Wednesday, May 23, 2018

Virtual primary care visits for follow-up hypertension care have outcomes similar to office visits

Online communication offers greater convenience for clinicians, practices and patients without compromising quality patient care


BOSTON – Virtual follow-up visits for patients with hypertension appeared to be just as effective as in-person office visits in helping maintain blood pressure control. In a study conducted among patients at Massachusetts General Hospital (MGH) and Brigham and Women’s Hospital (BWH), investigators found no significant difference in outcomes – including the need for specialty visits or inpatient hospitalization – between patients checking in with their primary care physicians via a secure website to report aspects of their hypertension care and those who did so via in-person office visits. The report has been published online in the Journal of General Internal Medicine.

“Our central finding was that you can use online, non-simultaneous communication to manage a chronic medical condition without office visits that can be inconvenient for patients and add to demands placed on busy primary care practices,” says study co-author Ronald Dixon, MD, of the MGH Division of General Internal Medicine. “It also supports scaling this concept to other chronic diseases with the addition of devices allowing collection of needed patient information.”

The study authors note that one in three U.S. adults have hypertension, and only half successfully control the condition. Hypertension is believed to account for 39 million office visits annually in this country, but whether traditional visits best serve the needs of patients and clinicians has not been determined. The growing pressures on primary care offices are well known, with patients often needing to wait months for non-urgent appointments. So any measures that could reduce the time and resources needed to provide primary care services without compromising the quality of care or increasing the need for specialty care could help relieve that pressure.

Select MGH primary care practices began offering virtual visits for common chronic conditions in December 2012. The current study compares data and outcomes for patients from MGH primary care practices who had at least one virtual follow-up visit for hypertension from December 2012 to February 2016 with those of a group of similar patients treated for hypertension at BWH primary care practices during the same time period. The MGH study group included 893 patients participating in virtual visits to follow up an initial in-office clinical visit, while the BWH group included 893 patients with similar demographic factors, chronic conditions and cardiovascular risk factors. Blood pressure readings during the six months prior to the initial office visit at the beginning of study participation were similar for both groups.

The virtual visits platform allowed patients to enter up to five blood pressure readings taken since their last visit – either in-office or virtual – report on whether they were taking medications as directed, describe any side effects and ask questions. Primary care clinicians reviewed what patients had entered to answer questions, make needed adjustments to treatment, and to recommend repeat virtual visits, follow-up phone calls or in-office visits. Whether or not to offer virtual visits was determined by the clinician on a case-by-case basis, and patients could choose whether or not to participate in the virtual visit program.

During the six months after participants’ initial clinical office visit, patients in both groups showed similar improvements in blood pressure control and other outcomes. But those in the virtual care group had an average of 0.8 fewer follow-up office visits, a decrease that was even greater among patients whose blood pressure control had been poor upon entry into the study. There were no significant differences between the two groups in specialist visits, emergency department visits or hospital admissions for any reason.

David Michael Levine, MD, of the BWH Division of General Internal Medicine and Primary Care, lead and corresponding author of the report, says, “The use of virtual visits to reduce in-person office utilization without negative effects on blood pressure control or the need for other services could significantly expand access for patients of busy primary care practices. Many groups, especially insurance companies, have been skeptical of virtual care because they believe it may increase the use of health care services, but our findings show that a virtual visit can substitute for, rather than add to, an in-person visit, decreasing overall health care utilization.”

At the MGH, virtual visit availability has been expanded to all primary care and several specialty care practices, where it now is used to follow up on the care of around 65 chronic conditions, ranging from rheumatologic conditions like gout to psychiatric illnesses like depression. It will soon be extended to practices at other Partners HealthCare facilities, beginning at BWH.

Dixon notes, “A paper that a colleague and I published in 2014 reported that conducting and documenting a virtual visit requires about one-fifth of the time a clinician needs for an in-person, office visit. And of course not needing to travel to and from the primary care office is definitely of benefit to patients. The challenge now is finding a way to fairly compensate clinicians for the time and effort devoted to virtual visits.”

Jeffrey A Linder, MD, MPH, formerly at BWH and now at the Feinberg School of Medicine at Northwestern University is a co-author of the Journal of General Internal Medicine paper. Support for the study includes Institutional National Research Service Award T32 HP10251 from the National Institutes of Health and the Ryoichi Sasakawa Fellowship Fund.

Brigham and Women's Hospital (BWH) is a 793-bed nonprofit teaching affiliate of Harvard Medical School and a founding member of Partners HealthCare. Through investigation and discovery conducted at its Brigham Research Institute, BWH is an international leader in basic, clinical and translational research on human diseases, supported by nearly $666 million in funding. For the last 25 years, BWH ranked second in research funding from the National Institutes of Health among independent hospitals. BWH is also home to major landmark epidemiologic population studies, including the Nurses’ and Physicians’ Health Studies and the Women’s Health Initiative as well as the TIMI Study Group, one of the premier cardiovascular clinical trials groups.

Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH Research Institute conducts the largest hospital-based research program in the nation, with an annual research budget of more than $900 million and major research centers in HIV/AIDS, cardiovascular research, cancer, computational and integrative biology, cutaneous biology, genomic medicine, medical imaging, neurodegenerative disorders, regenerative medicine, reproductive biology, systems biology, photomedicine and transplantation biology. The MGH topped the 2015 Nature Index list of health care organizations publishing in leading scientific journals and earned the prestigious 2015 Foster G. McGaw Prize for Excellence in Community Service. In August 2017 the MGH was once again named to the Honor Roll in the U.S. News & World Report list of "America's Best Hospitals.”

Media contact: Julie Cunningham, julie.cunningham@mgh.harvard.edu, 617 724-6433

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