key: cord-1018964-ymq5cge1 authors: Piskulic, Danijela; McDermott, Susanna; Seal, Lauren; Vallaire, Shelley; Norris, Colleen M title: Virtual visits in cardiovascular disease: a rapid review of the evidence date: 2021-10-11 journal: Eur J Cardiovasc Nurs DOI: 10.1093/eurjcn/zvab084 sha: 9079baece667a7e4cb7f64e197e4fcccfce637be doc_id: 1018964 cord_uid: ymq5cge1 Given the high prevalence of cardiovascular disease (CVD) in Canada and globally, as well as the staggering cost to human life and health systems, there is an urgent need to understand the successful applications of telemedicine in cardiovascular medicine. While telemedicine in cardiology is well documented, reports on virtual care in the form of synchronous, real-time communication between healthcare providers and patients are limited. As a result of the immediate suspension of ambulatory services for cardiology in Alberta, Canada, due to the Coronavirus Disease 2019 pandemic, we undertook a rapid review on the impact of non-virtual visits in cardiovascular ambulatory settings on patients’ healthcare utilization and mortality. Evidence from 12 randomized control trials and 7 systematic reviews was included in the rapid review, with the majority of papers (n = 15) focusing on telemedicine in heart failure. Based on our appraisal of evidence from the last 5 years, virtual visits are non-inferior, or more effective, in reducing hospitalizations and visits to emergency departments in patients with CVD compared to traditional standard in-clinic/ambulatory care. The evidence for a superior effect of virtual visits in reducing mortality was not supported in this review. While telemedicine is an appropriate tool for CVD follow-up care, more research into the efficacy of different components of telemedicine and virtual visits is required. Telemedicine, or exchange of medical information and communication using a variety of technological platforms aimed at improving patients' clinical health status, 1 has experienced a substantial surge in recent months due to the Coronavirus Disease 2019 (COVID- 19) pandemic. Telemedicine is a viable platform for connecting with patients considered out of in-person reach (e.g. remote settings, high dependency settings such as long-term care). It provides continued care of patients with chronic cardiovascular disease (CVD) who are vulnerable and those clinically compromised under the COVID-19 pandemic. The use of telemedicine has quickly spread and integrated into hospital operations, healthcare providers' offices, public health agencies, and patients' homes. 2 In Canada, 1 in 12, or 2.4 million adults live with diagnosed heart disease. 3 Given that CVDs are the leading cause of death worldwide with an estimated 17.9 million deaths annually, 4 and have increasing treatment-associated costs to health systems (over 75% of CVD-related deaths occur in low-middle-income countries), 4 there is a need to understand applications of telemedicine in cardiovascular contexts globally. Applications of Implications for practice • Telemedicine is an appropriate tool for follow-up care in patients with cardiovascular disease. • Virtual visits are non-inferior to standard in-clinic follow-ups in reducing hospitalizations and emergency department visits in patients with cardiovascular disease. • Heart failure remote monitoring programs have the potential to provide benefits for patients, their family caregivers, and health systems. telemedicine range from remote-monitoring and transmission of biometric data (i.e. teletransmission) and asynchronous communications, to synchronous, real-time assessment, and consultation via audio and video conferencing systems (i.e. virtual visits). Telemedicine aids the clinical management of CVD patients without in-person visits and has a potential for vast clinical utility across various clinical settings in acute and ambulatory services. While the COVID-19 pandemic saw an increase in the use of virtual visits in primary care, a platform that has been underutilized in Canada prior to the pandemic, 5 there is limited evidence as to its effects on patientlevel outcomes in cardiology. 6 Despite the reported usefulness of telemedicine in cardiology, 2 reports on virtual care in the form of synchronous, real-time communication between healthcare providers and patients are limited. Given the immediate suspension of ambulatory services for cardiology in Alberta, Canada, due to the COVID-19 pandemic, and a surge in telemedicine utilization, we undertook a rapid review of the evidence of the impact of virtual visits in cardiovascular ambulatory settings on patients' healthcare utilization and mortality outcomes globally. This undertaking was done as part of the broader scientific initiative, the Scientific Advisory Group (SAG), within the Strategic Clinical Networks (SCNs) at Alberta Health Services (AHS), the main health authority in the province of Alberta, Canada. The initial request for the current rapid review was issued by Alberta Health Services' (AHS) Scientific Advisory Group (SAG) that was tasked with creating high-quality, rapid evidence syntheses for the purpose of providing recommendations to support policy and operational decisions within AHS in the wake of the COVID-19 pandemic emergency response. The review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) methodology 7 as closely as possible due to time constraints associated with rapid reviews. 