Using administrative data to explore potentially aberrant provision of virtual care during COVID-19: a retrospective cohort study of Ontario provincial data (Preprint)

BACKGROUND The COVID-19 pandemic has led to a rapid increase in virtual care utilization across the globe. Many healthcare systems have responded, by creating virtual care billing codes that allow physicians to see their patients over telephone or video. This rapid liberalization of billing requirements, both in Canada and other countries, has led to concerns about potential abuse, but empirical data are limited. OBJECTIVE The objectives of this study were to examine whether there were substantial changes in physicians’ ambulatory visit volumes coinciding with the liberalization of virtual care billing rules and to describe the characteristics of physicians who significantly increased their ambulatory visit volumes during this period. We also sought to describe the relationship between visit volume changes in 2020 and the volumes of virtual care use in individual physicians and across specialties. METHODS We conducted a population-based, retrospective cohort study using health administrative data from the Ontario Health Insurance Plan (OHIP), which was linked to the ICES Physician Database (IPDB). We identified a unique cohort of providers based on physicians’ billings and calculated the ratio of total ambulatory visits (in-person and virtual) over January-June, 2020 (virtual predominating) relative to that over January-June, 2019 (in-person predominating) for each physician. Based on these ratios, we then stratified physicians into four groups: low, same, high and very high use physicians. We then calculated various demographic and practice characteristics of physicians in each group. RESULTS Among 28,383 eligible physicians in 2020, the mean ratio of ambulatory visits in January-June 2020: 2019 was 0.99, SD=2.53 (median 0.81; IQR 0.59-1.0). Only 2,672 physicians (9.4% of all physicians) fell into the high user group and only 291 (1.0% of physicians) fell into the very high users group. High user physicians were younger, more recent graduates, more likely female, and less likely to be international graduates. They also had on average lower volume practices. There was a significant positive correlation between percent virtual care and the 2020:2019 ratio only in the group of physicians who maintained their practice (R=0.35, p<.001). There was also a significant positive correlation between the 2020:2019 ratio and the percent virtual care per specialty (R=0.59, p<.01). CONCLUSIONS During the early stages of the pandemic, the introduction of virtual care did not lead to significant increases in visit volume. Our results provide reassuring evidence that relaxation of billing requirements early in the COVID-19 pandemic in Ontario were not associated with widespread and aberrant billing behaviors. Furthermore, the strong relationship between the ability to maintain practice volumes and the use of virtual care suggest that the introduction of virtual care allowed continued access to care for patients.

Profile and treatment of chronic coronary syndromes in European Society of Cardiology member countries

Background International guidelines recommend pharmacotherapy combinations for chronic coronary syndromes (CCSs) but medical management remains suboptimal. Design The CICD-LT registry is investigating short- and long-term outcomes and management in patients in European Society of Cardiology (ESC) member countries, in a longitudinal ESC EURObservational Research Programme aimed at improving CCS management. Methods Between 1 May 2015 and 31 July 2018, 9174 patients with previous ST-elevation myocardial infarction (STEMI), non-STEMI or coronary revascularisation, or other CCS, were recruited during a routine ambulatory visit or elective revascularisation procedure. Baseline clinical data were recorded and prescribed medications analysed at initial contact and discharge, and according to patient gender and age (<75 vs. ≥75 years). Results Poorly controlled cardiovascular risk factors, including current smoking (18.5%), obesity (33.9%), diabetes (25.8%), raised low-density lipoprotein cholesterol (73.3%) and persistent hypertension (24.7%), were common across all cohorts. At ambulatory visit or admission, the guidelines-recommended combination of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, beta-blocker, aspirin, statin and any antiplatelet agent was prescribed to 57.8% of patients with STEMI/NSTEMI. Differences in prescribing rates, including for combination therapies, were observed based on age and gender and persisted after adjustment for demographic factors. Conclusions Cardiovascular risk factors were common in contemporary CCS patients and secondary prevention prescribing was suboptimal. Patients aged ≥75 years and, to some extent, female patients were less likely to receive guidelines-recommended drug combinations than younger and male patients. One- and two-year follow-up will study prescribing changes and associations between baseline characteristics/prescribing and subsequent clinical outcomes.

Secondary prevention advices after cardiovascular index event: From drug prescription to risk factors control in real world practice

