Routine cardiology care ‘suffered greatly’ for many during pandemic
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The COVID-19 pandemic has had a profound effect on cardiology care, changing how, when and where physicians interact with their patients in ways large and small, seemingly overnight.
In the early months of 2020, cardiologists learned to navigate unprecedented shifts in practice. Most office visits switched from in-person to virtual, via telehealth; many elective procedures and noninvasive tests were suspended. Data also suggest telehealth patients underwent fewer diagnostic tests and received fewer medications compared with patients who saw their health care provider in person.
Patients, too, changed their behavior: Survey data from Cleveland Clinic showed 65% of patients with heart disease put off health screenings or checkups because of the pandemic, including annual physicals and BP and cholesterol checks.
Two and a half years later, cardiologists are still grappling with the effects of such changes on routine cardiology care, even as the pandemic wanes and many patients have returned to the clinic.
“In March 2020, practice changed on a dime,” Cardiology Today Editorial Board Member Jagmeet P. Singh, MD, DPhil, FACC, FHRS, founding director of the Resynchronization and Advanced Cardiac Therapeutics Program at Massachusetts General Hospital and professor of medicine at Harvard Medical School, said in an interview. “All of our nonessential procedures were, essentially, tabled. We converted into one large intensive care unit, as a whole hospital, looking primarily after COVID-positive patients. At any given point in time, we had almost 600 to 700 patients with COVID-19 across the hospitals, with nine floors of ICUs. We were operating in a mode of togetherness and camaraderie, toward tackling the disease. But the interesting thing is, the same disease that we were fighting against actually created silos over time. We were all cordoned off in our little territories, with our masks, no collective meetings. Even though the pandemic is easing, the preventive measures have siloed us more in our day-to-day operations.”
Patients are also returning to in-person visits in the midst of a dire shortage of nurses and other health care staff that has been exacerbated by the pandemic, according to Leslie Cho, MD, director of the Cleveland Clinic’s Women’s Cardiovascular Center.
“One thing we noticed is the increase in patient demand to see us is exponential,” Cho told Cardiology Today. “We need nurses, we need secretaries to handle appointments. It is not just physicians. It takes a village to make a hospital or a health system work. That has been challenging for us.”
Cardiology Today spoke with experts who discussed the impact of the COVID-19 pandemic on various aspects of patient care in cardiology, including telehealth, noninvasive tests and patient interaction, and what changes might be here to stay.
Telehealth: ‘The pendulum has swung back’
The pandemic brought with it a swift shift from in-person clinic visits to nearly all virtual visits, conducted online or by phone. In a retrospective study published in February in the Journal of Telemedicine and Telecare, researchers assessed ambulatory visits at a multispecialty CV center in Northern California from March 2019 to February 2020 and from March 2020 to February 2021. In April 2020, telemedicine use was above 75% of visits for all cardiology subspecialties and stabilized at rates ranging from more than 95% in electrophysiology to less than 25% in heart transplant and vascular medicine. From June 2020 to February 2021, cardiology subspecialties delivering a greater percentage of visits through telemedicine experienced larger increases in new patient visits.
For some clinicians and patients, it was a simple switch, with advantages of convenience, reduced travel and wait times. For others, telehealth became yet another barrier to care.
“There are patients who fell through the cracks,” Tochi M. Okwuosa, DO, FACC, FAHA, associate professor of medicine and cardiology, director of the cardio-oncology program at Rush University Medical Center, told Cardiology Today. “Not everyone is able to be monitored regularly or do virtual visits, because they do not have access to MyChart. We conduct phone visits with those people, but it is difficult to get a sense of their well-being because you cannot see them. What bothers me most is it is the marginalized patients — the poor, the elderly, underrepresented groups — who end up being affected the most, because they do not have the access.”
As the pandemic has slowed down, virtual visits have been gradually phased out and in-person visits have been encouraged, Okwuosa said. The goal going forward is to offer telehealth as an option to allow more patient flexibility, particularly during COVID-19 surges, she said.
