposition are depicted via flow diagram (Supplementary Figure) . Two-thirds of patients were seen post-discharge or for worsening HF. Weekly clinic volume trends by visit type are depicted in the Figure. During the initial COVID-19 response period, telemedicine accounted for 96 visits (58.5%): 70 tele-audio, 26 tele-video.

Home oral diuretic dose was increased at 16.7% of telemedicine visits and decreased at 6.3%. All patients remained at home after telemedicine visit except for 6 referred for in-person clinic assessment. Of 68 in-person visits, half resulted in IV diuretic administration. Home oral diuretic dose was increased at 48% of in-person visits. Eight patients were referred from clinic for inpatient management (Supplementary Figure) . Sixteen patients were tested for COVID-19; 2 tested positive. There were 27 patients hospitalized within 30 days after clinic visit: 3 were referred to hospice by clinic team.

In the 2019 comparison group, 221 patients were seen 326 times, with 62 (19%) IV diuretic visits and 34 (15.4%) hospitalized within 30 days of visit.

We demonstrate the role of telemedicine integrated into a HF disease management clinic evaluating at-risk HF patients during the COVID-19 pandemic. Additionally, we found continued access to in-person assessment and ambulatory IV diuresis paramount to keeping HF patients out of the hospital.

Though telemedicine has been previously successfully utilized in HF(6), the urgency with which its implementation occurred during the COVID-19 pandemic is unprecedented. We initially had delayed but ultimately successful conversion from in-person to virtual visits, with visit rates increasing over time. Initially, the majority were conducted via tele-audio, reflective of early barriers in accessing HIPAA-compliant videoconferencing. These and other barriers to telemedicine access remain a challenge and may further widen the socioeconomic healthcare disparities that already exist in HF (7) .

Despite in-person visits commonly prompted by worsening HF, acute hospitalization was rare, likely due to our ability to administer IV diuretics in the outpatient setting (8) . Complete physical examination and laboratories are also possible, unlike with telemedicine, and allow safe and timely HF medication optimization and HF hospitalization prevention. Thus, the role of inperson assessment is invaluable and should be emphasized to HF patients, who we found were often hesitant to come to clinic. Additionally, hospitalization rate appeared higher during COVID-19 period compared to 2019, however clinic volumes were half those in 2019, possibly due to more stable HF patients deferring clinic appointments.

From this initial experience, we recommend the following strategies be incorporated to optimize telemedicine in HF care: 1) Use hospitalization to educate and prepare patients for postdischarge virtual visits; 2) Empower and equip patients to perform self-care management and supply vital signs; and 3) Employ clinical infrastructure to receive, interpret and act upon data from increasingly available physiologic monitoring technologies. These initial experiences during COVID-19 lend insights to optimization of future outpatient HF care delivery, beyond the current global health emergency.

Patterns of hospital performance in acute myocardial infarction and heart failure 30-day mortality and readmission

Description and Proposed Management of the Acute COVID-19 Cardiovascular Syndrome

Unique Patterns of Cardiovascular Involvement in COVID-19

Virtual Visits for Care of Patients with Heart Failure in the Era of COVID-19: A Statement from the Heart Failure Society of America

Initial Public Health Response and Interim Clinical Guidance for the 2019 Novel Coronavirus Outbreak -United States

Web-based Internet telemedicine management of patients with heart failure

Racial disparities in health literacy and access to care among patients with heart failure

Spot Urine Sodium as Triage for Effective Diuretic Infusion in an Ambulatory Heart Failure Unit