The present study aims at evaluating the achievement of blood pressure, lipid and blood glucose targets, healthy lifestyle changes and appropriate drug prescription/adherence in patients attending secondary prevention/CR ambulatory visit after index cardiovascular event in a time period ranging 1 to 5 year. At ambulatory visit, a predetermined set of data collection was used, including demographic data, cardiovascular risk factors and lifestyle habits, type and time of index event, current symptoms, physical sign, biochemistry and current medical treatment (including type and dosage). Cardiovascular risk profile (smoking habits, physical activity and body weight), secondary prevention goals (LDL-cholesterol, blood pressure, resting heart rate, glycated haemoglobin level) and the use of recommended drugs were also evaluated and categorized. Study population consisted of 800 patients [644 men (84.5%), aged 69±10.9 years)]. Cardiovascular index events were coronary artery bypass graft (CABG) (20%) ST segment elevation myocardial infarction (STEMI) (28%), non-ST segment elevation myocardial infarction (NSTEMI) (21%) and stable angina (13%) by unstable angina (13%) and stroke (5%). About 30% of patients was symptomatic (angina or dyspnoea) at the time of ambulatory visit. Major comorbidities were hypertension (73%), dyslipidaemia (64%) and diabetes (40%). More than 80% of patients achieved target levels for blood pressure. Patients that have participated to cardiac rehabilitation programmes after cardiovascular index event showed best achievement in blood pressure target (83.8% vs 76.8%, p=0.02). LDL-cholesterol target (<70 mg/dl) was achieved in about 2/3 of patients; HbA1c target (<7%) was achieved in 56.4% of diabetic population. About 75% of study cohort was treated with RAAS inhibitors, 85% with beta-blockers, 92% with statins and 87% with acetylsalicylic acid. All drugs were increasingly adopted from index event. Implementing secondary prevention guidelines into the ‘real world’ clinical practice in "late" interval from 1 to 5 years after a cardiovascular event improved risk factors control and appropriate drug prescription. Whether these improvements translated into prognostic advantages remains to be elucidated.

Development of exercise-related values in heart failure patients supported with a left ventricular assist device

Following implantation of a left ventricular assist device, the build-up and long-term maintenance of adequate exercise capacity and functional performance become crucial. The aim of this study was to observe the development of exercise-related values at different times, as well as to detect possible influencing factors. We performed a prospective single-centre study: 10 patients (63 years, 100% male, body mass index = 27.5, 100% HeartWare) underwent the following diagnostic tests during cardiac rehabilitation and during two subsequent ambulatory visits: 6-min walking test, handgrip strength test, cardiopulmonary exercise test and Minnesota Living with Heart Failure questionnaire. Mean follow-up was 482 days after left ventricular assist device implantation. Significant improvements could be observed between the end of cardiac rehabilitation and ambulatory visit 1; 6-min walking distance increased from 367 to 449 m (p < 0.01), peak VO2 from 10.0 to 11.9 mL/kg/min (p < 0.05) and peak load from 62.4 to 83.0 W (p < 0.01). However, there were no further improvements between ambulatory visit 1 and ambulatory visit 2. In the long term, a significant mean weight gain of more than 10 kg could be observed (p < 0.01). A negative linear correlation between weight gain and absolute improvement in peak load (r = −0.77, p < 0.01) and peak VO2 (r = −0.75, p < 0.05) could be demonstrated. In conclusion, exercise-related values following left ventricular assist device implantation initially improve significantly. Later, however, no further improvements can be observed. In the long term, pronounced weight gain is conspicuous, concomitant with a significantly lower increase in exercise values of the patients. In the future, both dietary and structured physical activity follow-up interventions should be integrated in patient routines.

Determining Primary Care Physician Information Needs to Inform Ambulatory Visit Note Display

Citation: Erratum to: Clarke MA, Steege LM, Moore JL, Koopman RJ, Belden JL, Kim MS. Determining primary care physician information needs to inform ambulatory visit note display. Appl Clin Inf 2014; 5: 190e http://dx.doi.org/10.4338/ACI-2013-08-RA-0064e

Determining Primary Care Physician Information Needs to Inform Ambulatory Visit Note Display

Summary Background: With the increase in the adoption of electronic health records (EHR) across the US, primary care physicians are experiencing information overload. The purpose of this pilot study was to determine the information needs of primary care physicians (PCPs) as they review clinic visit notes to inform EHR display. Method: Data collection was conducted with 15 primary care physicians during semi-structured interviews, including a third party observer to control bias. Physicians reviewed major sections of an artificial but typical acute and chronic care visit note to identify the note sections that were relevant to their information needs. Statistical methods used were McNemar-Mosteller’s and Cochran Q. Results: Physicians identified History of Present Illness (HPI), Assessment, and Plan (A&P) as the most important sections of a visit note. In contrast, they largely judged the Review of Systems (ROS) to be superfluous. There was also a statistical difference in physicians’ highlighting among all seven major note sections in acute (p = 0.00) and chronic (p = 0.00) care visit notes. Conclusion: A&P and HPI sections were most frequently identified as important which suggests that physicians may have to identify a few key sections out of a long, unnecessarily verbose visit note. ROS is viewed by doctors as mostly “not needed,” but can have relevant information. The ROS can contain information needed for patient care when other sections of the Visit note, such as the HPI, lack the relevant information. Future studies should include producing a display that provides only relevant information to increase physician efficiency at the point of care. Also, research on moving A&P to the top of visit notes instead of having A&P at the bottom of the page is needed, since those are usually the first sections physicians refer to and reviewing from top to bottom may cause cognitive load. Citation: Clarke MA, Steege LM, Moore JL, Koopman RJ, Belden JL, Kim MS. Determining primary care physician information needs to inform ambulatory visit note display. Appl Clin Inf 2014; 5: 169–190http://dx.doi.org/10.4338/ACI-2013-08-RA-0064