“Things are almost back to the way they used to be,” Okwuosa said. “The good thing is people now know they have the option of virtual visits. For example, my patient who is on vacation can now switch the visit from in-person to virtual. Some people who test positive for COVID-19 but feel well may decide to do a virtual visit.”
Today, many patients prefer to be seen in-person after more than 2 years of virtual care, Singh said.
“The pendulum has kind of swung back,” Singh said. “A lot of the care we deliver now is in person, with a very limited number of visits now being video-based or telehealth-based care.”
Singh said better strategies are needed to make virtual care visits feel more comprehensive for patients.
“Virtual care, even today, seems like a glorified phone call,” Singh said. “You are not providing much objectivity to the clinic visit. But something all of us realize is that telehealth is the future. We need to find the right strategies and the right subset of patients [who benefit]. The pandemic has provided us reason to do that, yet we still have not gotten around to doing it in a uniform way across the country.”
Changes in CV procedures
In a cross-sectional study published in April 2021 in JAMA Network Open, researchers assessed whether the transition to remote visits for ambulatory CV care was associated with disparities in patient use of care, diagnostic test ordering and medication prescribing.
The researchers identified a stepwise reduction in the ordering frequency of both diagnostic tests and prescription medications when comparing pre-COVID-19 with COVID-19-era in-person and COVID-19-era video and COVID-era telephone visits. Additionally, patients accessing COVID-19-era remote visits were more likely to be Asian, Black or Hispanic.
“With COVID-19, one of the things that happened everywhere is the elective and noninvasive testing, including stress testing, echos and nuclear, volume went way down,” L. Samuel Wann, MD, MACC, FESC, a cardiovascular specialist at the University of New Mexico and editor of the Practice Management section for Cardiology Today, said in an interview. “However, the death rate from CVD has not climbed commensurate with that change. A lot of elective testing is just that — elective. It may alter things in the long run, but in the short term, we have learned that we do not need to perform an elective stress test on everyone without regard to how they are doing. I think that will last.”
As elective procedures resumed, the pandemic also ushered in a change in discharge protocols designed to minimize patient exposure to COVID-19, with clinicians relying more on virtual monitoring. In an analysis of data from Brigham and Women’s Hospital, researchers found that same-day discharge after atrial fibrillation ablation increased from 2020 to 2021, with reduction in total time spent in-hospital and no change in readmission rates for adverse events.
“We have gone back to doing elective procedures; however, our strategies of post-procedural care have changed quite a bit,” Singh said. “There are now a lot of same-day discharges that we talked about pre-COVID-19 but could never get into practice. Now, post-COVID-19, they are all in play. From a cardiovascular perspective, people getting ablation or implanted devices are discharged same day. That would have been anathema in the past. It is a big lesson learned. We can be more efficient.”
Impact on patient health
Even among people who did not contract SARS-CoV-2, data show changes in daily habits and lifestyle, coupled with widespread lockdowns and clinic closures, led to poorer health. In the Cleveland Clinic survey, almost half of patients with heart disease reported gaining weight during the pandemic.
“We have seen a fair amount of weight gain,” Cho said. “People did put off seeing their physician and were going without their medication. The survey shows one in three have been putting off taking their heart medication and are worried about going to the office for refills. About 47% gained weight and 25% gained more than 20 lb, which is really high. We also see a lot of depression and anxiety.”
In an American Psychological Association Stress in America survey conducted in February 2021, researchers found 42% of U.S. adults reported undesired weight gain since the start of the pandemic, with an average gain of 29 lb. Lockdown orders also further complicated lack of access to healthy foods for some at-risk groups; underserved groups were also more likely to work in so-called essential jobs, leaving little time for exercise.
“Many of my patients who were making so much progress completely fell to the wayside,” Okwuosa said. “So many gained weight. Some of them were drinking more alcohol. A good number of them could not go to the gym anymore, so they did not exercise.
