A universal electronic consultation programme at the cardiology department after general practitioner referrals to improve healthcare accessibility and outcomes in elderly patients
Authors: Garcia-Vega D , Mazon-Ramos P , Cinza-Sanjurjo S , Portela-Romero M , Rey-Aldana D , Sanmartin-Pena J , Alvarez-Alvarez B , Martinez-Monzonis A , Espasandin-Dominguez J , Gude-Sampedro F , Gonzalez-Juanatey J R 
Published: October 2022

Abstract

Background
The on-line healthcare models are an opportunity to improve the accessibility and efficiency in clinical assistance, however, analyses of the effects of outpatient care on healthcare quality, including safety, are limited, particularly in vulnerable populations such as elderly patients 1. The care of elderly patients (generally &gt;80 years) is usually characterized as having more chronic pathologies, particularly more cardiovascular diseases, resulting in having a worse risk profile 2. However, this group is also usually characterized by problems with functionality and dependency that can increase difficulties in moving from their homes to health care centres, particularly in areas of great geographical dispersion such as in our study 3.
The healthcare systems that have integrated electronic clinical records between different assistance levels provide an electronic consultation (e-consultation) as a first step of ambulatory care for all general practitioner (GP) referrals. Healthcare systems that include an e-consultation have already shown favorable health outcomes and reduced displacement of the population served 4,5 and could also improve accessibility to outpatient care, although there are not results to demonstrate its safety in this particular group of high-risk patients.

Purpose
We aimed to assess the accessibility and health outcomes (hospital admissions and mortality) in elderly patients referred to a cardiology department (CD) from primary care after inclusion of an e-consultation in outpatient care.

Methods
We included 9,963 patients &gt;80 years old referred to the CD from January 1st, 2010, to December 31st, 2019. In 2013, we instituted an e-consultation programme (2013–2019) for all primary care referrals to cardiologists that preceded patient in-person consultations when considered. We compared both models (in-person consultation and e-consultation) using I: an interrupted time series regression on delay time, hospital admission, and mortality, II: the accessibility measured as population-adjusted referred rate in both periods, and III: analysing the changes in each municipality in delay time, hospital admission and mortality.

Results
During the e-consult period, the demand of care increased (12.8±4.3% vs 25.5±11.1% per 1,000 inhabitants, p&lt;0.001), delay for care was reduced (−0.094 days; 95% CI [−0.063, −0.140], p&lt;0.001), and age-dependent delay disappeared. After the implementation of e-consults, hospital admission (incidence rate ratio [iRR]: 1.351 [95% CI, 0.787, 2.317], p=0.874), Figure 1, and mortality (iRR: 1.925 [95% CI: 0.889, 4.168], p=0.096) stabilised with a slight downward trend, Figure 2.

Conclusion
Implementation of e-consultations in the outpatient care programme in CD was associated with improved access to cardiology healthcare in elderly patients. After the implementation of the e-consultation, hospital admissions and mortality were stabilised and showed a slight non-significant downward trend.

Funding Acknowledgement
Type of funding sources: None.