key: cord-0844053-zw6kq75x
authors: Taylor, Prentiss; Berg, Collin; Thompson, James; Dean, Kristin; Yuan, Tony; Nallamshetty, Shriram; Tong, Ian
title: Effective Access to Care in a Crisis Period: Hypertension Control during the COVID-19 Pandemic via Telemedicine
date: 2021-11-15
journal: Mayo Clin Proc Innov Qual Outcomes
DOI: 10.1016/j.mayocpiqo.2021.11.006
sha: 350f7d4ecbf0397b49bb5ffe3d3e6299ce180951
doc_id: 844053
cord_uid: zw6kq75x

Objectives To assess the effectiveness of telemedicine video visits in the management of hypertensive patients at home during the first year of the COVID-19 pandemic. We also evaluated associated measures of patient satisfaction with these holistic visits. Patients and Methods A quantitative analysis was performed of all home video visits coded with a diagnosis of Essential Hypertension during the first 12 months of the COVID-19 pandemic (March, 2020 through February, 2021). A total of 10,634 patients with 16,194 hypertension visits were present in our national telemedicine practice database during this time period. Among this population, a total of 569 patients who had 1,785 hypertension visits met the criteria of having two or more blood pressure readings, with the last blood pressure reading occurring in the report period. We analyzed baseline characteristics and blood pressure trends of these 569 patients over the study period. Voluntarily submitted patient satisfaction ratings, which were systematically requested at the end of each visit, were also analyzed. Results The mean age of the patients in this study cohort of 569 patients was 43.9 years, and 48.3% were women. Over 62% of the patients had an initial systolic BP over140 mm Hg, and 25% had an initial SBP of greater than 160 mm Hg. The average number of visits over the study period was 3.1 visits per patient. An average of 6.4 BP measurements per patient were available over the study period. Over the study period, 77% of the patients experienced an improvement in either systolic or diastolic blood pressure, with mean reductions of -9.7 mm Hg and -6.8 mm Hg in systolic and diastolic blood pressures, respectively. A total of 416 patients in the cohort started with a blood pressure above 140/90 mm Hg. For this subset of patients, 55.7% achieved a BP of <=140/90 by the end of the study period, and the average reductions in systolic and diastolic blood pressures were -17.9 mm Hg and -12.8 mm Hg respectively, which corresponded to improvements of 11.2% and 12.4% respectively. These improvements did not vary significantly when patients were stratified by age, sex, or geographic region of residence (rural versus urban/suburban). Voluntarily submitted patient surveys indicated a high degree of patient satisfaction, with a mean satisfaction score of 4.94 (5 point scale). Conclusion Clinician-patient relationships established in a video-first telemedicine model were broadly effective for addressing sub-optimally controlled hypertension. Patient satisfaction with these visits was very high.

Objectives: To assess the effectiveness of telemedicine video visits in the management of hypertensive patients at home during the first year of the COVID-19 pandemic. We also evaluated associated measures of patient satisfaction with these holistic visits.

Patients and Methods: A quantitative analysis was performed of all home video visits coded with a diagnosis of Essential Hypertension during the first 12 months of the COVID-19 pandemic (March, 2020 through February, 2021). A total of 10,634 patients with 16,194 hypertension visits were present in our national telemedicine practice database during this time period. Among this population, a total of 569 patients who had 1,785 hypertension visits met the criteria of having two or more blood pressure readings, with the last blood pressure reading occurring in the report period. We analyzed baseline characteristics and blood pressure trends of these 569 patients over the study period. Voluntarily submitted patient satisfaction ratings, which were systematically requested at the end of each visit, were also analyzed.

The mean age of the patients in this study cohort of 569 patients was 43.9 years, and 48.3% were women. Over 62% of the patients had an initial systolic BP over140 mm Hg, and 25% had an initial SBP of greater than 160 mm Hg. The average number of visits over the study period was 3.1 visits per patient. An average of 6.4 BP measurements per patient were available over the study period. Over the study period, 77% of the patients experienced an improvement in either systolic or diastolic blood pressure, with mean reductions of -9.7 mm Hg and -6.8 mm Hg in systolic and diastolic blood pressures, respectively. A total of 416 patients in the cohort started with a blood pressure above 140/90 mm Hg. For this subset of patients, 55.7% achieved a BP of <=140/90 by the end of the study period, and the average reductions in systolic and diastolic blood pressures were -17.9 mm Hg and -12.8 mm Hg respectively, which corresponded J o u r n a l P r e -p r o o f to improvements of 11.2% and 12.4% respectively. These improvements did not vary significantly when patients were stratified by age, sex, or geographic region of residence (rural versus urban/suburban). Voluntarily submitted patient surveys indicated a high degree of patient satisfaction, with a mean satisfaction score of 4.94 (5 point scale).

