Enhancing Shared Decision Making in a Chronic Population. Use of an Advance Directive Decision Aid for Patients with Heart Failure and Their Caregivers

Background: The COVID-19 pandemic disrupted the way care is delivered to patients with chronic conditions such as heart failure (HF).Many outpatient encounters are now conducted virtually via telehealth.Whether virtual visit for HF results in similar type of interventions as when the patient is seen in person is not known.Methods: Starting on March 15, 2020, all non-time sensitive outpatient in-person appointments at our institution were cancelled and transitioned to virtual appointments where possible.We included all patients seen in a tertiary care HF clinic from February 18 to March 13 (pre-Covid) and from March 16 to May 15 (post-COVID).We examined the volume of in-person and virtual visits and compared medication titration rates pre-and post-COVID.Results: The study cohort included 745 patients, mean age 60.7+/-15.3years, 65.2% male, 80.9% Caucasian, 7.7% Hispanic/Latino.Of these, 227 patients were seen pre-COVID and 518 post-COVID.All appointments were in-person pre-COVID.After the change, only 18% of appointments were in-person while 82% were virtual.Outpatient volume decreased after March 15, but gradually increased, eventually to volumes that exceeded pre-COVID (Figure).Detailed results on medication titration are shown in Table .Diuretic titration took place in 33/227 (14.5%) of patients pre-COVID and 83/518 (16.0%) post-COVID (p=NS).Among 567 patients with HF with reduced ejection fraction (HFrEF), titration of guideline-directed medical therapy (GDMT) took place in 86/172 (50.0%) of patients pre-COVID and 159/395 (40.2%) post-COVID (p=0.03).Among the 395 HFrEF patients seen post-COVID, GDMT was titrated in 33/68 (48.5%) patients seen in person and 126/327 (38.5%) seen virtually -p=0.13.Barriers to medication titration in virtual visits were lack of blood pressure readings and lack of recent laboratory results.Conclusion: Telehealth has become an essential method of outpatient care delivery for chronic HF.Once implemented, it offered efficiencies including improved access to the HF clinic thanks to higher throughput capacity compared to physical clinic space.However, we identified that GDMT titration took place less frequently than during in-person visits.Since it is anticipated that telehealth use will continue into the future, approaches to maximize GDMT in the absence of traditional direct physical contact with HF patients are needed.