Nisha Gilotra, MD, on HF Care in the COVID-19 Era

In this audio interview, Nisha Gilotra, MD, talks about how the COVID-19 pandemic has affected heart failure care at Johns Hopkins, her team's experience managing patients via telemedicine, and how she envisions restarting in-person visits. 

Additional Resources:

• Umapathi P, Cuomo K, Riley S, Hubbard A, Menzel K, Sauer E, Gilotra NA. Transforming ambulatory heart failure care in the coronavirus disease-19 era: initial experience from a heart failure disease management clinic. J Cardiac Failure. 2020;26(7):637-638. https://doi.org/10.1016/j.cardfail.2020.06.003 
• Gorodeski EZ, Goyal P, Cox ZL, et al. Virtual visits for care of patients with heart failure in the era of COVID-19: a statement from the Heart Failure Society of America. J Cardiac Failure. 2020;26(6):448-456. https://doi.org/10.1016/j.cardfail.2020.04.008 

Nisha Gilotra, MD, is an assistant professor of medicine, director of Heart Failure Disease Management, and director of the Heart Failure Bridge Clinic at Johns Hopkins Hospital in Baltimore, Maryland.

Content collaboration with Johns Hopkins Medicine.

TRANSCRIPT:

Amanda Balbi: Hello everyone, and welcome to another installment of Podcasts360—your go-to resource for medical news and clinical updates. I’m your moderator, Amanda Balbi with Consultant360 Specialty Network.

The COVID-19 pandemic and the subsequent shelter-in-place order have affected all areas of medicine. Today we will be speaking about how the pandemic has affected heart failure care with our guest Dr Nisha Gilotra, who is an assistant professor of medicine, director of Heart Failure Disease Management, and director of the Heart Failure Bridge Clinic at Johns Hopkins Hospital in Baltimore, Maryland.

Thank you so much for joining me today, Dr Gilotra.

Nisha Gilotra: Thank you so much.

Amanda Balbi: In response to the COVID-19 pandemic, the Heart Failure Society of America recently published an expert consensus statement on the use of telehealth for patients with heart failure. How have you and your team used telemedicine in the HF clinic at Johns Hopkins?

Nisha Gilotra: Our team read with great interest the HFSA’s very timely statement on the role of virtual visits in the management of heart failure.

Just to kind of briefly summarize, the writing committee very nicely laid out both the benefits as well as the limitations of telemedicine use in the heart failure population. In the Johns Hopkins cardiology and advanced heart failure practices, we've certainly embraced telemedicine in order to continue providing care for our vulnerable heart failure patients who honestly can't risk going without seeing their providers during this pandemic.

So when the state of Maryland first announced its closures on March 16, we quickly transitioned to telemedicine, offering patients several different video platforms as well as an audio-only option.

If patients are equipped with things like a scale to weigh themselves or blood pressure cuff at home, the telemedicine visit can honestly be quite effective. Within our cardiology clinic, we actually have what's called the Johns Hopkins Heart Failure Bridge Clinic, which is a nurse-practitioner-led heart failure disease management clinic aimed at optimizing heart failure care and reducing readmissions.

And so, our normal workflow is to capture all patients who are discharged after a heart failure hospitalization into a clinic appointment within one week of discharge and then we follow them regularly up to weekly or as needed in that early post-discharge period.

The benefit is we're able to do lab work, give ambulatory IV diuretics right there in the clinic, and I've seen a tremendous reduction in readmission rates and healthcare utilization cost for patients in the clinic after hospitalization.

So, we didn't want to miss a beat with these vulnerable patients recovering from a recent hospitalization, and it was even more important to leverage telemedicine to closely monitor these patients. That's where we really needed to embrace telemedicine.

And then we also partner closely with our home care team, which provides remote home monitoring resources. In the era of the pandemic, this partnership grew even stronger for us managing heart failure in our clinic at Johns Hopkins.

Amanda Balbi: You and your team recently published a paper about these experiences. Can you tell us a little bit more about the study and its outcomes?

Nisha Gilotra: Yes, I would be happy to.