Clinician-patient relationships established in a video-first telemedicine model were broadly effective for addressing sub-optimally controlled hypertension. Patient satisfaction with these visits was very high. population awareness of having hypertension and rates of adequate control of hypertension have both declined over the past decade. 2, 3 The COVID-19 pandemic has exacerbated these issues by causing a greater than 25% decrease in primary care visits in the U.S. in 2020. 4 Multiple reports document the disruption of chronic care visits during the pandemic, 5 and the potential downstream negative impacts on population-level health as well as individual wellbeing. Many patients with chronic illnesses faced significant barriers to accessing care due to widespread primary care physician office visits closures during the initial months of the pandemic. Telemedicine visits were deployed by many health systems to address these issues.

As our group has previously reported, video visits were able to fill those gaps in access to care during the pandemic. 6 However, recent studies indicate that virtual visits, nationally, were much less focused on addressing hypertension and cardiovascular risk during 2020 than in recent non-pandemic periods. 7 This report describes the experience of our national telemedicine practice with primary care virtualist physicians trained to provide holistic hypertension care. We queried the effectiveness of video visits for hypertension for a national, commercially-insured population during the pandemic. In this study, our providers used the American Heart Association (AHA)-endorsed technique for home blood pressure (BP) monitoring to guide hypertension management via J o u r n a l P r e -p r o o f video visits with primary care physicians during the first COVID-18 pandemic year 2020-2021.

We also assessed patient satisfaction with this video-first approach to management of hypertension.

Encounters in the national Doctor on Demand Professionals database for the study period spanning from March 1, 2020 through February 28, 2021 were queried for essential hypertension visits (ICD10 code I10). We limited our analysis to patients with essential hypertension ICD I10 listed as the primary or secondary reason for visiting, with at least two hypertension-related visits, and at least two blood pressure readings with the last reading occurring during the study period ( Figure 1 ).

Video visits were conducted on home mobile devices or personal computers, with a board-certified primary care physician or a certified nurse practitioner. Over 95% of visits were performed by physicians. All clinicians followed AHA/ACC guidelines for hypertension treatment. 1 Self-measurement of BP used AMA-approved devices and the technique endorsed in AHA/ACC guidelines for hypertension. 1 The clinicians were trained to discuss AMA-or Consumer Reports-recommended, validated BP monitors with patients. Review of medications, family history, and comorbidities was captured in an EHR.

PCPs discussed diet (DASH diet), lifestyle, medication adherence, adverse effects, and shared decision-making with each patient. Screening for psychosocial stress was completed when indicated using the PHQ-2, PHQ-9, and/or GAD-7 questionnaire(s). Patients automatically received hypertension-specific follow-up instructions for home study and patient satisfaction J o u r n a l P r e -p r o o f surveys after each visit. Patients were prompted to provide feedback immediately following visits via a secure cloud-based digital platform using a 5-star rating system.

Systolic and diastolic BP reductions across all patients were determined by comparing initial BP to the last BP recorded within the study period (March, 2020 through February, 2021). Average systolic and diastolic BP reductions were stratified by age (<40 yrs, 41-60 yrs, and >60 yrs), sex (female vs male), geographic region (metro/urban vs rural), and initial systolic BP (<120 mm Hg, 120-129 mm Hg, 130-140 mm Hg, 140-160 mm Hg, and >160 mm Hg). Patient zip codes were self-entered and metro/urban vs. rural classification was based on a "Department of Labor -Office of Worker's Compensation Program" zip code dataset.

