Enhancing patient outcomes: Integrating electronic cardiology consultation in primary care for cancer patients

BACKGROUND

The prevalence of cancer patients with concomitant cardiovascular (CV) disease is on the rise due to improved cancer prognoses. The aim of this study is to evaluate the long-term outcomes of cancer patients referred to a cardiology department (CD) via primary care using e-consultation.

METHODS

We analysed data from cancer patients with prior referrals to a CD between 2010 and 2021 (n = 6889) and compared two care models: traditional in-person consultations and e-consultations. In e-consultation model, cardiologists reviewed electronic health records (e-consultation) to determine whether the demand could be addressed remotely or necessitated an in-person consultation. We used an interrupted time series regression model to assess outcomes during the two periods: (1) time to cardiology consultation, (2) rates of all-cause and CV related hospital admissions and (3) rates of all-cause and CV-related mortality within the first year after the initial consultation or e-consultation at the CD.

RESULTS

Introduction of e-consultation for cancer patients referred to cardiology care led to a 51.8% reduction (95%CI: 51.7%-51.9%) in waiting times. Furthermore, we observed decreased 1-year incidence rates, with incidence rate ratios (iRRs) [IC95%] of .75 [.73-.77] for CV-related hospitalizations, .43 [.42-.44] for all-cause hospitalizations, and .87 [.86-.88] for all-cause mortality.

CONCLUSIONS

Compared to traditional in-person consultations, an outpatient care program incorporating e-consultation for cancer patients significantly reduced waiting times for cardiology care and demonstrated safety, associated with lower rates of hospital admissions.

Systemic biomarker associated with poor outcome after futile reperfusion

BACKGROUND

Successful recanalization does not lead to complete tissue reperfusion in a considerable percentage of ischemic stroke patients. This study aimed to identify biomarkers associated with futile recanalization. Leukoaraiosis predicts poor outcomes of this phenomenon. Soluble tumour necrosis factor-like weak inducer of apoptosis (sTWEAK), which is associated with leukoaraiosis degrees, could be a potential biomarker.

METHODS

This study includes two cohorts of ischemic stroke patients in a multicentre retrospective observational study. Effective reperfusion, defined as a reduction of ≥8 points in the National Institutes of Health Stroke Scale (NIHSS) within the first 24 h, was used as a clinical marker of effective reperfusion.

RESULTS

In the first cohort study, female sex, age, and high NIHSS at admission (44.7% vs. 81.1%, 71.3 ± 13.7 vs. 81.1 ± 6.7; 16 [13, 21] vs. 23 [17, 28] respectively; p < .0001) were confirmed as predictors of futile recanalization. ROC curve analysis showed that leukocyte levels (sensitivity of 99%, specificity of 55%) and sTWEAK level (sensitivity of 92%, specificity of 88%) can discriminate between poor and good outcomes. Both biomarkers simultaneously are higher associated with outcome after effective reperfusion (OR: 2.17; CI 95% 1.63-4.19; p < .0001) than individually (leukocytes OR: 1.38; CI 95% 1.00-1.64, p = .042; sTWEAK OR: 1.00; C I95% 1.00-1.01, p = .019). These results were validated using a second cohort, where leukocytes and sTWEAK showed a sensitivity of 100% and specificity of 66.7% and 75% respectively.

CONCLUSIONS

Leukocyte and sTWEAK could be biomarkers of reperfusion failure and subsequent poor outcomes. Further studies will be necessary to explore its role in reperfusion processes.

Impact of a clinician-to-clinician electronic consultation in heart failure patients with previous hospital admissions

Aims

To evaluate the impact of an outpatient care management programme that includes a clinician-to-clinician e-consultation on delay time in care, hospital admissions, and mortality in a high-risk group of patients with heart failure (HF) and previous episodes of HF hospitalization (HFH).

