Bringing Medicine To The People: The Rise Of Telemedicine In PAH Management

Dr. Elwing:
Now let's talk about telemedicine. Bringing medicine to the people, the rise of telemedicine in PAH management. How can it work? And how can we use it to its fullest potential? The pandemic has forced us a rethinking of how PAH patients are managed. COVID-19 has adversely influenced PAH care, clearly, especially during the early pandemic. There were periods that there was clearly stay-at-home policies that decreased patients confidence coming to the hospital and coming to the office. PAH expert centers adopted telemedicine tools to evaluate potential complex patients. And telehealth was used broadly, and really encompassed any technology-enabled healthcare management tool we could find to deliver care at that time.

There's been a fundamental change in how we interact with patients, and it now includes telemedicine. That's what I believe at least. However, we lack data. There's no studies that yet have demonstrated the effectiveness of the use of telehealth to improve outcomes, specifically in PAH patients. PAH patients rely on this aggressive multimodal, regular evaluation of their risk assessment to see if they're worsening. And this can be subtle. Current guidelines for management of patients with PAH require ongoing objective risk assessment based on multiple factors: functional capacity, walk distance, exercise testing, BNP and NT-proBNP, as well as echocardiographic and hemodynamic findings. So, these are a lot of pieces of the puzzle we look at when we're seeing a PAH patient to decide how they're doing.

COVID-19 lockdowns reduced in-office visits and PAH treatment initiation. During the COVID-19 lockdown, there was close to a 50% decline in new patient appointments for PAH, with a similar reduction in the initiation of PAH-specific therapies. This is huge. That was a great number of patients who had a delay in their care. The US study looking at 77 centers found that fewer clinic visits were occurring, and a higher level of telemedicine visits were occurring in PAH patients during the early pandemic. The incidence of COVID-19 in PAH and CTEPH patients was found early in the pandemic to be about three per thousand and of these 30% more hospitalized and 12% died. This was worse than the general population. Making us aware that we had to protect our patients and offer them options to see us outside the clinic. Delayed referrals and assessments clearly have potential to harm patients and we needed to think of ways to overcome this.

So, let's look at this study a little closer. So, we can see that pre-and post-pandemic there was significant reduction. And you'll see here, typical number of outpatients weekly from 30 to down to a number less than 15 after COVID-19. Use of telemedicine increased from 7% to 83%. So we did our best to replace some of those visits with telemedicine. But at the same time, we reduced our exposure of our patients to testing. And you'll see here, there are fewer echos, fewer right heart catheterizations, fewer VQ scans and fewer initiations of medical therapy for our PAH patients. So we did our best to try to offer telemedicine, but we were not able to offer the full package early in the pandemic.

So let's look at this. Early in the pandemic, 2020 to 2021, telemedicine expanded exponentially. Initially, there was a use of telemedicine, both audio and visual, as well as phone calls. And the phone visits fell off and the bimodal telemedicine, with audio and visual, went up over that period, from 3/11 to 4/4/2020. We adapted quickly. So in this instance, we found in a study at NYU that 80% of in-person visits decreased, and there was an increase of more than 650% of telemedicine during that time.