Case Study: Telemedicine as an Option in the Metabolic Primary Care Patient

Introduction
Telemedicine can help deliver care for cardiometabolic disorders, however it has not been used often by primary care providers in Federally Qualified Health Centers (FQHC).(1,2) FQHC patients have higher prevalence of cardiometabolic disorders which increases their susceptibility to develop the SARS CoV2 infection. The application of telemedicine may improve access and outcomes for the direct consequences of cardiometabolic disorders and the indirect benefit of protection from COVID-19. In the year 2019, FQHCs saw 29,836,613 patients with 91% of patients below the 200% Federal poverty guidelines.(3) These patients are often in remote locations and have fewer resources.

The Centers for Disease Control and Prevention (CDC) indicated this vulnerable population would experience more complications should they develop the SARS CoV-2 infection.(4) There has been concern in the medical community that atrisk patients would not keep their routine office appointments, thereby increasing the number of actual cardiovascular events. Prior to the COVID-19 pandemic, due to federal regulations, primary care providers (PCP) of FQHCs were not reimbursed for telemedicine care provided to their patients.(5) The emergency lifting of these restrictions in the HB 6074, the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020, allowed patients of FQHCs to receive care by their PCPs in their homes using a telemedicine platform.(6) This case study will review a patient with multiple cardiometabolic features in our FQHC who was successfully treated during the pandemic via the use of telemedicine.

Case Presentation
Cathy is a 48-year-old homemaker who has been a patient in our care for more than three years. Her first visit was to establish as a patient in our primary care practice. Past medical history included bipolar disorder and smoking over one pack of cigarettes per day. She reported a strong family history of cardiovascular disease (CVD). Her father was diagnosed at an early age with hypertension, CVD, type 2 diabetes (T2DM) and was deceased by the age of 65. Mother is deceased and was diagnosed with early onset Alzheimer’s and T2DM. The patient did not follow a special diet and she denied a regular exercise routine. She was also under the care of her psychiatrist. She was not on cardiovascular medications but her psychiatric medications included sertraline (100 mg daily), gabapentin (800 mg three times daily), and alprazolam (0.5 mg four times daily).

Her physical examination showed no cardiovascular abnormalities and vital signs were unremarkable. Baseline laboratory testing was ordered on her initial visit which included comprehensive metabolic panel, hemoglobin A1C (HbA1C), thyroid panel, and lipid profile. She has severe hypercholesterolemia. Genetic testing for monogenic familial hypercholesterolemia (FH) was cost prohibitive. A high-intensity statin was prescribed and intensive lifestyle education was initiated. Abnormal results are listed in the table below. The rest of her test results were in normal range.

Treatment
The patient was referred to a registered dietitian nutritionist (RDN) and was prescribed atorvastatin (80 mg once daily). She was referred to a pain management specialist for her back pain. Representatives from the pain clinic insisted she meet with a cardiologist after noting on the MRI that she had “bad cardiovascular disease.” The cardiologist agreed that she required attentive lifestyle care and risk factor control, but no additional testing or concerns about revascularization procedures. She was counseled on a walking/exercise program and smoking cessation. 

Three months after her initial visit, she had started lifestyle modifications and was adherent to her medication regimen. Her lipid panel had shown improvement as her non-HDL-C which had decreased by over fifty percent and her HbA1C remained unchanged. She had decreased her cigarette smoking to less than one pack per day.

Throughout the next three years, Cathy had several missed appointments and demonstrated occasional nonadherence with her medications, diet, and exercise, but she continued to work on smoking cessation. She was scheduled for a clinic follow-up visit in April 2020. 

With the onset of the COVID-19 pandemic, Cathy was concerned she would contract the virus and was reluctant to keep her appointment. Therefore, we conducted her April 2020 visit via telemedicine and she agreed to come in person for the August 2020 visit. Because she did not feel comfortable attending a medical facility initially, we were unable to obtain labs. At the April visit, we focused on lifestyle management. We discussed her progress following her diet, type and frequency of exercise, medication adherence, and any symptoms she may be experiencing. Cathy was not checking her blood pressure or weight, but she was monitoring her glucose via finger stick. She was trying to walk for exercise but was limited due to chronic back pain. We discussed ways she could increase her activity. Because she was avoiding trips to the grocery store, she was not eating as many vegetables as she had been, and we discussed ways to incorporate healthier foods into her diet. At the in-person August 2020 visit, we obtained nonfasting laboratory tests and completed the physical examination. An overview of her laboratory results and treatment recommendations can be found in Table 1.

Summary
Historically, telemedicine has not been an option in FQHCs due to governing regulations on Community Health Centers (CHCs). As a result of the expanded access to care through temporary legislation related to the COVID-19 pandemic, telemedicine may now be utilized in FQHCs. As shown in this case, the use of telemedicine proved to be beneficial to this patient and shows that complicated cardiometabolic patients can be effectively managed via telemedicine. Through this modality, the patient was able to receive continuity of care, education regarding lifestyle changes, and reinforcement of medication adherence to promote healthcare success as demonstrated by improvement in laboratory results. 

Additional research is needed to determine the effectiveness of telemedicine utilization by PCPs in the FQHC setting, but cases like this support the notion that it could be a beneficial approach to care. Barriers to implementation of telemedicine include, but are not limited to, patient access to technology, patient understanding of technology, and infrastructure obstacles such as lack of internet access or lack of high-speed access to support telemedicine streaming, especially in the rural areas that are primarily served by FQHCs. The high cost imposed on the facility providing telemedicine must also be considered, as it can be a hindrance to implementation in smaller facilities. The use of telemedicine also limits the ability of the provider to obtain vital signs or physically assess the patient, as is routine in a face-to-face visit. Ultimately, health systems may have to develop outreach programs that facilitate the technological challenges and enable remote vital sign monitoring and recording.

Disclosure statement: Dr. Croy has no financial disclosures to report. Ms. Coleman has no financial disclosures to report.

References:

1. Tchero, H., Kangambega, P., Briatte, C., Brunet-Houdard, S., Retali, G.R. and Rusch, E., 2019. Clinical effectiveness of telemedicine in diabetes mellitus: a meta-analysis of 42 randomized controlled trials. Telemedicine and e-Health, 25(7), pp.569-583.
2. Sodhi, M., 2020. Telehealth Policies Impacting Federally Qualified Health Centers in Face of COVID-19. The Journal of Rural Health.
3. Health Resources Service Administration. National Health Center Data. 2020. 23 August 2020. https://data.hrsa.gov/tools/datareporting/program-data/national.
4. Centers for Disease Control. Coronavirus Disease 2019. 2020. 23 August 2020. https://www.cdc.gov/coronavirus/2019-ncov/needextra-precautions/people-with-medical-conditions.html.
5. Centers for Medicare & Medicaid Services. Federally Qualified Health Centers. 2019. 23 August 2020. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/fqhcfactsheet.pdf.
6. Congress.gov. H.R.6074 - Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020. 2020. 23 August 2020. <https://www.congress.gov/bill/116th-congress/house-bill/6074.