ABSTRACT
Background: The implementation of guidelines on LDL cholesterol levels after acute coronary syndrome (ACS) is very poor according to registries and surveys. Telemedicine could improve adherence to guidelines and facilitate clinical followup of patients with ACS, even with the limitations of Covid-19 pandemic. Aim of the study: To evaluate the efficacy of telemedicine follow-up in improving adherence to LDL guidelines and improving rates of prescription of PCSK9-inhibitors. Design and Methods: 650 consecutive patients discharged with diagnosis of ACS or Chronic CS were enrolled in the study and followed after 2 and 4 months. LDL levels and lipid lowering drug prescription were recorded. Data from 300 patients with ACS patients and <80 years were analyzed and LDL values of telemedicine followedup patients (telephone/smartphone app/pc teleconsultation) were compared with controls. Result(s): Baseline mean LDL levels were 120 mg/dl, 55% of patients were naive of lipid lowering therapy. At second follow-up mean LDL levels were 55 mg/dl (p<0.05 vs baseline) and rates of prescription of statins, ezetimibe and PCSK9-inhibitors were 98%, 79%, and 18% respectively. Rates of subjects with LDL levels below recommended threshold were 4% at baseline, 39% at first follow-up, 53% at second follow-up (p<0.05). Patients followed up with telemedicine showed lower LDL levels at second follow-up (55vs72 mg/dl, p=0.08) and higher rates of subjects below recommended LDL levels (63%vs30%, p=0.05). Conclusion(s): Telemedicine follow-up may improve the implementation of guideline recommended LDL levels after ACS..
ABSTRACT
ED patients with lower-acuity care needs often have long wait times for evaluation because of higher-acuity patients receiving priority for available beds. Challenges posed by the Covid-19 pandemic accelerated the launch in December 2020 of an already-developed and approved plan to integrate virtual visits into clinical care at Stanford. For both adult and pediatric EDs, Stanford extended this model into the emergency care environment by converting its existing Fast Track care unit into a Virtual Visit Track (VVT). This was done to speed the ability to evaluate lower-acuity patients in more than one ED with a single physician located at a satellite location. In the VVT, a remote physician provided care to lower-acuity patients who presented at either of the two sites, the pediatric ED or the adult ED. The physician is supported by virtual visit-enabling hardware, software, workflow development, and training, as well as by VVT-trained support staff. In the first 11 months, 2,232 patients received care through the VVT. Stanford met its resource investment break-even point of 12 patients seen during an 8-hour shift on day 6, but this patient volume was not sustained until 7.5 months into the program;this volume has remained constant since then. In a matched cohort of patients, the median ED length of stay (EDLOS) for VVT patients was 1.9 hours compared with 4.2 hours for patients cared for in the typical main ED workflow (P < .001). Also, 17 of 50 VVT physicians (34%) rated their ability to deliver a comparable level of care to in-person consultation as excellent, with the remaining 33 of 50 (66%) rating it as very good. The authors observed that the age range for VVT patients was 2-94 years, but overall, they were younger than a matched cohort of main ED patients. This may reflect generational differences in comfort with a virtual physician encounter. Within the matched cohort, they also found that the median return visit rate among VVT patients was lower than among those in the main ED for 72-hour revisits (6.7% vs. 7.2%;P = .60) and 7-day revisits (10.4% vs. 12.4%;P = .09), but the differences were not statistically significant. This suggests that VVT visit quality is not likely worse than main ED care for similarly lower-acuity patients. The aim was not to determine that the VVT model was superior, but rather that it was not inferior. Virtual care is a fast-growing method of care delivery. Although typically applied when a patient is outside of the care environment, a VVT program can be used in other situations in which options for in-person evaluation are limited.