A universal electronic consultation programme at the cardiology department after general practitioner referrals improves healthcare outcomes in patients with health failure
Authors: Garcia Vega D , Mazon-Ramos P , Portela-Romero M , Rey-Aldana D , Alvarez-Alvarez B , Cinza-Sanjurjo S , Gonzalez-Juanatey J R 
Published: November 2023

Abstract

Background
Electronic consultation (e-Consult) is an emerging health care innovation developed to address excess wait times for specialist care by enabling primary care physicians (PCPs) to obtain a specialist consultant’s expert opinion in a timely manner 1. A recent wait time report in England showed that in the first 7 months of 2017, 89.4% of patients waited up to 18 weeks to see a specialist. This result failed to meet their standard of 92% of patients waiting no more than 18 weeks for their consult 2. e-Consult services were shown to be effective in terms of providing faster access to specialist’s advice, with short response times (from 1 to 6 days) of the participating specialists and resulting in substantial avoidance of face-to-face referral visits 3. The recent ESC HF guideline made a "may be considered" recommendation for the use of home-based telemonitoring, according on a meta-analysis published in 2017 4,5. Nevertheless, never has been evaluated the impact on access to care and clinical outcomes of a clinician-to-clinician e-consult program as a first step for all the PCPs referrals to cardiologist in heart failure patients.

Purpose
We aimed to assess in patients with heart failure (HF) the clinical impact of the implementation of an outpatient care model that includes an initial e-consultation (from 2013 to 2021) and to compare it with a one-time in-person consultation model (from 2010 to 2012) for all the primary care physicians’ referrals to a cardiology department.

Methods
We selected 6,859 HF patients who visited the cardiology service at least once between 2010 and 2021: 4,851 were attended in e-consultation and 2,008 in one-time in-person consultations. Using an interrupted time series regression model, we analysed the impact of incorporating e-consultation into the health care model (started in 2013), and evaluated the elapsed time to cardiology care, cardiovascular (CV) and HF hospital admissions, and HF, CV and all-cause mortality.

Results
The interrupted time series regression model showed that the introduction of e-consultation substantially decreased waiting times to cardiology care (8.6 [8.7] vs 55.4 [79.9] days, p&lt;0.001). and a reduction in the need for visits to the emergency department 1-year after e-consultation compared with the previous period (HR [IC95%]: 0.07 [0.05-0.08]). After e-consultation implantation, hospital admissions were reduced (RRi [IC95%]: 0,867 [0,875-0,838] for HF, 0,838 [0,825-0,856] for CV and 0,639 [0,635-0,651] all-cause), figure 1; and lower mortality (RRi [IC95%]: 0,981 [0,977-0,983] due to HF, 0,977 [0,970-0,980] for CV and 0,985 [0,984-0,985] for all-cause), figure 2. These results were maintained during the COVID-19 pandemic.

Conclusion
In HF patients, an outpatient care program that includes an e-consultation significantly reduced waiting times to cardiology care and was safe, with a lower rate of hospital admissions and mortality in the first year.Figure 1Figure 2