Statistics. Paired t-tests were employed to analyze differences in mean systolic and diastolic BP in patients at the start and end of the study period. Comparisons of average BP reductions stratified by age range, sex, geographic location, and initial systolic BP were performed using unpaired t-tests (sex, geographic location) and ANOVA (age range, initial BP range).

In our study, we identified a total of 569 unique patients who had a total of 1,785 video visits and 3,626 blood pressure readings over the 2020-2021 pandemic study period. The study population was representative of the general US population with regards to key demographic factors and clinical characteristics (Table 1 ). In the cohort, 48.3% of patients identified as female and 51.7% of patients identified as male. The mean age of patients included in the analysis was J o u r n a l P r e -p r o o f 43.9 ± 10.5 years. Over 86% of the video visits were conducted in metro/urban or suburban zip codes, while approximately 14% of visits were in rural zip codes. The cohort consisted primarily of primary prevention patients (0.5% had a prior history of ischemic heart disease). The prevalence of concomitant risk factors was significant but lower than observed in the general US population. The most prevalent non-hypertension CV risk factor in the cohort was dyslipidemia, with over 15% of patients carrying a diagnosis of a lipid disorder. Approximately 12% of the patients in the cohort were either overweight or obese. In addition, over 10% of the cohort had We examined the effectiveness of video telemedicine visits in the treatment of hypertension over the pandemic period by determining the reduction in recorded systolic and diastolic BP across patients in the study cohort. When we compared initial and final recorded systolic and diastolic BPs over the study period, we found statistically significant reductions of 9.7 and 6.8 mm Hg in systolic and diastolic BPs, respectively (p<0.00001, Figure 2A ). These changes corresponded to a 6.5% and 7.2% reductions in systolic and diastolic BP, respectively. The majority of patients achieved at least 5 mm Hg reduction with over 48% of the patients achieving at least a 10 mm J o u r n a l P r e -p r o o f Hg reduction in systolic BPs ( Figure 2B ). We observed similar trends for diastolic BP as well, with 54.0% of patients attaining a reduction of at least 5 mm Hg in their diastolic BP ( Figure 2B ).

When we stratified patients across key demographic and clinical factors, we noted broad effectiveness of video visits with several important trends. We observed similar reductions in women and men for SBP (9.74 vs. 9.67 mm Hg, p=0.97) and DBP (6.73 vs. 6.76 mm Hg, p=0.98) ( Figure 2C ). In addition, there were no significant differences in BP reduction based on geographic location or the number of visits ( Figure 2D Figure 2E ). When we stratified patients by initial blood pressures, we found that individuals who had higher baseline readings had a larger decrease in BP (data not shown). Over 70% of patients in the cohort (n=416) had an initial systolic BP > 140 mm Hg or diastolic BP> 90 mm Hg. The mean reductions in systolic and diastolic BP for these patients were -17.9 mm Hg and -12.8 mm Hg, respectively. In contrast, mean reductions in systolic and diastolic BP for patients who started with an initial systolic or diastolic above 130 / 80 were -14.2 mm Hg and -9.7 mm Hg respectively and were observed in patients with initial BP above 130/80.

When we examined prescriptions across the study period ( Figure 3A ), we found that 478 of the 569 patients were started on at least 1 new anti-hypertensive medication. The anti-hypertensives prescribed aligned well with AHA/ACC guideline recommendations. Angiotensin converting enzyme inhibitors were prescribed most frequently (29.4%). A similar frequency of prescriptions was observed for diuretics (21.1%), calcium channel blockers (24.0%), and beta blockers (24.0%).

To evaluate patient satisfaction, we analyzed patient surveys that were automatically offered to each patient just after the end of each visit. Patients were asked to rate their overall satisfaction with visit on a 1 to 5 scale, with 5 being the highest rating. Of the 569 patients analyzed, satisfaction survey data was available for 89.3% (n=508). The mean patient satisfaction score was 4.94/5.0, with 96.6% of the patients rating the visit either 4 or 5 ( Figure 3 ). Clinicians receive these scores from all patients seen at the end of each workday, along with optional typed feedback comments from each patient.