“The good news is things are getting better,” Okwuosa said. “Many of my patients who are cancer survivors or on hormone therapy are now working on weight loss. One of my patients just lost 23 lb. Many are going back to where they were. I have seen this during the last 2 to 3 months. People are eating better and trying to lose weight.”
A lack of in-person connection during the pandemic also worsened mental health for many patients, particularly older adults who live alone, Cho said.
“The thing that makes people live well is interacting with other human beings,” Cho said. “That lack of connection was hard for some. I remember in March 2021, when vaccines were made available to more adults, and I saw an older patient who told me that visit [to receive the vaccine] was the first time anyone had touched her in a year.”
Lessons learned
There are many lessons, good and bad, to come out of the pandemic when it comes to cardiology care.
Despite its challenges, telehealth techniques that have proliferated to address the increased demand for medical care will have lasting and profound effects on the future practice of cardiology, Wann said.
“If you live in a wealthy community, there is no shortage of care,” Wann said. “In poorer and more rural communities, people have suffered greatly and continue to. The idea of Marcus Welby coming to your house to take your temperature looks good on a painting, but it is just not reality. Telemedicine is here to stay.”
Clinicians can also harness technology to reduce disparities in CV care, Okwuosa said.
“We already knew there were disparities, but the pandemic made it more obvious,” Okwuosa said. “We must find ways to be more inclusive with our patient population. And now, with Epic, you can incorporate a caregiver, like a daughter or son. We are learning a lot about what technology can do, and how we can use it to reduce disparities in health care.”
Clinicians must also work to rebuild trust with their patients in an era of misinformation on everything from COVID-19 “cures” to the efficacy of vaccines, Cho said.
“The trust between the physician and patient, which has always been a sacred bond, has been significantly changed by COVID-19,” Cho said. “That erosion of the physician-patient relationship, which was happening slowly, took a rapid turn for the worse since the COVID-19 crisis hit. It has been heartbreaking for me as a physician. I went into medicine because I value that relationship. To see patients so distrustful of science and medicine has been difficult.”
Cho said it is important for clinicians to actively listen to patient concerns.
“As physicians, we have to combat misunderstandings,” Cho said. “It is important to talk to our patients and listen to their concerns and have shared decision-making. This is a term that is used a lot. But really listen to your patients; hear where they are coming from.”
Moving forward, burnout among providers post-pandemic must also be adequately addressed, Singh said.
“We are not paying enough attention to wellness within the hospital staff,” Singh said. “The hospital administration often taps into the discretionary energy of its staff for these emergencies. People extend themselves and burn out. To tap into that energy, you have to make sure they are being looked after. That is something we have to learn — we must look after ourselves and each other if we are going to collectively look after our patients. The initial togetherness petered away with the silos that were created. I do not think anyone has found a smart way to do away with that — to get out of the Zoom calls and get people to feel like they belong. That is going to be a big ask of leadership, trying to ensure that the right culture prevails. Because at the end of the day, that impacts patient care.”
- References:
- Kalwani NM, et al. J Telemed Telecare. 2022;doi:10.1177/1357633X211073428.
- Rousseau LA, et al. Abstract AP-519. Presented at: Heart Rhythm 2022; April 29-May 1, 2022; San Francisco (hybrid meeting).
- Yuan N, et al. JAMA Netw Open. 2021;doi:10.1001/jamanetworkopen.2021.4157.
- Zhao M, et al. Int J Cardiol Heart Vasc. 2021;doi:10.1016/j.ijcha.2021.100811.
- For more information:
- Leslie Cho, MD, can be reached at chol@ccf.org.
- Tochi M. Okwuosa, DO, FACC, FAHA, can be reached at tochukwu_m_okwuosa@rush.edu; Twitter: @drtochiokwuosa.
- Jagmeet P. Singh, MD, DPhil, FACC, FHRS, can be reached at jsingh@mgh.harvard.edu; Twitter: @jagsinghmd.
- L. Samuel Wann, MD, MACC, FESC, can be reached at samuelwann@gmail.com; Twitter: @samuel_wann.
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