Methods and results

We selected 6444 HF patients who visited the cardiology service at least once between 2010 and 2021. Of these, 4851 were attended in e-consult, and 2230 had previous HFH. Using an interrupted time series regression model, we analysed the impact of incorporating e-consult into the healthcare model in the group of patients with HFH and evaluated the elapsed time to cardiology care, HF, cardiovascular (CV), and all-cause hospital admissions and mortality, calculating the incidence relative risk (iRR). In the group of patients with HFH, the introduction of e-consult substantially decreased waiting times to cardiology care (8.6 [8.7] vs. 55.4 [79.9] days, P < 0.001). In that group of patients, after e-consult implantation, hospital admissions for HF were reduced (iRR [95%CI]: 0.837 [0.840-0.833]), 0.900 [0.862-0.949] for CV and 0.699 [0.678-0.726] for all-cause hospitalizations. There was also lower mortality (iRR [95%CI]: 0.715 [0.657-0.798] due to HF, 0.737 [0.764-0.706] for CV and 0.687 [0.652-0.718] for all-cause). The improved outcomes after e-consultation implementation were significantly higher in the group of patients with previous HFH.

Conclusion

In patients with HFH, an outpatient care programme that includes an e-consult significantly reduced waiting times to cardiology care and was safe, with a lower rate of hospital admissions and mortality in the first year.

Gender differences on healthcare accessibility and outcomes of a electronic inter-clinician consultation program at the cardiology department in a Galician Health Area

AIMS

To assess the longer-term results (hospital admissions and mortality) in women versus men referred to a cardiology department from primary care using an e-consultation in our outpatient care programme.

METHODS

We selected 61,306 patients (30,312 women and 30,994 men) who visited the cardiology service at least once between 2010 and 2021: 69.1% (19,997 women and 20,462 men) were attended in e-consultation (from 2013 to 2021) and 30.9% (8920 women and 9136 men) in in-person consultations (from 2010 to 2012) without gender differences in the proportion of patients attended in each period. Using an interrupted time series regression model, we analysed the impact of incorporating e-consultation into the healthcare model and evaluated the elapsed time to cardiology care, heart failure (HF), cardiovascular (CV), and all-cause hospital admissions and mortality during the one-year after cardiology consultation.

RESULTS

The introduction of e-consultation substantially decreased waiting times to cardiology care; during the in-person consultation period, the mean delay for cardiology care was 57.9 (24.8) days in men and 55.8 (22.8) days in women. During the e-consultation period, the waiting time to cardiology care was markedly reduced to 9.41 (4.02) days in men and 9.46 (4.18) in women. After e-consultation implantation, there was a significant reduction in the 1-year rate of hospital admissions and mortality, both in women and men iRR [IC 95%]: 0.95 [0.93-0.96] for HF, 0.90 [0.89-0.91] for CV and 0.70 [0.69-0.71] for all-cause hospitalization; and 0.93 [0.92-0.95] for HF, 0.86 [0.86-0.87] for CV and 0.88 [0.87-0.89] for all-cause mortality in women; and 0.91 [0.89-0.92] for HF, 0.90 [0.89-0.91] for CV and 0.72 [0.71-0.73] for all-cause hospitalization; and 0.96 [0.93-0.97] for HF, 0.87 [95% CI: 0.86-0.87] for CV and 0.87 [0.86-0.87] for all-cause mortality, in men.

CONCLUSION

Compared with the in-person consultation period, an outpatient care programme that includes an e-consultation significantly reduced waiting time to cardiology care and was safe, with a lower rate of hospital admissions and mortality in the first year, without significative gender differences.

[Impact of the COVID-19 pandemic above a universal electronic consultation program (e-consultation) between general practitioners and cardiologists]

Blackground and objective

Virtual healthcare models, usually between healthcare professionals and patients, have developed strongly during the coronavirus disease 2019 (COVID-19) pandemic, but there are not data of models between clinicians. Our objective is to analyse the impact of the COVID-19 pandemic on the activity and health outcomes of the universal e-consultation program for patient referrals between primary care physicians and the Cardiology Department in our area.

Methods

Patients with at least one e-consultation between 2018 and 2021 were selected. We analysed the impact of the COVID-19 pandemic on activity and waiting time for care, hospitalizations and mortality, taking as a reference the consultations carried out during 2018.