A rapidly growing number of reports in the literature describe the use of telemedicine video visits to develop systematic, large-scale efforts to promote hypertension treatment. A recent Cochrane review that analyzed outcomes of telehealth remote monitoring or video visits compared with inperson or telephonic visits for chronic illnesses such as congestive heart failure and diabetes found similar health outcomes. 8 conditions such as hypertension compared to prior brick and mortar office visits for the same patients. 7 As such, a 2020 AHA expert position paper that supports the use of telemedicine approaches to manage chronic conditions such as hypertension, also highlights and underscores important concerns and limitations with purely telephonic telehealth visits. 9 In this study, we conducted a retrospective analysis of telemedicine video visits in the management of hypertensive patients at home during the first year of the COVID-19 pandemic.

As recommended by the most recent ACC/AHA guidelines for prevention, evaluation, and practitioners, which is one of the key characteristics of this report. The findings can arguably telemedicine visits has been reported in several studies. [12] [13] [14] Patient satisfaction specifically with hypertension care via video visits is reflected in the current study, which we believe to be the first report of such findings.

Our study has a number of limitations, including the self-measurement of patient-reported blood pressures, in addition to variability in the home devices used, which could not be standardized.

In addition, our database does not include information on care received outside of the virtual care practice network studied in this investigation. Our data is on a commercially insured population, and comprehensive assessment of all patient comorbidities, and ethnic/racial identifications are not captured in our database. Also, these results may not be generalizable to clinician workforces who have not been trained in the evaluation and management of patients via a telemedicine video visit. This study is not systematically comparing home video visits to inoffice visits. Also, this is an observational study, and the analysis is not comparing an intervention to a control group in a randomized clinical trial. We are aware that some experts recommend obtaining twice-daily SMBP readings for ideally five to seven consecutive days. 3 Following such a strict protocol is not practical in terms of patient expectations and satisfaction with real-world telemedicine visits.

Virtualist visits for hypertension in the U.S. during the pandemic were generally effective, when access to PCP care was disrupted. The holistic approach plus AHA/ACC guideline-adherent care may be key. Reductions in SBP and DBP compare favorably to in-person settings. Patient J o u r n a l P r e -p r o o f satisfaction scores were high. These results are a baseline for future population-level hypertension and cardiovascular risk interventions for populations with suboptimal access to quality health care across many rural and urban zip codes. Readers should be reminded that this study is focused on a national telemedicine practice which is providing access to quality care in a national health emergency, in conditions that are suboptimal for running detailed research protocols. We should also be reminded that follow-up by patients was good, over several visits in this cohort, which also speaks to the practical utility of these visits, patient acceptance and patient adherence to the holistic advice to achieve hypertension control.

The results of this study suggest that a holistic approach to hypertension management, attending to lifestyle changes and appropriate medications, is effective via virtual video primary care visits, nationwide. We did not find notable differences between patients in terms of rural or metro location, gender, ethnicity, or other factors, other than adherence to therapy. The few patients whose blood pressure did not improve were patients who admitted they were nonadherent to lifestyle or medication recommendations. Additional research to understand the barriers to care for this subset of the telemedicine patient population may yield useful insights. Patient satisfaction with these virtual hypertension visits was very high. These findings further support J o u r n a l P r e -p r o o f 

PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology

Treatment and Control of Hypertension in 2020: The Need for Substantial Improvement

Trends in Blood Pressure Control Among US Adults With Hypertension

A systematic review: effect of angiotensin converting enzyme inhibition on left ventricular volumes and ejection fraction in patients with a myocardial infarction and in patients with left ventricular dysfunction

The Effects of the Health System Response to the COVID-19 Pandemic on Chronic Disease Management: A Narrative Review

Where Virtual Care Was Already a Reality: Experiences of a Nationwide Telehealth Service Provider During the COVID-19 Pandemic

Use and Content of Primary Care Office-Based vs Telemedicine Care Visits During the COVID-19 Pandemic in the US

Interactive telemedicine: effects on professional practice and health care outcomes

Evidence and Recommendations on the Use of Telemedicine for the Management of Arterial Hypertension: An International Expert Position Paper

CardioClick an Innovative Telehealth Approach to Lifestyle Intervention in High Risk South Asians

Improved blood pressure control associated with a large-scale hypertension program

Patients' Satisfaction with and Preference for Telehealth Visits

Patterns of Use and Correlates of Patient Satisfaction with a Large Nationwide Direct to Consumer Telemedicine Service