Frequency and Predictors of Virtual Visits in Patients With Heart Failure Within a Large Health System: Retrospective Cohort Study

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Abstract
Background: Virtual care interventions have the potential to improve access to care and serial medication intensification for patients with chronic heart failure with reduced ejection fraction (HFrEF). However, concerns remain that these interventions might unintentionally create or widen existing disparities in care delivery and patient outcomes. Objective: This study aimed to characterize the health care use patterns of patients who have HFrEF, including specialty type and frequency of in-person and virtual visits. Methods: We conducted a retrospective cohort study of patients with HFrEF within a large health system. Inclusion criteria were patients alive with an ejection fraction ≤40% as of September 1, 2021, and at least one virtual or in-person outpatient visit to a primary care or cardiology clinician in the prior year. Descriptive statistics were used to evaluate baseline patient demographics and clinical use data and outcomes. Univariate analyses were performed both with virtual visits as a variable (received or did not receive) using the chi-square test for association and as a discrete outcome using the Wilcoxon rank-sum test to capture potentially important predictor variables that could influence use or frequency of using virtual visits. The primary outcome of interest was the odds of at least one virtual visit during the 1-year evaluation period from 2021 to 2022. Descriptive statistics were used to evaluate baseline patient demographics and care use. A logistic regression model was used to model at least one primary care or cardiology virtual visit. Results: A total of 8481 patients were included in the analysis. The mean age was 65.9 years (SD 15.1), 5672 (66.9%) patients were male and 6608 (77.9%) patients were non-Hispanic White. The majority of patients had no cardiology (7938/8481, 93.6%) or primary care (7955/8481, 93.8%) virtual visits during the evaluation period. Multivariable logistic regression showed significantly higher odds of having at least one virtual visit for patients with certain digital access—for example, email on file (odds ratio [OR] 9.3, P≤.001), cell phone on file (OR 2.9, P≤.001), and active electronic health record patient portal (OR 2.8, P≤.001)—than those without. Age, race, ethnicity, rurality, and Social Vulnerability Index were not associated with virtual visits. Conclusions: Only a minority of patients with HFrEF were seen via virtual visits. Patients who regularly used digital technology were more likely to have virtual visits. Patients were more likely to be seen in a cardiology clinic than by a primary care provider. Although there was no evidence of an association between social determinants of health factors like race, ethnicity, or rurality with digital divide indicators, these findings should be interpreted with caution given the limitations of these data. Future studies should aim to replicate the findings of this study and explore ways to enhance the effective and equitable use of virtual visits.

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