Results

We analysed 25,121 patients. Through logistic regression analysis, it was observed that a shorter delay in care and resolution of the e-consultation without the need for face-to-face care were associated with a better prognosis. The COVID-19 pandemic periods (2019-2020 and 2020-2021) were not associated with worse health outcomes compared to 2018.

Conclusions

The results of our study show a significant reduction in e-consult referrals during the first year of the COVID-19 pandemic with a subsequent recovery in the demand for care without the pandemic periods being associated with worse outcomes. The reduction in the time elapsed for solving the e-consult and no need for in-person visit were associated with better outcomes.

Impact of the COVID-19 pandemic upon a universal electronic consultation program (e-consultation) between general practitioners and cardiologists

BACKGROUND AND OBJECTIVE

Virtual healthcare models, usually between healthcare professionals and patients, have developed strongly during the coronavirus disease 2019 (COVID-19) pandemic, but there are no data corresponding to models between clinicians. An analysis was made of the impact of the COVID-19 pandemic upon the activity and health outcomes of the universal e-consultation program for patient referrals between primary care physicians and the Cardiology Department in our healthcare area.

METHODS

Patients with at least one e-consultation between 2018 and 2021 were selected. We analyzed the impact of the COVID-19 pandemic upon activity and waiting time for care, hospitalizations and mortality, taking as reference the consultations carried out during 2018.

RESULTS

A total of 25,121 patients were analyzed. Logistic regression analysis showed a shorter delay in care and resolution of the e-consultation without the need for face-to-face care to be associated to a better prognosis. The COVID-19 pandemic periods (2019-2020 and 2020-2021) were not associated to poorer health outcomes compared to 2018.

CONCLUSIONS

The results of our study show a significant reduction in e-consultation referrals during the first year of the COVID-19 pandemic, with a subsequent recovery in the demand for care, and without the pandemic periods being associated to poorer outcomes. The reduction in time elapsed for resolving the e-consultations and no need for face-to-face visits were associated to improved outcomes.

The impact of inter-clinician electronic consultation in patients diagnosed with atrial fibrillation in primary care

BACKGROUND

An early diagnosis and early initiation of oral anticoagulants (OAC) are main determinants for outcomes in patients with atrial fibrillation (AF). Inter-clinician electronic consultations (e-consultations) program for the general practitioner referrals to cardiologist may improve health care access by reducing the elapsed time for cardiology care.

OBJECTIVE

To evaluate the effect of a reduced elapsed time to care after a inter-clinician e-consultations program implementation (2013-2019) in comparison with previous in-person consultation (2010-2012) in the outpatient health care management in a Cardiology Department.

METHODOLOGY

We included 10,488 patients with AF from 1 January 2010, to 31 December 2019. Until 2012, all patients attended an in-person consultation (2010-2012). In 2013, we instituted an e-consult program (2013-2019) for all primary care referrals to cardiologists that preceded patient's in-person consultation when considered. The shared electronic patient dossier (EPD) was available between GP and cardiologist, and any change in therapy advice from cardiologist was directly implemented in this EPD.

RESULTS

During the e-consultation period (2013-2019) were referred 6627 patients by GPs to cardiology versus 3861 during the in-person consultation (2010-2012). The e-consultation implementation was associated with a reduction in the elapsed time to anticoagulation prescription (177.6 ± 8.9 vs. 22.5 ± 8.1 days, p < .001), and an increase of OAC use (61% [95% IC: 19.6%-102.4%], p < .001). The e-consult program implementation was associated with a reduction in the 1-year CV mortality (.48 [95% CI: .30-.75]) and all-cause mortality (.42 [95% CI: .29-.62]). The OAC reduces the stroke mortality (.15 [95% CI: .06-.39]) and CV mortality (.43 [95% CI: .29-.62]) and all-cause mortality (.23 [95% CI: .17-.31]).

