For patients with well-controlled hypertension, participation in virtual patient visits was significantly linked to equivalent blood pressure control and decreased use of in-office primary care services, according to a new study published in the Journal of General Internal Medicine.
Virtual visits could satisfy the need for closer follow-up in this population while reducing health-care resources, the researchers indicated. “Despite advances in treatment over several decades, management of hypertension remains a significant challenge due to nonadherence and challenges accessing care,” wrote authors led by David Michael Levine, MD, MPH, MA, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA.
The authors defined a virtual visit as an online visit with a patient that expands care past the initial office visit, with the intention of maintaining blood pressure control and decreasing in-person office visits. Previous researchers have shown that patients are happy with virtual visits; however, clinical outcomes and subsequent health-care utilization, including primary care, have yet to be elucidated.
In the current retrospective, difference-in-differences study, the authors compared blood pressure control and health-care utilization between patients who did and did not participate in virtual visits.
The virtual visits took place over a secured connection and were “check-ins” following the previous visit (virtual or in-person) in which patients could input as many as five blood pressure readings, report medication use and adverse effects, and ask questions. Primary care physicians then reviewed these data and managed patient care in an asynchronous manner.
After mining electronic health records for 1,051 virtual visits and 24,848 usual care visits, the team matched 893 patients (average age ~61 years, 44% female, 85% white) from each group for age, gender, smoking, race and ethnicity, health insurance coverage, number of chronic health conditions, average pre-visit systolic blood pressure (SBP), pre-visit primary care visits, number of pre-visit antihypertensive medications, pre-visit specialist visits, pre-visit emergency visits, and pre-visit inpatient admissions. Patients in the virtual visit group needed to have at least one virtual visit for hypertension between December 2012 and February 2016.
The researchers found that when compared with patients receiving routine care, patients in the virtual patient group differed only in primary care office visits, with an adjusted 0.8 fewer visits (95% CI = 0.3–1.2). The team observed no significant adjusted differences in mean SBP control, specialist visits, emergency department visits, or inpatient hospitalizations. Notably, the investigators considered two-sided P values of
Of interest, the authors performed a subgroup analysis of patients with poorly controlled (ie, SBP >140 mmHG). They found that patients in this subgroup came in for fewer office visits than those with well-controlled SBP did.
Dr. Levine and colleagues suggested that virtual visits can help improve office workflow efficiency in primary care settings and make the best use of the limited number of in-person office visits.
“Several barriers exist to scaling interventions like virtual visits,” the authors wrote. “Reimbursement for asynchronous visits is limited in traditional fee-for-service and is governed at the state level. For example, licensure requirements, particularly the need to have state-level credentials, preclude clinicians from providing virtual visits to their out-of-state patients.” Moreover, patients need to have access to the Internet, which may be an issue for poorer patients.
This study had limitations. For instance, it was of quasi-experimental design leveraging a difference-in-differences statistical approach devoid of causal inference. The team could not control for covariates including patient communication preferences, internet access, literacy, computer literacy, access to home blood pressure monitoring, or reasons why a patient was given a virtual visit.
“Among patients with reasonably well-controlled hypertension,” the researchers concluded, “virtual visit participation was associated with equivalent blood pressure control and reduced in-office primary care utilization.”
According to study coauthor Ronald Dixon, MD, the findings of the current study also support “scaling this concept [of virtual visits] to other chronic diseases with the addition of devices allowing collection of needed patient information.”