Clinical Feature: Lipid-Management in the Era of COVID-19 Using Telehealth and Other EHR-Based Tools

The SARS CoV-2 pandemic has become the primary focus of the healthcare system and a primary concern for our patients. The pandemic has required months of social distancing, and in-person medical visits have been partially replaced with telehealth visits. This transformation of care delivery has challenged every aspect of medicine, especially the management of chronic diseases such as hyperlipidemia. 

Care of the patient with hyperlipidemia has traditionally involved regular inperson visits for physical examination, vital signs collection (i.e., blood pressure, heart rate, weight), as well as regular laboratory visits for evaluating lipid levels. The interventions employed both focus on lifestyle changes, mainly by improving diet and exercise, as well as adherence to pharmacotherapy. Statins represent the foundation of this pharmacotherapy but newer medications such as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, icosapent ethyl, and bempedoic acid have added to the evidence-based medications available to treat hyperlipidemia. Each of these medications requires upfront discussions of risks/benefits to make a shared decision on initiation, followed by regular checkins to assess adherence, determine efficacy, and monitor for potential side effects. Hyperlipidemia management requires a multi-disciplinary approach by a clinical team comprised of physicians, nurses, pharmacists, dieticians, genetic counselors, program coordinators, prior authorization specialists, and social workers, each providing a different layer of expertise, support, and encouragement as the patient engages with this silent disease. Hyperlipidemia is managed over years by these dedicated teams to prevent the morbid consequences of decades of atherosclerosis.

COVID-19 defined 2020 and could define 2021 and beyond as well, bringing with it a new way of life and a new platform through which to provide healthcare: telehealth. The American Hospital Association defines telehealth as a service that connects patients to vital healthcare services through videoconferencing, remote monitoring, electronic consults, and wireless communications. During just a two-week span in mid-March, as the virus took hold of the world, 75% of all outpatient cardiology encounters moved to telehealth.(1) A recent contribution by Athena Poppas, President of the American College of Cardiology, and colleagues, on the current state and future prospects of telehealth describes it as, “the ultimate value proposition,” with the potential to “make healthcare more personalized, efficient, and coordinated.”(2) This seismic shift in the care of patients with cardiovascular disease raises the question, how specifically will it impact the care of patients with hyperlipidemia?

This review will explore key opportunities that the COVID-19 pandemic and parallel surge in telehealth technologies have brought to lipid management. These include increased access to lipid management specialists and increasing patient-centeredness in care delivery. Telehealth allows specialists to meet patients where they are, with the click of a mouse on a computer or touch of a button on a smartphone, vastly increasing access to expert care. An additional opportunity is improved medication adherence via telehealth communication and EHRbased tools. Telehealth can increase care efficiency, allowing patient engagement to ensure access to the medications they need and reduce COVID-induced abandonment at this challenging time. Despite the barriers that this pandemic has placed upon our patients and our clinics, lipid management is uniquely well-positioned to succeed on telehealth platforms now and in the post-pandemic world.

Improved Access and Personalization of Lipid Specialty Care
Patients with lipid disorders require frequent and regular medical attention. They are at increased risk for atherosclerotic cardiovascular events and, in the case of hypertriglyceridemia, at risk for acute pancreatitis. Additionally, cardiovascular disease is a common comorbidity in those with COVID-19, particularly those with more severe disease.(3) Combined, this is a patient group that must be monitored closely during normal times and even more closely during this pandemic. With limited access to in-person visits and mandatory social distancing, telemedicine is now the avenue through which this close monitoring can now occur. Lipid management visits are well-suited for this transition to telemedicine.

At the authors’ home institution, Johns Hopkins Hospital, several examples of effective telehealth management are worth highlighting. PCSK9 inhibitor injection training is now accomplished with telehealth visits. Genetic counselors can still pursue genetic testing remotely via saliva samples to investigate inherited lipid disorders like familial hypercholesterolemia. On occasions when patients have reported possible side effects of lipid therapy (e.g., muscle symptoms on statin therapy), scheduling a prompt telemedicine visit has been an efficient and effective way to address the symptoms and discuss next steps.