CONCLUSION

A shared EPD-based inter-clinician e-consultation program significantly reduced the elapsed time for cardiology consultation and initiation of OAC. The implementation of this program was associated with a lower risk of stroke and cardiovascular/all-cause mortality.

A clinician-to-clinician universal electronic consultation programme at the cardiology department of a Galician healthcare area improves healthcare accessibility and outcomes in elderly patients

Aim

We aimed to assess the longer-term results (accessibility, and hospital admissions and mortality) in elderly patients referred to a cardiology department (CD) from primary care using an e-consultation in outpatient care.

Methods

We included 9,963 patients &gt;80 years from January 1, 2010, to December 31, 2019. Until 2012, all patients were attended in an in-person consultation (2010-2012). In 2013, we instituted an e-consult programme (2013-2019) for all primary care referrals to cardiologists that preceded patient’s in-person consultation when considered. We used an interrupted time series (ITS) regression approach to investigate the impact of the e-consultation on (1) cardiovascular hospital admissions and mortality. We also analyzed (2) total number and referral rate (population-adjusted referred rate) in both periods, and (3) the accessibility was measured as number of consultations and variation according to distance from municipality and reference hospital.

Results

During the e-consultation, the demand of care increased (12·8 ± 4·3% vs 25·5 ± 11·1% per 1,000 inhabitants, p &lt; 0·001) and referrals from different areas were equalized. After the implementation of e-consultation, we observed that the increasing of hospital admissions and mortality were stabilised (incidence rate ratio [iRR]: 1·351 [95% CI, 0·787, 2·317], p = 0·874) and (iRR: 1·925 [95% CI: 0·889, 4·168], p = 0·096), respectively. The geographic variabilities in hospital admissions and mortality seen during the in-person consultation were stabilized after e-consultation implementation.

Conclusions

Implementation of a clinician-to-clinician e-consultation program in the outpatient care was associated with improved accessibility to cardiology healthcare in elderly patients. After e-consultations were implemented, the hospital admissions and mortality were stabilised.

Synergistic effect of a universal electronic consultation program and oral anticoagulation on outcomes in patients with atrial fibrillation

Background

Recently, the temporal association between episodes of AF and the risk of ischaemic stroke has been assessed, emphasising that the risk is higher in patients who encountered episodes of AF a few days before stroke [1]. In recent years, the use of direct oral anticoagulants (OACs) has increased, which has improved the outcomes of healthcare with important reductions in mortality [2,3].

Despite the growing implementation of telematic consultation models and recommendations to regularly evaluate the quality of care to ensure patient safety, there is scanty evidence to support the quality of healthcare in terms of delays, prognostic impact, and patient and professional satisfaction. We recently published the characteristics of our ambulatory care model for referrals between general practitioners (GPs) and our cardiology department (CD), and the impact on the delay time of care, health care accessibility, and clinical outcomes after the implementation of an e-consultation as a first step in our ambulatory care program [2,4].

Purpose

To evaluate the long-term results of our universal e-consultation program in patients with AF, assessing the impact of the temporal trend in OAC and delay of care on clinical outcomes.

Methods

We included 10488 e-consultations referrals from primary care in patients with diagnoses of AF in this study. We have analysed the outcomes in e-consultation period versus in-person consultation period. We used an interrupted time-series regression on outcomes. To investigate the impact of this program and the use of OAC on the prognosis of AF-related stroke and haemorrhage, the annual incidence of each outcome in both periods was calculated, while deriving the incidence relative risk (iRR) with these incidences. Finally, to individualise the effect of e-consultation and OAC in both outcomes, the analysis was completed using a Spearman correlation between e-consultation or OAC and the incidence of stroke and mortality.

Results

Following e-consultation, the use of OAC increased (iRR 1.56 (1.13–1.99); p&lt;0.001), Figure 1; hospital admissions due to stroke were lower (iRR: 0.09 [95% CI: 0.02–0.41]) with similar incidences of haemorrhagic complications (iRR: 0.32 [95% CI: 0.04–2.58]), figure 2. The total mortality was lower (iRR 0.36 (95% CI: 0.33–0,39). The independent impact on the risk of stroke mortality after the increase in the OAC rates and e-consultation implementation showed an odds ratio (OR) of 0.270 and 0.403, respectively.

