VASCULAR DISEASE MANAGEMENT 2020;17(10):E191-E193.
Key words: Laser atherectomy, distal embolization, COVID-19, thrombus, aspiration
Program introduced to improve health outcomes delivers additional value in protecting those most at-risk from COVID-19. When Vascular Care of Texas originally started looking into remote patient monitoring (RPM) as a means of improving health outcomes among its most elderly, highly vulnerable patient population in early 2019, the novel coronavirus known as COVID-19 had not affected a single person yet. The practice, which serves the vascular needs of thousands of patients each year from its three offices in the Dallas-Ft. Worth area, was simply looking for a way to improve health outcomes of patients with conditions such as peripheral artery disease, carotid artery disease, deep venous thrombosis, aortic aneurisms, critical limb ischemia and other issues, as well as the 30% of its patient population who require dialysis.
Typically, after a procedure the patient would come in for a post-operative visit and all tests would look good, meaning the surgery had been successful. The surgeon would then schedule follow-up visits at the standard interval recommended by the Society of Vascular Surgery. While that was acceptable for most patients, for a small percentage something unpredictable would happen within that timeframe that would cause the condition to deteriorate so significantly that the patient would be in trouble.
For example, after a limb salvage procedure, the results would appear normal during the post-operative visit and even after one or two weeks. But when the patient came back in after three months the bypass might have clotted off, placing the patient at a-high risk for limb loss.
“Somewhere along the way we’d miss the data point where it went bad,” said Edic Stephanian, MD, FACS, a vascular surgeon at Vascular Care of Texas, PLLC and the Medical Director of Acute Aortic Emergency Program & Vascular Surgery at Medical City Plano hospital. “As a practice, we believed that if we could keep a closer, more frequent watch on our patients, especially the ones with the highest risk of a negative outcome, we could take action before the patient got in trouble. But with thousands of patients on our panels, many of whom have difficulty with traveling, we knew that increasing the frequency of office visits was not a practical solution.”
Filling the Gaps
Dr. Stephanian had heard stories about how telehealth and RPM were being applied in other areas and thought it might be the ideal solution to help Vascular Care of Texas stay ahead of developing issues in its patients between visits. When the practice began looking into its options, however, it discovered none of the vendors had a program for vascular surgery patients. Yet that would not be an obstacle for one of them.
“Vivify Health told us they would work with us to develop the program,” Dr. Stephanian says. “They helped us develop the entire algorithm for managing these patients. Every day we text patients to measure their temperature, blood pressure (BP), pulse oximetry and other parameters using their own devices or Bluetooth®-enabled devices we provide and have them send the results to us. Many patients have BP cuffs and often have pulse oximetry. For the patients that do not have a BP cuff, we give them a bluetooth-enabled cuff at our expense. We ask them the same questions about their conditions we ask when they come to the office, such as ‘How are you feeling today?’ or ‘Are you seeing any rashes or swelling around the wound?’. Their answers help us stay ahead of developing conditions.”
For example, one of the key tests the practice performs in the office to check for peripheral arterial disease is an ankle-brachial index (ABI), which compares the blood pressure measured at the patient’s ankle and arm. The normal ABI is 1 or slightly greater. Clinicians are looking at changes in ABI over time as an indication of bypass grafts that are at risk for thrombosis or percutaneous interventions that might be at risk for acute occlusion, as well as correlating changes in the ABI with changes in the patient’s symptoms. With the RPM technology, the patient can perform the same test at home.
Vascular Care of Texas received permission from various professional organizations to include their information when developing the pathways. For example, the National Kidney Foundation approved the inclusion of its information on renal insufficiency, dialysis access, permacaths and home dialysis. After a data upload, Vascular Care of Texas might also include a link back to the National Kidney Foundation where patients can find even more information about various topics.
In all, Vascular Surgery of Texas and Vivify Health co-developed 16 pathways:
• Aortic aneurisms
• Atrial fibrillation
• Carotid artery disease
• Chronic kidney disease
• Coronary artery disease
• Deep venous thrombosis
• Leg swelling
• Peripheral vascular disease
• Pulmonary embolism
• Peripheral vascular disease with carotid artery disease
• Renal failure
• Tobacco cessation
• Varicose veins
• Weight management
• Wound management
If the data indicates a problem is developing, Vascular Care of Texas will contact the patient about the next steps.
