Optimizing Face-to-face Vs. Telehealth Visits: Decision-making Regarding Medication Changes And Reliance On Data From In-person Visits

INTRODUCTION: The COVID 19 pandemic fueled a rapid shift for medical care to be provided in a virtual or telehealth platform. Medications changes can be challenging to implement over the phone due to lack of data from physical exam findings and vital signs to support medical decision making. In-person visits allow for complete vital signs and proper physical examination to inform medical decision making. We sought to determine which types of cardiac care are best positioned to succeed in a telehealth environment and which require greater emphasis on in-person care. METHODS: We sought to determine what cardiology visit type was associated with a higher rate of medication changes and what factors informed those changes. We compared medication changes made between heart failure (HF), electrophysiology (EP), and general cardiology (GC) visits completed in-person in the pre-pandemic era. Number of medication changes, type of medication change, and clinical data used to implement medication changes were compared between the three providers types. RESULTS: During February 2020 each provider completed a total of 48 HF visits, 23 EP visits and 35 GC in-person visits. A total of 116 medication changes were made. HF visits were associated with the highest rate of medication changes per visit (1.79 changes per visit) followed by EP (0.61 changes per visit) and GC (0.46 changes per visit), overall p<0.001 (See Table). Individual comparisons showed that medication changes were made more frequently in HF compared to both EP and GC (each p<0.001). There was no statistical difference between frequency of medication changes between EP and GC (p=0.50). Types of medication changes included initiations, discontinuations, and dose titrations, each of which were made more frequently in HF. Medication changes were made during most HF visits but during only a minority of visits for EP and GC. Medication changes during HF visits were based on both vital sign and physical exam assessment most (67.5%) of the time, but rarely for EP or GC visits (0 and 18%, respectively). CONCLUSIONS: Our study demonstrated that HF visits incorporate a higher rate of medication changes compared to EP and GC, and that these decisions were based on physical exam and vital signs more often compared to other cardiology sub-specialties. Despite a shift towards increased telehealth due to the pandemic, these data suggest that HF management may require more in-person visits compared to EP and GC, which appear more amenable to telehealth care delivery.