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 from all the VA facilities. We will use a difference-in-a telehealth stopcode/CHAR4 code, including VVC) 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. Unfortunately, the methods used to identify e-consults and telehealth encounters did not identify a substantial enough sample to cohort facilities into high and low utilizers for quantitative analysis.

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. As noted with Aim 1, due to the small number of facilities with usable trend data, we could not cohort facilities for quantitative analysis and instead analyzed admission rates in aggregate.

FINDINGS/RESULTS:
Aim 1: Prior to the COVID pandemic, both ACSC and CHF related hospitalizations were marginally decreasing. After COVID, ACSC hospitalizations decreased dramatically. CHF-related hospitalizations appeared to follow a similar trend, however were not significantly decreased. We observed a multi-phased mortality trend after COVID-19 with two sharp increases, one at the beginning of the pandemic (April 2020) and another at the end of 2020 (November and December). Neither spike was readily explained by COVID-related deaths alone. Due to limitations in how telehealth encounters were documented within Veteran records, we could not identify separate cohorts to measure the differential impact of high and low telehealth utilizing facilities.

Aim 2: Patients and clinicians were successfully recruited and interviewed regarding their experiences with telehealth. Patients' reported telehealth experiences varied widely. Many indicated that CHF care via telehealth was adequate but not the same as in-person care. Clinicians described challenges to telehealth adoption and strategies they used to keep patients healthy.

Aim 3: We observed substantial month-to-month variation in the rate of CHF readmissions (range: 7-15%). After COVID-19, we observed a similar degree of variation and no significant difference was observed. As with Aim 1, the administrative data did not allow for us to identify unique cohorts of facilities with high and low use of telehealth.

IMPACT:
Hospitalizations decreased and mortality increased immediately after COVID-19 began to spread in the US. Our data reflect trends reported elsewhere, and provide detailed insight to how care was provided to patients and how patient outcomes were affected during the COVID-19 pandemic. Interviews suggested that telehealth is often acceptable for remote management of CHF patients who cannot be treated in person. While many patients may not prefer telehealth, they do not feel that the quality of care is less than that received in traditional face-to-face settings. Providers discussed situations where patients needed to be seen in-person, but also highlighted the value of telehealth in many situations. Integrating patient and provider suggestions into telehealth policy may improve patient experience.

PUBLICATIONS:

None at this time.