8, 9 It is worth noting that a number of PRISMA guidelines have been adapted for the purpose of the current rapid review, including but not limited to: (i) accelerated evidence synthesis; (ii) date-restricted literature search; (iii) publication language limitations; (iv) inclusion of higher quality designs only; (v) limited outcomes; and (vi) exclusion of grey literature. Figure 1 illustrates a flow diagram of the literature search and study selection process. 7 A range of virtual technology interventions are utilized and described in review articles, many referring to remote monitoring and patient care using both asynchronous and synchronous provider-patient communication. Asynchronous communication refers to a one-way 'store-and-forward' transmission of health information. It includes remote monitoring (i.e. telemonitoring), or collection of clinical patient data, such as blood pressure, heart rate, heart rhythm, oxygen saturation, weight, electrocardiography, and other cardiac-related measurements with home-based teletransmission systems. For the purpose of the rapid review, we use the most frequently occurring term, 'telemedicine' to encapsulate all other related terms (e.g. telehealth, e-health, m-health etc.). In this context, telemedicine is defined as synchronous telecommunication-based management of patients using telephone and video-based care or support, with or without additional function of teletransmission or transfer of patients' biometric information to the healthcare provider via internet connection. 10 For this rapid review, virtual visits were defined as a clinical interaction involving synchronous bi-directional communication between a healthcare provider and a patient using information communication technology. Standard treatment, in comparison, was defined as in-clinic/ambulatory care and followup that does not involve telemedicine. The inclusion criteria for the rapid review included: (1) Randomized controlled trials, systematic reviews, and/or metaanalyses published between 2015 and 2020; (2) Study focus on adult ambulatory patients with cardiovascular disease (e.g. heart failure, acute coronary syndrome, heart attack, myocardial infarction, and arrhythmia); (3) Studies that included provider-patient synchronous virtual or remote communication (including mention of telemedicine, telemonitoring, telecommunication, remote monitoring/consultation, and videoconferencing); (4) Studies that reported healthcare utilization (i.e. hospitalization, emergency department visits, visits by emergency medical services) and mortality (i.e. all-cause and/or disease-specific mortality) as the primary outcomes; (5) Articles written in English. As this was a rapid review, grey literature was excluded from the search and published research referenced in relevant systematic reviews and meta-analyses was extracted for review only if the publication dates fell within the review's publication time frame of 5 years. Limiting the search strategy to the last 5 years was in direct response to the large volume of articles published on this research question. Finally, studies that only included and described asynchronous provider-patient communication were excluded from the rapid review. Research questions, inclusion and exclusion criteria, and a plan for the review design were discussed with a qualified librarian (LS) prior to the search. A search was performed on 27 January 2021, on articles published between 2015 and the day of the search per the inclusion criteria (see Supplementary material online, SA for the comprehensive list of search headings and the search strategy by database, and Supplementary material online, SB for the research question and data dictionary). Using the key terms, the Librarian performed a comprehensive literature search of the following databases that focus on health sciences research: CINAHL, OVID MEDLINE, PubMed, TRIP Pro, and Google Scholar. Briefly, the Librarian used major headings such as cardiovascular disease, telemedicine, videoconferencing, telecommunications, acute care, and ambulatory care as well as a range of combinations of search terms across all databases. Title and abstract screening were initially performed independently by three reviewers: C.N., D.P., and S.M. In case of disagreements or uncertainty regarding inclusion of articles, the reviewers had a discussion until a consensus was reached. The review of full-text articles was performed by D.P. and S.M., whereby each reviewer was designated half of all articles selected for the screen. In case of uncertainty or disagreement regarding the inclusion of an article, the final decision was made by the senior author, C.N. Data extraction from full-text articles was performed independently by the two reviewers: D.P. and S.M. While the data extraction sheet included 14 different categories, general information relating to virtual visits and their descriptions has been outlined in Table 1 Quality analysis of included articles was performed using the AMSTAR 2 assessment tool for systematic reviews, 29 and the Downs and Black Checklist for randomized controlled trials. 