The report is a product of the VA/HSR&D Evidence Synthesis Program.
Systematic Review: Virtual Care for the Longitudinal Management of Chronic Conditions
Early in the COVID-19 pandemic, many healthcare systems, including VA, rapidly converted 70% or more of their outpatient visits from in-person to virtual care. This shift was part of a critical effort to reduce the risk of viral transmission – but was not based on evidence of equivalence between visit modalities. As a result, many patients with chronic medical conditions traditionally considered to require in-person evaluation (i.e., patients with type 2 diabetes, congestive heart failure, and/or chronic obstructive pulmonary disease) received disease management virtually to unknown effect. Moving forward, virtual modalities are expected to remain a core method of delivering real-time (i.e., synchronous) VA healthcare. Therefore, it is important to understand what controlled studies tell us about whether synchronous virtual care is an adequate substitute for in-person care as part of the ongoing management of chronic conditions.
Assessing virtual care is particularly important to VA’s management of chronic conditions such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and type 2 diabetes mellitus (T2DM), as these are among the most common and costly conditions, affecting nearly 5%, 10%, and 25% of all Veterans, respectively.
A first step toward addressing the question of equivalence of virtual vs in-person care for chronic disease is a review focused specifically on evidence from the comparative literature. If this literature suggests that virtual care is inferior to in-person care for relevant clinical outcomes, such as exacerbations of heart failure or COPD or increases in emergency room visits for poor glycemic control, then VA policy around incorporation of virtual modalities could be shaped accordingly.
This systematic review examined the published literature regarding the effect of virtual care (by phone and/or video) compared to in-person care (or compared to phone if synchronous video care) for the chronic management of CHF, COPD, and T2DM on key disease-specific clinical outcomes and healthcare use (i.e., hospital admission rates and ER visits). Investigators from VA’s Evidence Synthesis Program (ESP) Center in Durham, NC searched the literature, including MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from inception through February 7, 2021. They also examined the bibliographies of recent reviews for additional relevant studies. After identifying 8,662 citations – 129 for full text review – investigators included five articles reporting on randomized trials (no articles using other eligible study designs were identified) in this systematic review. However, no articles were identified that addressed COPD in this context. Given the modest eligible literature, investigators added a horizon scan [process of gathering and analyzing value-added information to support decision-making] which identified a potential additional three ongoing trials relevant to the current question.
Summary of Findings
Investigators found five articles evaluating the effect of synchronous virtual care delivered by a prescribing clinician as a substitute for in-person care for chronic disease management of common conditions, namely CHF, COPD, T2DM (1 in CHF and 4 in T2DM). Among the included studies, there was significant heterogeneity around the structure, purpose, and delivery of virtual care visits. While not statistically significant and with very low certainty of the evidence, this analysis suggested that A1c reduction among virtual care interventions vs in-person comparators may be greater or at least no different. Regarding the single CHF article, there were no significant differences in clinical outcomes between in-person and virtual care groups. One study reported subgroup analysis by patient characteristics (i.e., age, gender). However, details regarding race/ethnicity and rural status were not reported in the eligible literature.
One limitation of this literature is that all included studies took place in specialty care clinics, while in practice much of the long-term management for these chronic conditions occurs within the context of primary care. Primary care likely has different pressures and challenges with virtual modalities given the need to address multiple comorbidities during the same visit, so these results may not be applicable.
Implications for VA
Providing healthcare via video or telephone is frequently being used to replace in-person clinic visits for managing chronic conditions without supporting evidence. There is scant evidence from the comparative literature of equivalent effectiveness to support this practice for the most common chronic conditions such as CHF, COPD, and T2DM. Continued exploration and production of evidence is needed to guide the use of virtual care as a substitute for in-person care: for which patients, for which conditions, and at what frequency.
Research Gaps/Future Research
Overall, investigators suggest a research focus on five key areas that could fill existing gaps and/or could improve the approach to knowledge in this area:
- Virtual care interventions should be thoroughly described in order to maximize reproducibility and generalizability in other clinical contexts.
- There is a need to evaluate how best to integrate virtual care as a replacement for in-person care. There also is a need to evaluate which clinical settings are best suited to the virtual environment (e.g., primary care vs specialty care settings).
- Some important outcomes were not addressed by any study, including the impact on clinical workflow, patient satisfaction with virtual care experience, and subsequent utilization.
- Investigators should be encouraged to consider a priori subgroup evaluations, so that future reviews can identify patient-level characteristics associated with better outcomes with virtual care.
- Investigators should consider utilizing non-inferiority analytic approaches when hypotheses center on whether virtually delivered care is equally effective to in-person care.
As the evidence base grows around the substitution of in-person care with virtual care for chronic disease management, updating this review may be valuable.
Walsh C, Lewinski AA, Rushton S, Soliman D, Carlson SM, Luedke MW, Halpern D, Crowley M, Shaw R, Sharpe J, Alexopoulos AS, Alishahi Tabriz A, Dietch JR, Uthappa DM, Hwang S, Ball Ricks KA, Cantrell S, Kosinski AS, Ear B, Gordon AM, Gierisch JM, Williams JW, Goldstein KM. Virtual Care for the Longitudinal Management of Chronic Conditions. VA ESP Project #09-009; 2021.
To view the full report, go to vaww.hsrd.research.va.gov/publications/esp/virtual-care.cfm (VA network access only)
ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.
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