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Telehealth appointments improve follow-up care in patients with heart failure

Kaiser Permanente study is first to compare early telehealth approach to early in-person follow-up

By Sue Rochman

A structured telephone appointment with a specially trained nurse or pharmacist is as effective as an in-person doctor’s appointment in preventing early hospital readmissions in patients with heart failure, new Kaiser Permanente research shows.

The study, published September 24 in the journal Circulation: Cardiovascular Quality and Outcomes, is the first to look at the use of telehealth to manage follow-up care for patients after hospitalization for heart failure.

“High heart failure readmission rates are a major problem nationally,” said the study’s first author Keane K. Lee, MD, an adjunct investigator with the Kaiser Permanente Northern California (KPNC) Division of Research and a cardiologist with The Permanente Medical Group. “This is the first study to compare a telehealth approach to traditional in-person clinic visits for early follow-up of patients recently hospitalized for heart failure.”

Keane K. Lee, MD, adjunct investigator, Division of Research, cardiologist, The Permanente Medical Group.

In the study, 2,091 adult heart failure patients discharged from a KPNC hospital were randomly assigned to one of 2 types of 7-day follow-up appointments: an in-person visit with a primary care provider or a telephone call with a nurse or pharmacist trained in heart failure management. No significant difference was seen between the two groups in readmission rates — for heart failure or any cause — within 30 days of hospital discharge. There was also no significant difference in the number of deaths within 30 days. However, telehealth was superior to in-person visits in follow-up completion rates; 92% of patients assigned to telehealth successfully completed 7-day follow up compared to 79% of patients assigned to in-person appointments.

“This study adds very important data showing that within an integrated health care delivery system, providing early follow-up with a structured phone call from a heart failure manager is safe and improves follow-up rates significantly,” said the study’s senior author Alan S. Go, MD, a research scientist at the Division of Research and regional medical director of the KPNC Clinical Trials Program based at the Division of Research. “Also, because we implemented a systems-level intervention leveraging existing follow-up options, this telehealth program has the potential for more widespread adoption in other hospital systems.”

Heart failure is a serious ongoing health condition that occurs when the heart cannot pump the amount of oxygen and blood needed to support the body’s other organs. It affects an estimated 6.2 million people in the U.S. and is a leading cause of hospitalization among older adults. Common symptoms of heart failure include feeling weak, trouble breathing, and weight gain with swelling in the legs or abdomen. Heart failure is treated with medications that remove excess fluid and improve the heart’s function.

Alan Go, MD, research scientist, Kaiser Permanente Division of Research, regional medical director, Clinical Trials Program.

To reduce readmission rates, the American Heart Association’s current guidelines recommend patients hospitalized for heart failure have an in-person appointment with a health care provider within 7 days of being discharged. The recommendation was based on observational studies that suggested early follow-up improved patient outcomes. The new Kaiser Permanente study is the first large randomized clinical trial to compare the effectiveness of an alternative type of follow up to the recommended standard of care.

An important component of the telehealth strategy was the ability to arrange expedited in-person visits when needed. During the study, 39% of the patients in the telehealth group also subsequently saw a doctor in person within 7 days. “If the nurse or pharmacist felt the patient was not doing well, they could quickly escalate care, which was a key part of the telehealth strategy to prevent readmissions,” said Lee. “A system that uses early telehealth follow-up can streamline care by efficiently identifying and treating patients most at-risk for readmission, while reducing the burden of clinic visits for those who are less likely to benefit from them.”

Go and Lee said the study provides important reassurance for physicians and health care systems that have substantially increased their use of telehealth during the COVID-19 pandemic. “Clinicians are now asking what types of appointments are appropriate for telehealth,” said Lee. “For many conditions, we don’t yet know the answer. But the data from our study show that even for frail patients with heart failure being discharged home, telehealth can be delivered effectively and provide good outcomes.”

This study was funded by The Permanente Medical Group Delivery Science Research Program.

Co-authors include Rachel C. Thomas, RN, Thida C. Tan, MPH, and Thomas K. Leong, MPH, of the Kaiser Permanente Division of Research and Anthony Steimle, MD, of The Permanente Medical Group.

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About the Kaiser Permanente Division of Research

The Kaiser Permanente Division of Research conducts, publishes and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. It seeks to understand the determinants of illness and well-being, and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 600-plus staff is working on more than 450 epidemiological and health services research projects. For more information, visit divisionofresearch.kaiserpermanente.org or follow us @KPDOR.