30 The literature search generated 301 articles, and 4 additional articles were identified through searching the references of search-generated articles. After deduplication, 168 articles underwent a title and abstract screening. Of those, 67 studies were selected for a full-text screen, and 19 were included in the rapid review based on our inclusion criteria. Seven studies were systematic reviews (4 of which included a meta-analysis), and 12 were randomized controlled trials (RCTs). Figure 1 shows a PRISMA diagram of the study screening and selection process. All included articles were peer-reviewed. The active study period described in included articles ranged from 1999 and 2018. Four studies (20%) had unspecified study periods: one systematic review, 11 one systematic review and meta-analysis, 20 and two RCTs. 17, 24 Of the five remaining systematic reviews, reported study periods ranged from 8 to 18 years; of the 10 remaining RCTs, study periods ranged from <1 to 6 years. The majority of studies were conducted in North America and Europe. The most-reported cardiovascular disease (CVD) was heart failure (HF) with 15 out of 19 studies (79%) making it their focus (n = 5 systematic reviews, n = 10 RCTs) ( Table 1) . Patients in the HF group were in all stages of the disease process, with and without implantable devices, such as implantable cardioverter-defibrillators (ICD). The remaining studies (n = 4) described clinical outcomes of patients recovering from the acute myocardial infarction (AMI), 27 cardiovascular surgery, 11 post-operative patients requiring an ICD, 16 and chronic cardiovascular conditions. 22 Telemedicine consultations described in the literature Asynchronous communication Asynchronous communication described in the included studies included remote monitoring from implantable cardiac devices (n = 4), 14, 16, 23, 26 and patient-initiated data collection and transfer (n = 9). 15, [17] [18] [19] 21, 24, 25, 27, 28 Synchronous communication: virtual visits Synchronous, bi-directional real-time communication between patients and healthcare providers described in the included RCTs consisted of either telephone/audio conference (n = 6), 14, 18, 19, [21] [22] [23] video conference (n = 3), 17, 24, 27 or the combination of both (n = 3). 15, 16, 18 Clinical patient outcomes of interest included mortality (all-cause and disease-specific) and healthcare utilization. In the context of the rapid review, healthcare utilization included hospitalizations (all-cause and disease-specific), and visits to the emergency department (ED). The rates of hospitalizations ranged between 7% and 51% in the remote monitoring patients compared to standard care patients (8.5-55%). Studies reported effects of virtual visits on both all-cause and cardiovascular disease-specific hospitalizations. For all-cause hospitalization rates, four studies reported no difference between patients who were followed up remotely using virtual technology and patients receiving standard follow-up care. 14, 21, 24, 25 In contrast, three studies reported significantly reduced rate of hospitalizations in remote follow-up patients. Comin-Colet et al. 15 reported 25% vs. 45% hospitalization rate, mainly driven by the prevention of CVD and HF-related hospitalizations. Idris et al. 17 reported reductions in remote monitoring group in the first 30 days, but not at follow-up. Jimenez-Marrero et al. 18 reported statistically significant decreases in cardiovascular-related, HF-related, and all-cause hospitalizations among the telemedicine group. One study, Luthje et al. 23 reported an increased rate of urgent care visits in the remote monitoring group due to early detection of HF decompensation; the researchers commented that patients who were not monitored remotely may have spontaneously improved, which may have explained this discrepancy in urgent care visits between the groups. For disease-specific (including device-specific) hospitalizations, a number of studies (n = 5) reported a significant reduction in diseasespecific hospitalization rates in patients receiving the remote monitoring. 14, 15, 18, 19, 26 According to Boriani et al., 14 the 38% reduction in HF-related hospitalizations in their study was mainly affected by a reduction of in-clinic visits. In contrast, the remaining studies (n = 4) reported no group differences in hospitalization rates, 21, 23, 27 or ED visits. 24 Mortality Mortality rates reported in the literature ranged 6-15% with no statistically significant difference between patients receiving virtual visits and those receiving standard care. This was true for studies that reported all-cause mortality, [14] [15] [16] [17] 19, 21, 25, 26 and CVD-specific mortality. 14, 21, 23 One study reported decreased all-cause mortality (12% vs. 6%) and decreased CVD-related mortality (9% vs. 4%) among the telemedicine group in comparison to standard care. 18 Findings from systematic reviews and meta-analyses From 2017 to 2020, seven systematic reviews and meta-analyses evaluated the effects of telemedicine on clinical outcomes of patients with HF ( Table 1) . Findings from critical appraisals of the evidence vary widely, ranging from no effect of telemedicine technologies on clinical health outcomes and mortality to reduced healthcare utilization and mortality rates in patients undergoing telemonitoring compared to those assigned to standard care. Aronow et al. 12 interventions in patients with HF concluded that structured telephone support and telemonitoring were successful at reducing the risk of death and hospitalizations due to HF compared to standard care. A similar conclusion was reached by Kruse et al. 22 who critically appraised 20 studies and reported that telemedicine successfully reduced readmissions, hospitalizations, and mortality rates of patients with chronic CVD. In contrast, Lin et al. 10 reviewed 39 studies on effects of telemedicine in patients with chronic HF, and reported that nurse-led telephone-supported care was no different from standard care at improving clinical outcomes in HF patients, with the exception of reducing HF-related hospitalizations. The authors reported also that teletransmission was successful at improving clinical patient outcomes. 