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The utility of telehealth services for lipid management remains understudied.
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Telehealth has had a positive to neutral impact on improving lipid metrics.
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Facilitators to telehealth include multidisciplinary care and patient-centeredness.
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Technology dexterity and clinician reimbursement remain major barriers to telehealth.
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Future interventions should emphasize a hybrid model of patient-centered care.
Abstract
Telehealth services have been implemented to deliver care for patients living with many chronic conditions and have expanded greatly during the COVID-19 pandemic. Little is known about the current or future impacts of telehealth on lipid management practices. The PubMed database was searched from inception to June 25, 2021, with the keywords “lipids or cholesterol” and “telehealth,” which yielded 376 published articles. Telehealth was defined as a synchronous visit between a patient and clinician that replaced an in-office appointment. Studies that solely used remote monitoring, mobile health technologies, or callbacks of results, were excluded. Articles must have measured lipid values. Review articles and protocol papers were not included. After evaluation, 128 abstracts were included for full text evaluation, with 55 full-text articles eventually included. Of the articles, 29 were randomized clinical trials, 15 were pre-post evaluations, and 11 were other study designs. Telehealth had positive to neutral impacts on lipid management. Reported facilitators include easier implementation of multidisciplinary approaches to care, and utilization of patient-centered programs. Reported barriers to telehealth services include technological barriers, such as various skill levels with technology; systems barriers, such as cost and reimbursement; patient-related barriers, including patient non-adherence; and clinician-related barriers, such as difficulty standardizing care. Clinicians reported improved satisfaction among patients but had mixed feelings regarding their ability to deliver quality care. Telemedicine use to provide care for individuals with lipid conditions has expanded during the COVID-19 pandemic, but more research is needed to determine its potential as a sustainable tool for lipid management.
Clinicians have used telehealth services for decades and evidence shows that it reduces hospital readmissions, increases savings for both patients and providers, and enhances quality of patient care.
According to the World Health Organization, telemedicine is defined as the use of information and communication technologies to improve patient outcomes by increasing access to care and medical information.
Prior to the COVID-19 pandemic, telehealth services were used sparingly and mainly addressed shortages of specialty care in rural areas, including care for neurology, psychiatry, and radiology.
However, once the COVID-19 pandemic began in 2020, Centers for Medicare and Medicaid Services (CMS) rules changed and states created telehealth law waivers. These changes allowed clinicians to utilize significantly more telehealth services to address public health crises and provide chronic disease management services.
While some states have reinstated telehealth restrictions since then, access to telehealth services remains much greater than prior to the pandemic. Telehealth services have been utilized by clinicians to eliminate barriers and improve care for patients living with many chronic conditions, including hypertension, gastrointestinal disease, diabetes, and hyperlipidemia.
Lipid management includes a multi-faceted group of interventions that requires a shared responsibility between the clinician and patient to modify lipids to reduce atherosclerotic cardiovascular disease (ASCVD) risk and other sequelae.
2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
Authors/Task Force M, Guidelines ESCCfP, Societies ESCNC 2019 ESC/EAS guidelines for the management of dyslipidaemias: Lipid modification to reduce cardiovascular risk.
2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
Telehealth use within the practice of lipidology remains understudied, yet this modality may prove effective in managing patients with dyslipidemia. This review was performed to gain insight into the current state of telehealth in lipidology and its potential as a future tool for lipid management.
Methods
A scoping review of the literature was performed to understand the current state of telehealth use in lipid management and to identify existing gaps in this field.
We defined telehealth as a synchronous visit between a patient and a clinician (defined as a physician, advanced practice clinician, pharmacist, dietician, or registered nurse) that replaces a traditional in-office appointment. Additionally, our definition of telemedicine does not include sole use of mobile health technology, remote monitoring systems, or telephone calls to patients for the return of testing results.
The PubMed database was searched from inception to June 25, 2021, using the terms “lipids OR cholesterol” and “telehealth” [Table 1]. This initial search yielded 376 published articles. Abstract screening was performed by a single member of the research team. Abstracts that measured lipid values and performed telehealth visits were included for full-text screening, whereas abstracts that did not fit our definition of telehealth (i.e. sole use of mobile health technologies or remote telemonitoring) or did not measure lipid values were excluded. Full-text exclusion criteria included: studies that did not fit our group's definition of telehealth; review articles, including systematic reviews and meta-analyses; articles that outlined study protocols; and studies that did not measure lipid values.