Conclusion

Thus, a quicker cardiological evaluation of patients with AF and optimised OAC use influence improved clinical outcomes. The healthcare systems need to merge OAC and outpatient ambulatory management that evaluate the patients quickly to reduce the ischaemic strokes.

Funding Acknowledgement

Type of funding sources: None.

A universal electronic consultation programme at the cardiology department after general practitioner referrals to improve healthcare accessibility and outcomes in elderly patients

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.

Impact of a universal electronic consultation program at the cardiology service of a galician health area on hospital admissions and on the accessibility and equity of healthcare services

Background

The implementation of integrated electronic medical record projects between healthcare levels allows all healthcare professionals access to all the clinical information of patients, which is a key factor in optimizing the management of healthcare resources, facilitating the communication between professionals and avoiding medical acts that do not add value, always from the premise of safety and quality for patients [1]. The benefits that telemedicine models can bring in reducing waiting times and the role they can play in organizing the growing demand for care have been described [2,3]. A matter of concern is the lack of accessibility for patients who live further away from their reference hospital centers, not only from a management point of view but also from a clinical point of view, since they are patients who are usually admitted with more complications and therefore could have a worse prognosis.

Purpose

To assess the impact on accessibility to healthcare provision and hospital admissions of an outpatient care management program that includes an e-consultation through an integrated medical record.

Patients and methods

It was registered the epidemiological and clinical data available from the 41,258 patients referred from January 1, 2010 to December 31, 2019, from Primary Care to the Cardiology Service of a health area, in which all doctors share the same electronic medical record. The municipality where the patients live and the admissions for cardiovascular causes in any hospital service during the first year after consultation in the Cardiology Service was recorded.

Results

After the e-consultation was implemented, the demand for care increased in all municipalities (7.2±2.4 vs 10.1±4.8 rates per 1,000 habitants-year, p&lt;0.001). In general, higher delay times were recorded in the regional hospital area, the furthest patients; the spatial effects also were similar in both periods; however, these differences were lower in the e-consultation period than in the in-person consultation period, Figure 1. Also, during the single act consultation period, we observed a progressive reduction in the delay to cardiology consultation which was markedly reduced after the implementation of the e-consultation. The interrupted time series analysis showed that the number of hospital admissions during the period of the Single Act Consultation has increased at approximately 1.1% per month (RR: 1,011 [IC95%: 1.003–1.018]), and after the implementation of the E-Consultation, this upward trend is stabilized in mean with a constant trend (RR: 1.011*0.989 ∼ 1), Figure 2.

Conclusions

The implementation of an e-consultation in the outpatient management model increases the demand for care and improves accessibility to health care for patients furthest from the referral hospital. After the implementation of the e-consultation, the upward trend of hospital admissions observed during the single act period, was stabilized with a slight downward trend.

Funding Acknowledgement

Type of funding sources: None.

Impact of the implementation of electronic consultation in outpatient care for patients with cardiovascular disease in a Cardiology Service of a tertiary hospital

 

The main objective of health systems is to organize health care in a universal way, by including the population as a whole, cost-effectively, and incorporating care methodologies that allow personalized health care (1). The integrated electronic medical records between levels of care allows non-face care modalities such as electronic consultation. In it, a health professional, most commonly a General Physician, consults with a Hospital doctor through a computer system in which the clinical history is housed, allowing part of the health care to be resolved without displacement of the patients (2). Despite the growing implementation of telematic consultation models and the recommendations to regularly evaluate the quality of care, to ensure patient safety and the best possible diagnosis and treatment practices in telemedicine (3). This aspect acquires a special relevance in the case of patients with an established diagnosis of cardiovascular disease since an e-consultation through the electronic medical record could be less efficient than a face-to-face consultation, in identifying symptoms and clinical signs of alarm and compromise in some cases its clinical evolution.