10 Two other systematic reviews by Bashi et al. 13 and Zhu et al. 28 concluded that telemedicine was associated with a significant reduction in the total number of all-cause and disease-related hospitalizations and mortality. Healthcare provision and monitoring for patients in the virtual visit groups differed by provider type, the information provided during virtual visits, and frequency and length of follow-up ( Table 2) . Treatment providers ranged from physician specialists, primary care physicians, study clinicians, to nurse practitioners and registered nurses. Mode of communication during virtual visits between providers and patients included telephone follow-up and videoconferencing technology. While some virtual visits were scheduled consultations as per followup protocol, other calls occurred at the discretion of healthcare providers, often based on patients' clinical data and symptoms. Patient-level factors were reported as major facilitators of successful virtual visits. These included high adherence to the intervention protocol which was reported as a facilitator in n = 4 studies, 15, [23] [24] [25] and patient empowerment due to inclusion in care decision making (n = 3). 17, 19, 27 Other facilitators included technology-related factors, such as the reliable transmission of biometrics and alerts (n = 1) and simplicity of the technology, and healthcare provider-level factors, such as flexible monitoring time by healthcare providers. 21 Nonadherence to intervention protocol, by both patients and healthcare providers, was a single most frequently reported barrier to virtual to the healthcare provider. Median follow-up of 24 months; follow-up appointments in-office. Patients in the intervention group received remote checks alternating with in-office visits. Comin-Colet et al. 15 Heart Failure Outpatient Clinic (Single-Centre) Home Tele-Healthcare platform consisted of tracking of patient biometrics a questionnaire-prompted selfreport of symptoms, warning alarms and alerts (abnormal biometric data, system integrity). Systematic reviews Table 3 summarizes the quality assessment of systematic reviews. 29 Of the 7 systematic reviews, quality levels ranged from critically low to high: 22 studies were rated as high, 10,13 3 were rated as moderate, 12,20,28 and 2 were rated as critically low. 11, 22 Randomized controlled trials Quality assessment of RCTs is shown in patients (standard care/control group) were followed by their primary cardiologist or HF clinic. Ong et al. 25 Medical Centres, Transplant Centres (Multi-Centre) Home telemonitoring of weight, blood pressure, heart rate, and symptoms. Patients received a weight scale, blood pressure and heart rate monitor, integrated with a device that could display text questions and send simple text responses. Follow-up for 6 months. Intervention patients were scheduled to receive 9 telephone calls over a 6-month period; calls started 2-3 days post-discharge, initially weekly, until after the first month and were then conducted monthly. Sardu et al. 26 Medical Centres In this rapid review, we summarized the evidence on the impact of virtual visits on clinical outcomes of ambulatory patients with CVD. We reviewed twelve randomized-control trials (RCTs), including 5508 participants, of whom 1726 were female and 3782 were male, ranging between 58.5 and 84.9 years of age. Ten RCTs (83%) focused on telemedicine in HF. Evidence from 7 systematic reviews, spanning 232 RCTs and systematic reviews, was included. Five (71%) of the systematic reviews focused on HF in telemedicine. Based on our appraisal, virtual visits are either non-inferior, or more effective, in reducing hospitalizations and ED visits in patients with CVD. As suggested by Nouryan et al., 24 higher adherence to telemonitoring protocol in their study resulted in fewer all-cause hospitalizations and ED visits compared to patients receiving standard care. This is in line with reports regarding medication adherence whereby high adherence significantly improved survival of HF patients while low adherence, 31 or non-adherence, to medication protocols correlated with risk of mortality and CVD-related hospitalizations. 32 In the current review, adherence to the telemedicine intervention protocol was identified as a facilitator of favourable clinical outcomes in CVD patients, alongside patient empowerment. In other words, patient involvement in treatment, bi-directional dialog, and rapport with healthcare providers, as well as increased decisionmaking capacity, promoted favourable clinical outcomes. The evidence for a superior effect of virtual visits in reducing mortality was not supported in this rapid review. While the rapid review reflects what has been reported in the previous systematic reviews on the impact of telemedicine to reduce healthcare utilization of patients with CVD compared to standard treatment, [10] [11] [12] [13] 20, 22, 28 we found no evidence to suggest that virtual visits are superior in reducing mortality apart from a single report by Lin et al. 10 who reported decreased mortality as a result of virtual visits. Telemedicine is a communication modality that is useful as an intervention; however, technology alone cannot be expected to alter CVD patient outcomes. 