Telehealth Support From Cardiologists to Primary Care Physicians in Heart Failure Treatment: Mixed Methods Feasibility Study of the Brazilian Heart Insufficiency With Telemedicine Trial

Abstract

Background: Heart failure is a prevalent condition ideally managed through collaboration between health care sectors. Telehealth between cardiologists and primary care physicians is a strategy to improve the quality of care for patients with heart failure. Still, the effectiveness of this approach on patient-relevant outcomes needs to be determined.

Objective: This study aimed to assess the feasibility of telehealth support provided by cardiologists for treating patients with heart failure to primary care physicians from public primary care practices in Rio de Janeiro, Brazil.

Methods: We used mixed methods to assess the feasibility of telehealth support. From 2020 to 2022, we tested 2 telehealth approaches: synchronous videoconferences (phase A) and interaction through an asynchronous web platform (phase B). The primary outcome was feasibility. Exploratory outcomes were telehealth acceptability of patients, primary care physicians, and cardiologists; the patients' clinical status; and prescription practices. Qualitative methods comprised content analysis of 3 focus groups and 15 individual interviews with patients, primary care physicians, and cardiologists. Quantitative methods included the baseline assessment of 83 patients; a single-arm, before-and-after assessment of clinical status in 58 patients; and an assessment of guideline-directed medical therapy in 28 patients with reduced ejection fraction measured within 1 year of follow-up. We integrated qualitative and quantitative data using a joint display table and used the A Process for Decision-Making After Pilot and Feasibility Trials framework for feasibility assessment.

Results: Telehealth support from cardiologists to primary care physicians was generally well accepted. As barriers, patients expressed concern about reduced direct access to cardiologists, primary care physicians reported work overload and a lack of relative advantage, and cardiologists expressed concern about the sustainability of the intervention. Quantitative analysis revealed an overall poor baseline clinical status of patients with heart failure, with 53% (44/83) decompensated, as expected. Compliance with guideline-directed medical therapy for the treatment of heart failure with reduced ejection fraction after telehealth showed a modest improvement for β-blockers (17/20, 85% to 18/19, 95%) and renin-angiotensin-aldosterone system inhibitors (14/20, 70% to 15/19, 79%) but a drop in the prescription of spironolactone (16/20, 80% to 15/20, 75%). Neprilysin and sodium-glucose cotransporter 2 inhibitors were introduced in 4 and 1 patient, respectively. Missing record data precluded a more precise analysis. The feasibility assessment was positive, favoring the asynchronous modality. Potential modifications include more effective patient and professional recruitment strategies and educational activities to raise awareness of collaborative support in primary care.

Conclusions: Telehealth was feasible to implement. Considering the stakeholders' views and insights on the process is paramount to attaining engagement. Missing data must be anticipated for future research in this setting. Considering the recommended adaptations, the intervention can be studied in a cluster-randomized trial.

Keywords: family practice; heart failure; intersectoral collaboration; low- and middle-income countries; primary health care; telehealth; telemedicine.

Figure 1

Telehealth online platform landing page used in all study phases for intervention delivery (provider-to-provider support from cardiologists to primary care physicians via telehealth) from August 2020 to December 2022. Permission obtained by the authorship for the use of the image without attribution.

Figure 2

Log-in page for the online platform, restricted to registered users to protect data access and ensure their safety.

Figure 3

Procedural diagram—timeline, interventions, tasks, and data management by study phase. c-RCT: cluster-randomized controlled trial; EHR: electronic health record; REDCap: Research Electronic Data Capture.

Figure 4

Flow diagram of patient inclusion in the study and quantitative before-and-after follow-up for 1 year based on the CONSORT (Consolidated Standards of Reporting Trials) framework for reporting clinical trials (data from August 2020 to December 2022).