So, we recently published our early experience during the COVID-19 era caring for heart failure patients in our Heart Failure Bridge Clinic at Johns Hopkins, which was published in the Journal Cardiac Failure in July.

In our study, we described 164 patient visits. This was 116 unique patients over the course of about 6 weeks, and two-thirds of the patients were actually seen after recent hospital discharge or for complaints of worsening heart failure symptoms at home.

Overall, we found that 60% of the visits were done via telemedicine and 40% were in-person. Notably, we found that it took a few weeks for our patient population and our clinic to transition from in-person to televisit.

Initially, there was a lot of use of tele-audio, but as folks got more comfortable with the different video platforms that were available, over time we demonstrated an increase utilization of them.

Through telemedicine, we were actually able to adjust home diuretics at 25% of the telemedicine visits, and [in] only 6 of the patients who were seen via telemedicine, we then said, “Okay, you need to come in for an in-person visit.”

None of them required a direct triage to the hospital at the time of visit. And again, these are patients who are highly vulnerable, have just been discharged, are actually having an appointment, because they're having worsening heart failure symptoms.

Then we were also able to identify a subset of patients—about 40% of all of our visits—that required in-person visits despite the pandemic. That's important to note: Actually 50% of these visits that were in-person resulted in IV diuretic administration in the clinic, so we actually found that continued access to in-person assessment and ambulatory IV diuresis, in particular, was really important in keeping heart failure patients out of the emergency department and out of the hospital where they might be exposed to higher risk of infection.

Amanda Balbi: How else has the COVID-19 pandemic affected your practice in heart failure?

Nisha Gilotra: I think the pandemic has, of course, affected the field of heart failure across the board. Heart failure is a chronic condition highly dependent on self-management.

And so it's actually empowered patient more to monitor themselves for things like fluid retention or blood pressure, effect of medication changes.

And the pandemic has also brought on a greater interest in telemonitoring in heart failure. Whether it's the already implanted devices [inaudible 6:05], ICDs, or remote patient monitoring via homecare.

Lastly, we've witnessed that because patients are avoiding the hospital, those that do come in have had a higher severity of illness than average. So, you know, I think time will tell what the impact of the pandemic will have on readmission rate, heart-failure-related mortality, and heart transplant ventricular assist device implantation. But it certainly affected heart failure broadly.

Amanda Balbi: With more medical practices starting to reopen, especially on the East coast, do you feel confident about restarting in-person visits? If not, what are your hesitations?

Nisha Gilotra: Yeah, that's a great question, the million-dollar question! You know, I think the short answer for this question is “Yes.” We, like others, have completely revamped our clinical workflow and are taking many precautions to allow patients and staff to safely return to clinic.

I think there are clearly patients that benefit from in-person visits, as we demonstrated in our study, especially those with advanced heart failure who may miss that window of opportunity to be able to stay out of the hospital or, you know, be candidates for advanced therapies.

There's definitely that to keep in mind, but I think there is a continued role for telemedicine. And with the ongoing pandemic, the smartest thing is really to choose telemedicine vs in-person visits based on what's best for the specific patient and taking into account the patient’s preferences, their risk factors, and their clinical needs at that time.

Amanda Balbi: Overall, what would you say is your key take-home message for your peers in heart failure?

Nisha Gilotra: I would say that because these are uncertain times, without a clear sense of when the pandemic will abate, that we continue to optimize telemedicine in heart failure care.

I would encourage teams to utilize hospitalizations to educate patients on heart failure self-care, ensure medication reconciliation, that they have their medications in hand, and make sure patients and caregivers are equipped for successful telemedicine post-discharge.

So, whether that means they need to get your hospital’s app on their phone or need to involve a caregiver who may be more tech savvy, all of those things can really be leveraged during a hospitalization.

At the same time, I would encourage my peers in heart failure to remind their patients that we're all still here to care for them through the pandemic, whether it's virtually or in-person, that they should really not delay their care.

So, I think that's an important message for not only peers but for patients as well.

Amanda Balbi: Great. Thanks again for speaking with me today, Dr Gilotra.

Nisha Gilotra: Thanks so much for having me.