“Sometimes we will have a nurse call the patient on the phone to gather more information,” he says. “Other times we will use a voice-and-video telehealth call so the surgeon can use the phone or tablet’s camera to get a look at the affected area, such as when there is discoloration around an incision. We only have the patient come in if there is an emergency that cannot be resolved remotely. It’s more convenient and less costly for the patient, and it helps our clinicians use their time more efficiently.”
The RPM program had been running successfully for roughly six months when COVID-19 was first identified in the U.S. As the disease moved from a “cause for concern” to a “global health emergency” to an official pandemic, Vascular Care of Texas became more concerned for its patients. The practice is located in a large metropolitan area, and the Centers for Disease Control and Prevention (CDC) has stated that patients over 65 as well as those with conditions such as heart disease, chronic kidney disease being treated with dialysis, and other co-morbidities are among the most vulnerable to its worst effects.
These concerns were addressed in March when Vivify released a COVID-19-related pathway that enables patients to self-screen for the virus. The practice immediately sent it to all its patients participating in the RPM program.
“The COVID-19 Screening Pathway is a great tool to have,” Dr. Stephanian says. “Rather than sitting back and worrying about our patients, we are able to deliver information to them proactively that can help them recognize the signs and reassure them if they develop a normal cough or some other minor symptom. It also tells them the steps to take if they suspect they do have it. There is a lot of bad information on the Internet. The Pathway gives them evidence-based information they can rely on so they can make better decisions, and even avoid putting themselves at needless additional risk by seeking out a test or visiting a healthcare facility when it is not necessary.”
In addition to providing the information, Vascular Care of Texas is also keeping a watchful eye for warning signs of COVID-19 in daily data its patients are providing, such as a sudden temperature spike. Fortunately, however, to date, none of its patients have exhibited any alarming symptoms.
Improved Compliance and Outcomes
Although Vascular Care of Texas does not have any formal data yet, anecdotally the practice has observed that patients who are in the RPM program are tending to have higher compliance rates with their plans of care, fewer negative incidents and better overall outcomes.
The regular communication between the practice and its patients is also helping physicians get in front of other issues as well. In fact, patients who started out not being part of the RPM and telehealth program or not actively participating in it would show marked improvement once they began following the pathway.
“Peripheral vascular disease isn’t something you treat once in the legs and it’s solved. It’s a chronic condition that affects multiple areas, including the heart and carotid arteries,” Dr. Stephanian says. “Roughly 35% of patients who have it will pass from heart disease in five years, which is why we ask those patients if they are having chest pains or shortness of breath after exertion when they come to the office. Many do not realize it can be a symptom of a larger problem. Now, with the RPM program we can ask them these questions on a daily basis so we can address them before they become life-threatening.”
Patient satisfaction also is reported to be higher for those on the RPM program versus those who choose not to participate. Many appreciate that they do not need to disrupt their entire lives to make an office visit when they have a question or a concern. With 16 months of RPM experience, Vascular Care of Texas is developing a survey questionnaire to measure patients’ satisfaction with the program and to obtain quantifiable feedback to augment anecdotal feedback.
“An office visit can be very difficult for patients to manage, particularly older ones,” explains Dr. Stephanian. “Some of my patients might live 100 miles away from my office or the hospital. If they cannot drive, they need to find someone to take them. If they have trouble moving, or they are in a weakened state, the effort involved can be tremendous. RPM and telehealth remove those barriers in many cases. And with the COVID-19 pandemic, avoiding bringing highly vulnerable patients into areas where they might be exposed to the virus is particularly critical. Our patients are very appreciative of all these factors.”
The next step for Vascular Care of Texas is to expand the program to serve more of its patient population. Currently, 100 patients are enrolled in the RPM program at any given time. The practice wants to raise that number to 250 within the next year, at which point the medical assistant (MA) who is dedicated to it will probably have to be relieved of her other clinical responsibilities so she can manage the patient load.
Asked if he had any advice for other practices in any area considering adding RPM, Dr. Stephanian’s answer was simple.
“Just plunge into it,” he says. “It’s one of those things you need to learn along the way. When we started, we didn’t know how to bill for the service but we learned. Start small and build. Make sure you have someone in the practice dedicated to the program, who is personally invested in seeing it succeed. And, of course, be sure you partner with a technology company that is willing to work with you as learn and grow.” n
Disclosure: The author has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest.
Address for correspondence:
Edic Stephanian, MD, FACS
Vascular Care of Texas, PLLC