28 Zhu et al. 28 noted that telemedicine reflects complex healthcare strategies, which cannot be limited to a simple amassing of data. Telemedicine is heterogeneous in its clinical parameters and interventions. The interventions are often ill-defined, making comparisons among studies difficult. The heterogeneity of communication technology, interventions, and communication parameters in reported studies indicates insufficient standardization of telemedicine for remote monitoring-including terminology for technologies and communications, healthcare provider involvement, follow-up parameters, and intervention modes. With the increase of CVD prevalence globally, 33 and in addition to its treatment and management complexity, patient monitoring needs to be timely to reduce reliance on patient self-efficacy, and to mitigate healthcare system strain. Heart failure dominant telemedicine-focused research in CVD and detrimental effects of HF on patient and health-system level outcomes indicate that affected patients are significant users of healthcare resources. Therefore, making HF monitoring programs more accessible with virtual options may benefit patients, their family caregivers, and health systems. 28 While the current evidence suggests that telemedicine can complement and promote healthcare delivery, monitoring, and management of patients with CVD, more guidance regarding intended applications of telemedicine is required. 34 In the context of the COVID-19 pandemic and its effect on telemedicine in healthcare, it is worth mentioning that virtual visits in Canada increased from 1% pre-pandemic to 70% 4 weeks into the pandemic. 35 Virtual visits in cardiovascular disease excellence that upholds care quality while supporting care continuity within healthcare teams. 36 Lastly, it is important to note potential limitations of the rapid review, which by virtue of its methodology (mainly the rapid synthesis of evidence) required streamlining of PRISMA guidelines. 9 While the review focused on studies with strong methodologies, such as RCTs and systematic reviews, the timeline was restricted to the last 5 years and excluded grey literature. This was done due to a large volume of literature addressing the rapidly changing, heterogeneous definitions and practices that fall under the umbrella terms of virtual visits in CVD. As our goal was a rapid review to inform practice on the safety and efficacy of virtual care, we inadvertently excluded a number of potentially informative studies, thus acknowledging that we may have excluded studies outside of our 5-year inclusion criteria. The outcomes of interest in the rapid review were limited to health utilization and mortality and did not include other patient-level outcomes, such as treatment satisfaction and quality of life, or health-system level outcomes. Additionally, treatment provision of care was broad and not restricted to a single healthcare provider. It is therefore unclear if provider type affects virtual visits within patient-level outcomes. Finally, there is the heterogeneity of virtual visit definitions, which reflects a lack of consensus in the literature on definitions of telehealth, telemedicine, and virtual visits. It is imperative to define the meaning of virtual visits across studies being compared to better discern if differences in clinical outcomes are due to virtual visit parameters or the communication modality. With the increase in rates of CVD prevalence and the COVID-19 pandemic, patient monitoring has moved towards telemedicine. In this rapid review, we summarized the evidence on the impact of virtual visits compared to in-clinic visits on clinical outcomes of ambulatory patients with CVD. Based on our appraisal of evidence, virtual visits are either non-inferior to-or more effective than traditional care in reducing hospitalizations and ED visits in patients with CVD. The evidence for a superior effect of virtual visits in reducing mortality was not supported in this rapid review. Given that HF patient care dominates telemedicine-focused research in CVD, making HF monitoring programs more accessible has the potential to benefit patients, their family caregivers, and health systems. While more research is needed, telemedicine is an appropriate tool for CVD follow-up care. Supplementary material is available at European Journal of Cardiovascular Nursing. Manuscripts used in this review were retrieved via the University of Alberta library and are also available through Google Scholar a freely accessible web search engine that indexes the full text or metadata of scholarly literature across formats and disciplines. The role of continuous monitoring in a 24/7 telecardiology consultation service-a feasibility study Telecardiology and its settings of application: an update Heart Disease in Canada. Canada: Public Health Agency of Canada World Health Organization. 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Virtual Care: Recommendations for Scaling-up The authors would like to thank senior knowledge management consultants Patricia Hanson and Meenakshi Kashyap with Knowledge Resource Services at Alberta Health Services for providing expert resources for conducting the literature search. Funding for this work was provided by the Cardiovascular Health and Stroke Strategic Clinical Network TM , Alberta Health Services.