key: cord-1026318-w6p7k1mt authors: McIlvennan, Colleen K.; Allen, Larry A.; DeVore, Adam D.; Kaltenbach, Lisa A.; Granger, Christopher B.; Granger, Bradi B. title: Changes in Care Delivery for Patients with Heart Failure During the COVID-19 Pandemic: Results of a Multicenter Survey date: 2020-06-04 journal: J Card Fail DOI: 10.1016/j.cardfail.2020.05.019 sha: 8d41d79f41df234b239a01225cde780fea5e95ec doc_id: 1026318 cord_uid: w6p7k1mt nan For patients with heart failure (HF), the impact of the COVID-19 pandemic on care delivery and access to guideline-directed therapies known to reduce morbidity and mortality 1 is largely unknown. To better understand how COVID-19 has affected HF care, we queried clinicians across the United States participating in the CONNECT-HF clinical trial. Leveraging the infrastructure of the CONNECT-HF clinical trial (methods are published elsewhere) 2 , an electronic survey was developed by expert consensus and sent to CONNECT-HF site investigators. Data were analyzed using descriptive statistics, Wilcoxon-rank sum test for continuous variables, and chi-square or Fisher's exact test for categorical variables in SAS (Version 9.4). Content analysis was performed for free text responses. Between 4/30/2020-5/13/2020, surveys were sent to 149 site investigators. A total of 83 unique HF programs in 32 states responded (56% response rate). No statistically significant differences between responders and non-responders were noted; however, data may be biased towards Midwest, South, and not-for-profit programs (Supplement). Compared to pre-COVID, programs reported several changes in care for patients with HF. All experienced decreased in-person outpatient visits (n=82/82, 100%), with the majority converted to telehealth (median=71 [IQR 50-91] of pre-COVID clinic volume converted to telehealth). For patients presenting with worsened HF symptoms, the majority of programs did not change their threshold for hospitalization (n=46/80, 57.5%). Of the programs that reported changes in admission thresholds, most reported a higher threshold (n=29/33; 87.9%). Most programs reported routine assessment of guideline-directed medical therapy (GDMT) during telehealth visits, including medication dosage (n=70/74, 94.6%). Potential concern about increased risk of COVID-19 infection with use of angiotensin converting enzyme inhibitors or angiotensin II receptor blockers was discounted by half of HF programs (n=42/76, 55.3%). Referral to cardiac rehabilitation (n=49/77, 63.6%) was less likely while most programs reported no change in referrals for implantable cardioverter defibrillator implantation (n=58/75, 77.3%). Free text responses revealed several themes (Table) . HF programs reported patients' expressions of fear and reluctance to visit the hospital along with a lower likelihood of reporting symptoms early. Programs reported a lower volume of HF admissions and inpatient census. Most HF research activities were halted and most study coordinators were no longer onsite. Our survey results confirm that the COVID-19 pandemic and resultant policy changes have affected the usual patterns of care for patients with HF including a higher threshold for admitting patients to the hospital, conversion of over half of stable outpatients to telehealth visits, decreased referrals to cardiac rehabilitation, and limited research activities. The shift to telehealth and provision of care in the outpatient setting versus the inpatient setting is not unique to HF. 3 According to the programs we surveyed, almost all reported practicing a thorough assessment of GDMT via telehealth. Less obvious and more difficult to empirically assess is the unanticipated effect of fear on hospital evaluation of symptom exacerbation. As demonstrated by recent data from Mississippi, a 50% reduction in HF hospitalizations was identified, even before a state of emergency was declared. 4 Moving forward, there needs to be a concerted effort of health systems and clinicians to address these fears and implement appropriate protocols to ensure the safety of patients seeking care. We were unable to control for COVID-19 cases or hospital volume given data collected and small sample. The number of respondents based on region and type of organization may limit generalizability. The COVID-19 pandemic has created a rapid evolution of HF care delivery. As a consequence, there is a need for further evaluation of the impact of these changes, revised guidelines and protocols for telehealth care delivery, and efforts to address patients' fear of seeking care. FUNDING: None. Dr. Allen has received research funding from AHA, NIH, and PCORI, and consulting fees from Abbott, ACI Clinical, Amgen, Boston Scientific, Cytokinetics, and Novartis. Adam DeVore has received research funding through his institution from the American Heart Association, Amgen, AstraZeneca, Bayer, Intra-Cellular Therapies, American Regent, Inc, the NHLBI, Novartis and PCORI. He also provides consulting services for Novartis. Dr. Chris Granger has received research funding from Novartis, and all disclosures are listed at: https://dcri.org/about-us/conflict-of-interest/. Dr. Bradi Granger has received grant funding from Novartis, Janssen, Sanofi-Aventis, and AstraZeneca. ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America Care Optimization Through Patient and Hospital Engagement Clinical Trial for Heart Failure: Rationale and design of CONNECT-HF Duty to Plan: Health Care, Crisis Standards of Care, and Novel Coronavirus SARS-CoV-2. NAM Perspectives. 2020. National Academy of Medicine Reductions in Heart Failure Hospitalizations During the COVID-19 Pandemic