Real-World Outcomes in Cystic Fibrosis Telemedicine Clinical Care in a Time of a Global Pandemic

Lindsay A L Somerville, Rhonda P List, Martina H Compton, Heather M Bruschwein, Deirdre Jennings, Marieke K Jones, Rachel K Murray, Elissa R Starheim, Katherine M Webb, Lucy S Gettle, Dana P Albon, Lindsay A L Somerville, Rhonda P List, Martina H Compton, Heather M Bruschwein, Deirdre Jennings, Marieke K Jones, Rachel K Murray, Elissa R Starheim, Katherine M Webb, Lucy S Gettle, Dana P Albon

Abstract

Background: During the COVID-19 pandemic, the University of Virginia adult cystic fibrosis (CF) center transitioned from in-person clinical encounters to a model that included interdisciplinary telemedicine. The pandemic presented an unprecedented opportunity to assess the impact of the interdisciplinary telemedicine model on clinical CF outcomes.

Research question: What are the clinical outcomes of a care model that includes interdisciplinary telemedicine (IDC-TM) compared with in-person clinical care for patients with CF during the COVID-19 pandemic?

Study design and methods: Adults with CF were included. The prepandemic year was defined as March 17, 2019, through March 16, 2020, and the pandemic year (PY) was defined as March 17, 2020, through March 16, 2021. Patients were enrolled starting in the PY. Prepandemic data were gathered retrospectively. Telemedicine visits were defined as clinical encounters via secured video communication. Hybrid visits were in-person evaluations by physician, with in-clinic video communication by other team members. In-person visits were encounters with in-person providers only. All encounters included previsit screening. Outcomes were lung function, BMI, exacerbations, and antibiotic use. FEV1 percent predicted, exacerbations, and antibiotic use were adjusted for the effect of elexacaftor/tezacaftor/ivacaftor treatment.

Results: One hundred twenty-four patients participated. One hundred ten patients were analyzed (mean age, 35 years; range, 18-69 years). Ninety-five percent had access to telemedicine (n = 105). Telemedicine visits accounted for 64% of encounters (n = 260), hybrid visits with telemedicine support accounted for 28% of encounters (n = 114), and in-person visits accounted for 7% of encounters (n = 30). No difference in lung function or exacerbation rate during the PY was found. BMI increased from 25 to 26 kg/m2 (t100 = -4.72; P < .001). Antibiotic use decreased from 316 to 124 episodes (z = 8.81; P < .0001).

Interpretation: This CF care model, which includes IDC-TM, successfully monitored lung function and BMI, identified exacerbations, and followed guidelines-based care during the pandemic. A significant decrease in antibiotic use suggests that social mitigation strategies were protective.

Trial registry: ClinicalTrials.gov; No.: NCT04402801; URL: www.

Clinicaltrials: gov.

Keywords: BMI; COVID-19; antibiotic use; clinical outcomes; cystic fibrosis; exacerbation rate; lung function; pandemic; telehealth; telemedicine.

Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

Figures

Graphical abstract
Graphical abstract
Figure 1
Figure 1
Study design and enrollment flowchart. All 143 adult patients with cystic fibrosis at the University of Virginia were considered for eligibility. Two were excluded because of inability to provide informed consent. One patient declined to participate. Sixteen were unable to be reached for consent. One hundred twenty-four patients were enrolled and participated in the telemedicine intervention. One hundred ten patients were analyzed; 14 of the participants were excluded from final analysis because of lack of retrospective prepandemic data.
Figure 2
Figure 2
A, Bar graph showing clinic encounters during the pandemic year (PY) by quarter. A total of 407 clinical encounters were conducted between March 17, 2020, and March 16, 2021. B, Pie graph showing encounter types as a percentage of all encounters for the PY. Telemedicine encounters made up most visits at 64% (n = 260). Hybrid visits that included in-clinic telemedicine support accounted for 28% (n = 114), whereas 7% were in-person visits (n = 30) and less than 1% were by phone (n = 3). All phone visits took place between March 17 and June 30, 2020.
Figure 3
Figure 3
A-C, Bar graphs showing changes in lung function during the PY. A, Without adjusting for ETI use and other variables, FEV1 percent predicted increased significantly from 69.3% in the PPY to 73.5% during the PY (P < .01). B, Determining the effect of triple combination cystic fibrosis transmembrane conductance regulator modulator therapy on lung function adjusting for year and other variables. Lung function improved by 4.4% because of therapy (P < .01). C, Adjusting for ETI use and other variables revealed no change in lung function from the PPY to PY (70.0 PPY vs 70.2 PY; P = .55). ETI = elexacaftor/tezacaftor/ivacaftor; PPY = prepandemic year; PY = pandemic year.
Figure 4
Figure 4
A-C, Bar graphs showing exacerbation rates. A, Exacerbation rate declined during the PY from 0.133 exacerbations/person/y to 0.053 exacerbations/person/y (P < .01). B, Exacerbation rates adjusted for ETI therapy and other variables demonstrated no significant difference in the PPY vs PY (0.065 vs 0.054 exacerbations/person/y; P = .68). C, All antibiotic use, including both IV and oral antibiotics, adjusted for ETI therapy and other variables, decreased from 0.612 occurrences/person/y during the PPY to 0.366 occurrences/person/y during in PY (P = .02). ETI = elexacaftor/tezacaftor/ivacaftor; PPY = prepandemic year; PY = pandemic year.
Figure 5
Figure 5
Graph showing preservation of BMI during the PY. An increase in BMI was observed during the pandemic period, with mean BMI of 25.2 kg/m2 during the PPY and 26.2 kg/m2 during the PY (n = 101; P < .001). Six patients were excluded because of pregnancy and 1 because of missing data. BMI was not adjusted for elexacaftor/tezacaftor/ivacaftor (ETI) treatment because of lack of data before and after ETI treatment. Lines show each patient’s change. Subgroup analysis for BMI less than the patient’s goal (BMI < 22 kg/m2 for women or < 23 kg/m2 for men) and for BMI at goal (BMI of 22-27 kg/m2 for women and 23-27 kg/m2 for men) demonstrated significant improvement during the PY (P < .001 and P = .008, Adj., respectively). For BMI of more than the patient’s goal, no significant change in BMI was observed during the PY (P = .183, Adj.). Adj. = adjusted; F = female; M = male; PPY = prepandemic year; PY = pandemic year.

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Source: PubMed

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