Changes in Clinician Telemedicine Use and Care Patterns for Patients With Heart Failure in the United States

BACKGROUND: The impact of telemedicine use on heart failure (HF) care is unknown. We assessed the association between telemedicine use and rates of diagnostic testing and prescribing for patients with HF. METHODS: We extracted electronic health record data for patients with HF at an academic cardiovascular center in Northern California. We assigned patients to the cardiologist providing >50% of their visits from March 2019 to May 2023. This interval was divided into 8 nonoverlapping 6-month periods, excluding March through May of 2020. All patients seen and orders placed in each period were included. Orders of interest included diagnostic tests (Holter monitors, electrocardiograms, echocardiograms, natriuretic peptide tests, chemistry panels) and new prescriptions (beta blockers, aldosterone antagonists, renin angiotensin inhibitors, hydralazine, nitrates, total guideline-directed medical therapy, diuretics). We assessed the association between clinician-period ordering rates and telemedicine use (proportion of visits via video/phone) using negative binomial regression with adjustment for the period, number of patients, and clinician random intercepts. We report incident rate ratios of per-patient ordering associated with a 50-percentage-point increase in telemedicine use. Subgroup analyses were conducted for patients with reduced/preserved ejection fraction. RESULTS: There were 7741 patients seen by 44 clinicians (1941 patients with HF with reduced ejection fraction seen by 28 clinicians). Mean age was 65 years (SD, 16.8) with 41% female. A 50-percentage-point increase in telemedicine use was associated with significantly reduced ordering of electrocardiograms (incident rate ratio, 0.30, [95% CI 0.25-0.35]), echocardiograms (0.70 [0.59-0.82]), natriuretic peptide tests (0.66 [0.49-0.88]), and chemistry panels (0.66 [0.56-0.76]). For the HF with reduced ejection fraction subgroup, this increase in telemedicine use was associated with reduced ordering of aldosterone antagonists (0.72 [0.52-0.99]) and total guideline-directed medical therapy (0.80 [0.69-0.94]). CONCLUSIONS: Greater clinician telemedicine use was associated with decreased diagnostic testing for patients with HF and reduced guideline-directed medical therapy initiation for patients with HF with reduced ejection fraction. Novel interventions are needed to ensure guideline-concordant care regardless of care modality.