Being invited into a patient’s home has given clinicians an even greater opportunity to provide teaching and counseling. Dosages or use of medications can be immediately clarified by looking at the medicine with the patient and has led to more in-depth conversations regarding proper storage of medications and potential drug interactions. The best place for dietary counseling to occur is in the kitchen while looking inside the patient’s food pantry, where one can visualize the patient’s food choices. Clinicians can affirm the foods that are currently being consumed and recommend changes by looking at the actual food label with the patient. Creative approaches can be used to address concerns about not being able to achieve an appropriate amount of exercise throughout the pandemic. Individuals have been surprised to find that common household items like food cans (e.g., can of beans) can serve as light weights and walking paths can be constructed through the home, with suggestions for removal of potential obstacles, such as throw rugs.

Telemedicine allows care delivery to patients at a time and location that is convenient for them. Furthermore, telemedicine allows for increased access to patients in rural and remote areas, as well as those with limited mobility, access to transportation, or occupational time restraints. A visit that previously required a half-day off from work can now take place in 15-60 minutes and prevent decreased productivity, loss of wages, and save associated travel costs. This, in turn, can improve patient satisfaction. (4) Meanwhile, the same clinical goals of medication adherence to guideline-directed pharmacotherapy, healthy diet, and regular physical activity can still be achieved.

The physical exam, if assessed previously at an in-person appointment, is less essential to guide therapy decisions surrounding hyperlipidemia management. In new patients, the lack of direct physical exam is more of a limitation, as the initial visit represents an important opportunity to build trust and confidence in the clinician. Furthermore, the quality of telemedicine video does not yet facilitate the appreciation of corneal arcus. Still, frank xanthomas may be viewed during a video visit and patients may be guided, as needed, through a self-assessment of their Achilles tendons thickness compared to normal (e.g., in relation to the thickness of a pencil) or take photos of the tendons. In balance, the improved access for patients in need of expert lipid care who were unable to schedule or attend appointments previously is a welcome advantage of telemedicine.

It is illuminating to look at Epic Health Research Network data pooled from 22 health systems spanning 17 states in the US, covering 7 million patients. In the brief time period of March 15 to May 8, 2020, lipid management has been prominent in this new telehealth environment. Hyperlipidemia ranks second in the top ten visit diagnoses, behind only hypertension, with telehealth visits representing 69% of total visits for that diagnosis.(5) More than 38,000 telehealth visits have taken place for hyperlipidemia during the above time period in this small fraction of the US population. Meanwhile, as a sign of how patients are using telehealth, visits that require a physical exam or procedures show relatively low rates of telehealth adoption, with only 25% of General Health Exams being conducted via telehealth. Furthermore, those specialties that manage hyperlipidemia have led the way in telehealth adoption. Family medicine (57%), internal medicine (71%), and cardiology (62%) have all conducted the majority of their visits via telehealth.

Adherence
The main reason telehealth is here to stay, as many are predicting, is patients find it more convenient than traditional office visits. As described above, encounters can fit more flexibly into the lives of our patients. Furthermore, patients may be communicating more regularly with their care teams. The COVID-19 testing workflow has required thousands of individuals to create secure online patient profiles, that they may never have otherwise activated, to access their electronic medical records (EMR). It is through these patient-centered platforms that test results are often communicated. These same platforms are the key to chronic disease management, active clinician-patient communication, lab results tracking, and medication refills. EMR messages from patients now trigger alerts on the mobile phones of clinicians. This level of access and communication afforded by telemedicine is vital to improving adherence to lipid-lowering therapies.