Purpose

To evaluate the clinical impact of the introduction of an electronic consultation in the ambulatory care model of a Cardiology Service to patients with an established diagnosis of cardiovascular disease, comparing it with a face-to-face single act consultation model.

Methods

The epidemiological and clinical data available from the 47,337 patients referred from January 1, 2010 to December 31, 2019, to the Cardiology Service of a health area were recorded, in which all physicians share the same electronic medical record. Patients with cardiovascular disease were considered if they had a history of ischemic heart disease, heart failure, peripheral arterial disease and ischemic cerebrovascular disease. The number of visits to the emergency room, the number of admissions due to cardiovascular causes and mortality were analyzed as events of interest during the first year after attending the Cardiology Service.

Results

Patients without CVD were resolved more frequently in the e-consultation (24.8% vs 11.3%, p&lt;0.001) and patients with CVD required more follow-up consultations (69.8% vs 40.8%, p&lt;0.001). The analysis of time trends showed that since the implementation of the e-consultation, waiting times were reduced in a similar way in both analysis groups (p&lt;0.001) and, in addition, there was a decrease in emergency services assistance (p&lt;0.001) and in mortality (RR: 0.78 [CI95%: 0.65–0.95], p&lt;0.001), Figure 1; and a stabilization in admissions (RR: 0.95 [CI95%: 0.87–1.04], p&lt;0.001), Figure 2

Conclusions

The introduction of an e-consultation in the outpatient management model of referrals for consultation to a cardiology service is effective in reducing waiting time and is safe, since it reduces mortality in patients with cardiovascular disease.

Funding Acknowledgement

Type of funding sources: None.

Longer-Term Results of a Universal Electronic Consultation Program at the Cardiology Department of a Galician Healthcare Area

BACKGROUND

Telemedicine models play a key role in organizing the growing demand for care and healthcare accessibility, but there are no described longer-term results in health care. Our objective is to assess the longer-term results (delay time in care, accessibility, and hospital admissions) of an electronic consultation (e-consultation) outpatient care program.

METHODS

Epidemiological and clinical data were obtained from the 41 258 patients referred by primary care to the cardiology department from January 1, 2010, to December 31, 2019. Until 2012, all patients were attended in an in-person consultation (2010-2012). In 2013, we instituted an e-consultation program (2013-2019) for all primary care referrals to cardiologists that preceded patients' in-person consultations when considered. We used an interrupted time series regression approach to investigate the impact of the e-consultation on (1) delay time (days) in care and (2) hospital admissions. We also analyzed (3) total number and referral rate (population-adjusted referred rate) in both periods (in-person consultation and e-consultation), and (4) the accessibility was measured as number of consultations and variation according to distance from municipality and reference hospital.

RESULTS

During the e-consultation, the demand increased (7.2±2.4% versus 10.1±4.8% per 1000 inhabitants, P<0.001), and referrals from different areas were equalized. The reduction in delay to consultation during the in-person consultation (-0.96 [95% CI, -0.951 to -0.966], P<0.001) was maintained with e-consultations (-0.064 [95% CI, 0.043-0.085], P<0.001). After the implementation of e-consultation, we observed that the increasing of hospital admission observed in the in-person consultation (incidence rate ratio, 1.011 [95% CI, 1.003-1.018]), was stabilized (incidence rate ratio, 1.000 [95% CI, 0.985-1.015]; P=0.874).

CONCLUSIONS

Implementing e-consultations in the outpatient management model may improve accessibility of care for patients furthest from the referral hospital. After e-consultations were implemented, the upward trend of hospital admissions observed during the in-person consultation period was stabilized with a slight downward trend.

Universal electronic consultation (e-consultation) program of a cardiology service. Long-term results

INTRODUCTION AND OBJECTIVES

Many health systems have initiated electronic consultation (e-consultation) programs, although little is known about their impact on accessibility, safety, and satisfaction. The aim of this study was to assess the clinical impact of the implementation of an outpatient care model that includes an initial e-consultation and to compare it with a one-time face-to-face consultation model.

