Experiences and Perceptions of Patients and Providers Participating in Remote Titration of Heart Failure Medication Facilitated by Telemonitoring: A Qualitative Study (Preprint)

BACKGROUND Guideline-directed medical therapy (GDMT), optimized to target doses, improves health outcomes in patients with heart failure (HF). However, GDMT remains underutilized, with less than 25% of patients receiving target doses in clinical practice. A randomized controlled trial (RCT) was conducted at the Peter Munk Cardiac Centre in Toronto to compare a remote GDMT titration intervention with standard in-office titration. This RCT found that remote titration increased the proportion of patients that achieved optimal GDMT doses, decreased the time to dose optimization, and reduced the number of necessary clinic visits. This paper presents findings from the qualitative component of the mixed-methods study, which evaluated the implementation of the remote titration intervention. OBJECTIVE The objective of the qualitative component was to assess the perceptions and experiences of clinicians and HF patients who participated in the remote titration intervention to identify factors that impacted the implementation of the intervention. METHODS We conducted semi-structured interviews with clinicians (n=5) and patients (n=11) that participated in the remote titration intervention. Questions probed the experiences of the participants to identify factors that can serve as barriers and facilitators to its implementation. Conventional content analysis was first used to analyze the interviews and gain direct information based on the participants’ unique perspectives. Subsequently, the generated themes were delineated and mapped following a multi-level framework outlined by Chaudoir et al. RESULTS Patients and clinicians indicated that the intervention was easy to use, was integrated well into their routines and removed practical barriers to titration. Key implementation facilitators from the patients’ perspective included the reduction in clinic visits and daily monitoring of their condition, while clinicians emphasized the benefits of rapid drug titration and efficient patient management. Key implementation barriers included the resources necessary to support the intervention and lack of physician remuneration. CONCLUSIONS This study presents results from a real-world implementation assessment of remote titration facilitated by telemonitoring. It is among the first to provide insight into the perception of the remote titration process by clinicians and patients. Our findings indicate that the relative advantages that remote titration presents over standard care strongly appeal to both clinicians and patients. However, to ensure uptake and adherence, it is important to make sure that suitable patients are enrolled, and impact on the physicians’ workload is minimized. The implementation of remote titration is now more critical than ever as it can help provide access to care for patients during times when physical distancing is required. CLINICALTRIAL ClinicalTrials.gov NCT04205513; https://clinicaltrials.gov/ct2/show/NCT04205513 INTERNATIONAL REGISTERED REPORT RR2-10.2196/19705

Feminization of the rheumatology workforce: A longitudinal evaluation of patient volumes, practice sizes and physician remuneration

Objective To compare differences in clinical activity and remuneration between male and female rheumatologists and to evaluate associations between physician gender and practice sizes and patient volume, accounting for rheumatologists’ age, and calendar year effects. Methods We conducted a population-based study in Ontario, Canada between 2000-2015 identifying all rheumatologists practicing as full-time equivalents (FTE) or above and assessed differences in practice sizes (number of unique patients), practice volumes (number of patient visits), and remuneration (total fee-for-service billings) between male and female rheumatologists. Multivariable linear regression was used to evaluate the effects of gender on practice size and volume separately, accounting for age and year. Results The number of rheumatologists practicing at or above one FTE increased from 89 to 120 from 2000 to 2015, with the percentage of females increasing from 27.0% to 41.7%. Males had larger practice sizes and practice volumes. Remuneration was consistently higher for males (between $46,000-$102,000 annually). Our adjusted analyses estimated that in a given year, males saw a mean of 606 (95% CI 107-1105) more patients than females did, and had 1,059 (95% CI 345- 1773) more patient visits. Among males and females combined, there was a small but statistically significant reduction in mean annual number of patient visits, and middle-aged rheumatologists had greater practice sizes and volumes than their younger/older counterparts. Conclusion On average, female rheumatologists saw fewer patients and had fewer patient visits annually relative to males, resulting in lower earnings. Increasing feminization necessitates workforce planning to ensure that populations’ needs are met.

P2853Contemporary reporting of acute complications from implantable cardioverter defibrillator surgery

Background Defibrillator placement carries an inherent risk to the patient. Traditionally, major adverse events defined as cardiac arrest, tamponnade, pneumothorax, infection requiring re-operation, MI and CVA within 30 days are reported to occur between 3 and 4%. Minor complications such as heamatomae or lead dislodgement are reported between 8 and 13%. Novel lead technologies, protocolised programming and reduced use of Heparin bridging have been reported to reduce adverse outcomes. However, patients are still typically monitored in hospital for 24 hours to mitigate these risks. There is little evidence that discharge delay is effective yet incurs significant additional costs. Purpose We sought to evaluate the frequency and timing of adverse events relating to defibrillator surgery (ICD and CRT-D) at a large Canadian tertiary care center (UOHI). Methods We retrospectively reviewed all patients who received a defibrillator placed from 1st April 2013 to 31st March 2018 inclusive. Patient comorbidities were extracted from the hospital electronic medical record (EMR) system. Device related information and complications were extracted from UOHI PaceartTM system and EMR and cross referenced with physician remuneration databases. Results A total of 2221 procedures were performed on 2153 patients (78% male, mean age 65 years). The majority (60%) of defibrillator implants were de novo, with 884 (40%) pulse generator replacements/ upgrades and 868 (39%) defibrillators had CRT capability. Patients were routinely discharged within 24 hours of ICD surgery. Post-operative follow up ≥30 days was complete in 97% patients. Major adverse events occurred within 30 days in 9 patients (0.4%); 9 (100%) were infection requiring re-operation. An additional 32 patients (1.5%) required repeat interventions or readmission within 30 days of implant, most commonly due to lead dislodgement. Only 2 patients required readmission within 24 hours of surgery (0.1%). All procedure-related adverse events during clinical follow up (≤5 years) were 131 (5.9%) occurring in 122 patients. There were no apparent predictors of adverse events in this cohort. Conclusion(s) Contemporary risks to patients undergoing defibrillator surgery are considerably lower than that reported in 2010. The risk of infection appears constant despite increased antibiosis. Patients receiving an ICD or CRT-D can safely be discharged within 24 hours if no complications are apparent. Acknowledgement/Funding None