Medication non-adherence has been reported to occur in ~60% of patients with cardiovascular disease.(6) A study by Kaiser Permanente found that 12% of statin prescriptions are never filled and another 12% are filled but never taken. Another 29% of patients fill but never refill their statin prescriptions, leaving only 47% of patients who are adherent after one year. (6) Adherence remains a major barrier to lipid management and the COVID19 pandemic has only exacerbated this challenge. Patients face challenges both in accessing and affording their medications. Pharmacy hours have changed. Many patients face economic uncertainty and insecurity that forces them to deprioritize their chronic disease care and medication adherence. Fortunately, telehealth and other EHR-based tools may allow clinicians to more effectively track adherence and predict medication abandonment than ever before. A recent review of the efficacy of mobile health trials in patients with cardiovascular disease found that mobile and tech-empowered interventions including text messages, Bluetooth-enabled electronic pillboxes, online messaging platforms, and interactive voice calls improved medication adherence in patients with hypertension, ischemic heart disease, heart failure, and stroke.(7)

In addition to the telemedicine innovations discussed, the COVID-19 pandemic has brought with it a rise in home delivery of medications. This has important and lasting implications for lipid management and medication adherence. Mail-order drug delivery has skyrocketed during the pandemic, as patients require medications but are required to remain at home. CVS Health saw a 10-fold increase in pharmacy home deliveries during the first three months of 2020, spurred by an elimination of delivery fees. Walgreens and Express Scripts both reported similar spikes during the pandemic.(8) Once patients switch to home delivery, it is likely they will continue with home delivery, and this has important implications for lipid management and medication adherence. A study by Kaiser Permanente found that patients who received automated delivery of statins exhibited an adherence rate of 88%, compared with just 56% of patients who had to take additional steps to acquire their medications.(9) A separate study by the same group found that 85% of patients who used mail-order pharmacies achieved their cholesterol goals compared to 74% of patients who used only the local pharmacy. (10) EHR-based tools and patient portals that can seamlessly connect a patient with such services have expedited this transition to home delivery, connecting patients with home delivery pharmacies with increasing ease and frequency.

Challenges to Telehealth Adoption
Barriers to broad telehealth adoption remain, however, as access to and experience with the necessary technologies and infrastructure can vary across more vulnerable patient populations. Elderly patients could be the greatest beneficiaries of telehealth expansion, but may also find encounters uniquely challenging due to unfamiliarity with the technologies required. In many cases, this requires additional family members to support the visits, at least initially.

Furthermore, there exist significant racial and geographic disparities in internet use in patients with ASCVD.(11) Recent studies have shown that internet use is lower among individuals with ASCVD as compared with the general population and lower among black and Hispanic patients compared with white patients. Access to smartphones with video capacity also varies according to socioeconomic status. The Pew Foundation found that only 53% of adults with annual incomes below $30,000 owned a smartphone.(12) Fortunately, The Center for Medicare and Medicaid Services (CMS) expanded telehealth reimbursement to cover audioonly visits, allowing an estimated onethird of Medicare beneficiaries to access healthcare providers with audio-only telephone visits.(13)

The expansion of telehealth has maintained critical access to lipid management experts during this pandemic and the opportunity for further expansion exists. To fully leverage these advancing technologies, however, greater investment is needed to reach those more vulnerable populations. It is important to note that several programs are striving to address this digital divide. The Federal Communications Commission (FCC) supports discounted phone and broadband services, for less than $10 per month for each, through the Lifeline program. (14) Comcast is one commercial provider addressing the digital divide through the Internet Essentials program that includes broadband access along with devices and technology coaching.(15) 

Next Steps
Overall, it is our view that the pandemic has brought much disruption but also much needed positive change to lipid management. The volume of visits for lipid management that so rapidly transitioned to telehealth appointments is evidence of how well-suited the care is for such platforms and how amenable the patients are to video and phone-based appointments. The movement toward EHRtriggered home delivery of lipid therapies and data showing increased adherence is a parallel positive outcome of this pandemic. Patients may be more engaged with their health, not just their COVID19 test results, than ever before and the EHR facilitates that engagement. Moving forward, telehealth platforms and EHRbased patient portals will need to become even more patient-centered, connected to mobile health tools, and adaptable to the lives and resources of our underserved patients. The COVID-19 pandemic will pass, but fortunately, these changes to lipid care are here to stay. 

Disclosure statement: Mr. Duffy is a prior employee of Butterfly Network. Dr.Marvel is a co-founder and holds equity in Corrie Health. Ms. Byrne has no financial disclosures to report. Dr. Martin has received honoraria from AstraZeneca, Amgen, Esperion, Kaneka, REGENXBIO, Sanofi, and 89bio.

References

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