METHODS

We selected patients who visited the cardiology service at least once between 2010 and 2019. Using an interrupted time series regression model, we analyzed the impact of incorporating e-consultation into the health care model (started in 2013), and evaluated waiting times, emergency services, hospital admissions, and mortality.

RESULTS

We analyzed 47 377 patients: 61.9% were attended in e-consultation and 38.1% in one-time face-to-face consultations. The waiting time for care was shorter in the e-consultation model (median [IQR]: 7 [5-13] days) than in the face-to-face model (median [IQR]: 33 [14-81] days), P<.001. The interrupted time series regression model showed that the introduction of e-consultation substantially decreased waiting times, which held steady at around 9 days, although with slight oscillations. Patients evaluated via e-consultation had fewer hospital admissions (0.9% vs 1.2%, P=.0017) and lower mortality (2.5% vs 3.9%, P<.001).

CONCLUSIONS

An outpatient care program that includes an e-consultation reduced waiting times significantly and was safe, with a lower rate of hospital admissions and mortality in the first year.

[Analysis on the impact of the introduction of a quality management plan of the diabetes care process in a Health Area of Galicia (Spain)]

OBJECTIVE

To analyse the impact of a management plan for the diabetes process on the level of control of HbA1c and the rate of hypoglycaemia.

MATERIAL AND METHODS

The Health Area had a catchment population of 446,603. An anti-diabetic drug prescription (29,705 patients) was used to select diabetic patients. The variables recorded were: percentage of patients with HbA1c <8% and the hypoglycaemia rate before and after implementation of the quality program.

RESULTS

The prevalence of diabetes was 11.8%, with 71.3% of them receiving some pharmacological treatment. In the year 2016, in the Integrated Health Area of Santiago de Compostela (Spain), 59.6% (95% CI: 57.9% -61.2%) of the patients had an HbA1c of less than 8%. After the implementation of the quality program, there was an increase in the number of controlled patients, reaching 63.6% (IRQ: 16.0%) in 2017, and 63.8% (95% CI: 62.5% - 65.2%) in 2018. The annual rate of hypoglycaemia increased non-significantly from 2.8 (95% CI: 2.22-3.35) in 2016, to 2.94 (95% CI: 2.35-2.35) in 2017 (P=.083), and 3.0 (95% CI: 2.44-3.56) in 2018 (P=.399).

CONCLUSIONS

The implementation of the diabetes process management program enabled the level of control of HbA1c to be improved, as well as increase the percentage of patients who undergo regular check-ups, without increasing hypoglycaemia.

[Temporal trend analysis of poorly controlled anticoagulated patients in a cohort of primary care patients]

OBJECTIVE

To determine the temporal trend in poorly-controlled anticoagulated patients.

MATERIAL AND METHODS

A longitudinal study was conducted on a non-unselected sample of all patients seen in a health centre over a period of 3 years (2011-2013). Patients who received anti-vitamin K anticoagulation for at least 6 months due to non-valvular atrial fibrillation were selected, obtaining a final sample of 130 patients.

RESULTS

The mean age of the sample was 77.0±1.5 years and 53.1% were male. The prevalence of hypertension and diabetes mellitus was 90% and 33.8%, respectively, and 11.5% and 14.6% had had heart failure or a stroke, respectively. The mean number of medications taken by patients was 7.6±0.6. The prevalence of insufficient control of time in therapeutic range, calculated by Rosendaal, was 60.2% in 2011, 54.2% in 2010, and 43.4% in 2012. On analysing the time in the therapeutic range in patients with impaired control in the first quarter of follow-up, it was observed to remain low in subsequent years: 69.7% vs 55%, P=.0005, in 2011; 71.9% vs 59.3%, P=.0015 in 2012; and 74.7% vs 60%, P=.0005 in 2013.

CONCLUSIONS

Our study shows that patients with inadequate time in therapeutic range have a tendency to stay in poor control, suggesting the need for early clinical decisions in patients on anticoagulants, taking into account the prognosis and economic costs of atrial fibrillation and treatment.