Digital consultations increase adherence to heart failure guidelines

By putting consultations in a digital format, the quality of care can be improved and the amount of work can be reduced. Information from home measurements can be shared with the doctor more often and more easily through digital consultations. For all healthcare contexts, it is not clear how exactly digital consultations affect the quality of care. Nature Medicine recently published the results of a Dutch study on digital consultations for heart failure patients. Digital consultations seem to lead to better adherence to guidelines, indicating a higher quality of care provided.

Cardiologist Mark Schuuring (Medisch Spectrum Twente) had to conduct digital consultations with patients during the corona pandemic. “Covid caused a sudden shift from physical consultations to remote consultations,” he says. “Negotiations were suddenly done via telephone or video connection. And while it was technically possible, there were concerns about how safe and effective these digital consultations were. But the increasing pressure on healthcare makes the use of these types of digital solutions – if they are safe and effective – very desirable.”

The aging of the population and improved treatment options for cardiovascular diseases increase the number of patients with heart failure, Schuuring continues. “Thanks to better treatment, people today die less often from heart attacks. That’s fantastic, of course, but it also leads to more patients with chronic heart failure. Hospitalization due to heart failure lasts an average of eight days, which is a significant burden on the health care system.

According to Schuuring, there have been several golden years in the field of heart failure, during which many positive results have been achieved in research. In order to change these results into better patient care, new guidelines have been drawn up, but the application of the new guidelines has lagged behind. “Digital consultation can help implement these guidelines, improve care, prevent hospitalizations, and ultimately ease the burden on the healthcare system.”

The new directive

In 2021, the European Society for Cardiology (ESC) published a new guideline for the treatment of heart failure, which was updated in 2023.^1,2 Unfortunately, cardiologists often do not have enough time to optimize patient treatments based on the guidelines, says Schuuring.

“Hospitalization can be prevented with the right medicines. But in practice, it is difficult to prescribe the recommended medication for each patient, as this is a very labor-intensive process. Currently, only a small proportion of patients receive optimal treatment. These patients therefore regularly require additional treatment, which increases the pressure on the healthcare system. Because of the high workload that results, we don’t have enough time to provide the patient with optimal care, and we end up in a negative cycle.”

According to Schuuring, better adherence to guidelines can also limit variation in practice. “There is a lot of variation in the prescription. This varies between different hospitals, but also between different doctors in the same hospital. Ideally, you want to compare doctors’ drug choices to an internal standard. The electronic patient record (EPD) could be that mirror. By providing EPD with guideline advice, all doctors receive the same treatment advice based on the latest scientific insights.

Digital contact information useful

Previous studies have shown that digital contacts are beneficial in patients with irritable bowel syndrome.³ There have also been several studies on digital consultations for heart failure, but they took place in one hospital and lacked a control group. “If there is no control group, it is impossible to compare the intervention with regular treatment. Studies conducted in one hospital do not provide clarity on how effective the intervention is in other treatment environments.”

So there was room for improvement. “We conducted a randomized trial involving five hospitals to clarify the value of digital consultants in heart failure patients. The research is coordinated by technical doctor and doctoral student Jelle Man. Both academic and non-academic hospitals participated in the study: UMC Utrecht, Amsterdam UMC, Netherlands Cardiology Center and Red Cross Hospital.⁴ A total of 150 patients with heart failure participated in the study. About half were assigned to the intervention group and received digital consultation, while the other half were assigned to the control group and received regular therapy.

The digital consultation consisted of three parts, Schuuring explains. “First of all, the patients took measurements at home, including blood pressure and heart rate. This information then ended up in the EPD, giving access to the attending cardiologist.”

In addition, patients received additional information about home measurements, their condition and treatment. The researchers found that patients also shared this information with their families, who helped them follow the advice. In this way, patients remained more aware of the information. Schuuring: “Finally, the EPD advises cardiologists on the optimal treatment of patients. These recommendations are therefore based on the new heart failure guidelines and have been compiled manually by Jelle Man. We want to automate this step in the future.”

Better compliance

These digital consultations appeared to lead to better adherence to guidelines. “Our study showed that the ‘guideline-directed medical therapy’ (GDMT) score is higher when heart failure patients receive a digital consultation compared to patients receiving regular care,” says Schuuring. “The GDMT points are between zero and six, and you get one point for a medicine according to the instructions. Therefore, the GDMT determines the extent to which the physician follows the instructions. Previous studies have shown that higher GDMT is associated with lower morbidity and mortality⁵.”

But don’t digital consultations make healthcare accessible to patients with less digital skills? Schuuring did not see it in his study. “It is often said that these types of digital interventions do not work for elderly patients. Our research certainly didn’t show that. The median age of the study participants was 70 years. So half of the participants were younger and the other half were over 70 years old. Digital consultations increased GDMT scores in both younger and older patients. The older participants sometimes needed a little more support from their families, but it didn’t cause any problems. Elderly patients are increasingly digitally savvy, and it is good for patients with reduced mobility to come to the hospital for consultation less often.

Impact on healthcare

In follow-up research, Schuuring is further investigating the impact of digital consultants on the treatment of heart failure patients. “The new research is being coordinated from the University of Twente. We will find out in more hospitals and with a larger group of patients the effects of digital consultants on, for example, the health of patients, the number of hospital visits and healthcare costs.

Finally, digital consultations can reduce the workload of potential healthcare personnel, Schuuring expects. “In this study, the instructions were drawn up manually. By automating this, the doctor’s workload can be reduced. EPD based on home measurements and guidelines reduces the amount of treatment needed and facilitates the transfer of patients from one healthcare provider to another.