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C19 20-217 – HSR&D Study

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C19 20-217
Effectiveness of telehealth to adequately manage ACSC such as admission for congestive heart failure (CHF)
David E Winchester MD MS BS
Gainesville, FL
Funding Period: August 2020 - April 2021

BACKGROUND/RATIONALE:
The COVID-19 pandemic has forced VHA Facilities to rapidly adopt and deploy telehealth alternatives to provide continuity of care to Veterans while minimizing physical contact. This has led to widespread cancellation of face-to-face clinics as well as elective procedure and noninvasive testing. For the past several years, the VHA has generated transparent reports on quality of care, the Strategic Analytics for Improvement and Learning (SAIL) report including ambulatory care sensitive conditions (ACSC) and hospital readmissions. Questions remain about the effectiveness of telehealth to adequately manage ACSC such as admission for congestive heart failure (CHF) This proposal seeks to address how VHA can better prepare for future infectious disease outbreaks by comparing qualitative and quantitative outcomes between facilities with strong existing telehealth use and those forced to adopt telehealth in response to COVID-19.

OBJECTIVE(S):
Specific Aim 1: We will measure the impact of COVID-19 on overall ACSC trends and specifically on CHF admissions, stratified by facilities' use of e-consultations in cardiology.

Specific Aim 2: We will interview Veterans and clinicians at two high-utilization and two low-utilization sites with regards to e-consultation in order to understand how Veterans felt their CHF was managed via virtual visits and to identify clinician recommended best practices, challenges, or facilitators to implementing virtual care for CHF patients.

Specific Aim 3: We will analyze trends in CHF 30-day disease specific readmission, stratified by facilities' use of e-consultations in cardiology. We will also measure the rate of admission for emergent conditions such as acute myocardial infarction or stroke.

METHODS:
Aim 1 Methods: We will identify rates of e-consultation in cardiology departments in 2019 to identify sites with high and low utilization. We will use a difference-in-difference analysis to assess ACSC trends at each site for 6 months prior to the first in-state case of the COVID-19 pandemic and 6 months after.

Aim 2 Methods: High and low utilization sites will be identified as part of Aim 1. We will select two sites from the highest and two sites from the lowest quartile of utilization. We will interview six Veterans who received care for CHF via telehealth/e-consults at each site, three who were hospitalized after their telehealth/e-consult encounter and three who were not. We will also interview two cardiologists at each site, and up to two additional staff members. Veterans and Cardiologists will be identified in CDW data. We will use snowball sampling in interviews with cardiologists to identify additional team members that support telehealth visits. Veteran interviews will focus on experience receiving routine care via telehealth/e-consults, and whether they felt that their needs were addressed adequately and in a timely manner. Clinician interviews will identify actions that were taken to implemented virtual care in response to COVID-19 and identify any challenges, facilitators, or best practices related to virtual care for patients with CHF.

Aim 3 Methods: We will compare admission rates 6 months pre- and 6- months post-COVID-19 related changes to patient care using data available in CDW, including fee-basis data. Comparisons will be made across cohorts of VHA facilities based on the rates of e-consultation identified in Aim 1.

FINDINGS/RESULTS:
Pending

IMPACT:
Pending

PUBLICATIONS:
None at this time.

DRA: Cardiovascular Disease
DRE: TRL - Applied/Translational
Keywords: Care Management Tools, Symptom Management
MeSH Terms: None at this time.

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