Table 1PubMed search strategy.
1st term: Lipids or Cholesterol
AND
2nd term: Telehealth
(“lipids”[All Fields] OR “lipidate”[All Fields] OR “lipidated”[All Fields] OR “lipidates”[All Fields] OR “lipidation”[All Fields] OR “lipidations”[All Fields] OR “lipide”[All Fields] OR “lipides”[All Fields] OR “lipidic”[All Fields] OR “lipids”[MeSH Terms] OR “lipids”[All Fields] OR “lipid”[All Fields] OR “cholesterol”[MeSH Terms] OR “cholesterol”[All Fields] OR “cholesterols”[All Fields] OR “cholesterole”[All Fields] OR “cholesterols”[All Fields])
(“telehealth”[All Fields] OR “telemedicine”[MeSH Terms] OR “telemedicine”[All Fields] OR “telehealth”[All Fields])
This process yielded 128 abstracts for full-text screening. In total, 55 studies (29 completed in the U.S., 26 completed in other countries) were included in our review of an analysis of the barriers, facilitators, and current and future impacts of telehealth in the practice of lipidology (Figure 1).
Of the 55 studies, 29 were randomized control trials, 15 were pre-post studies, and 11 were classified as other study designs. Specifically, the types of other study designs included: 4 evaluation studies, 2 cross-sectional studies, 2 comparative studies, 2 case-control studies, and 1 mixed-method study. To understand telehealth use and its relation to the COVID-19 pandemic, this search yielded 14 studies that were published during or after 2019, while 41 studies were published before 2019. Additional demographics of each included study are presented in Table 2.
Telemedicine assists in the management of proatherogenic dyslipidemia and postprandial glucose variability in patients with type 2 diabetes mellitus: a cross-sectional study.
Impact of ENHANCED (diEtitiaNs Helping pAtieNts CarE for Diabetes) Telemedicine Randomized Controlled Trial on Diabetes Optimal Care Outcomes in Patients with Type 2 Diabetes.
The sustained effects of extending cardiac rehabilitation with a six-month telemonitoring and telecoaching programme on fitness, quality of life, cardiovascular risk factors and care utilisation in CAD patients: The TeleCaRe study.
24-month CHOICEplus or CHOICE program significantly improved cardiovascular risk profiles in ACS survivors. CHOICEplus telehealth program was not associated with any additional benefits compared to the original CHOICE program.
Long-term, telephone-based follow-up after stroke and TIA improves risk factors: 36-month results from the randomized controlled NAILED stroke risk factor trial.
An evidence-based approach to the use of telehealth in long-term health conditions: development of an intervention and evaluation through pragmatic randomised controlled trials in patients with depression or raised cardiovascular risk.
No significant difference in LDL-C levels among both groups. However, the baseline LDL-C was low at 75 mg/dL and 81% of patients were using statins. High patient satisfaction.
Telemedicine diabetes consultations are cost-effective, and effects on essential diabetes treatment parameters are similar to conventional treatment: 7-year results from the Svendborg Telemedicine Diabetes Project.
Social impact analysis of the effects of a telemedicine intervention to improve diabetes outcomes in an ethnically diverse, medically underserved population: findings from the IDEATel Study.
LDL-C reduction was not impacted by patient's level of income. However, the range of income among study participants was too narrow to detect a difference.
Lipid treatment in ethnically diverse underserved older adults with diabetes mellitus: statin use, goal attainment, and health disparities in the informatics for diabetes education and telemedicine project.
Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: the IDEATel project.
Significant LDL-C reductions and higher health locus of control internal score in the telehealth group. Patients viewed intervention as highly acceptable.
A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus.
Telehealth use in lipid management had a positive to neutral impact on improving composite lipid metrics, medication adherence to lipid-lowering therapies, or lipid management education among studies analyzed in this review. A commonality among studies in this review was that telehealth services can increase the amount of collected patient data, which provided clinicians with a more complete understanding of each individual patient. Examples of collected metrics that helped clinicians facilitate better individualized care for their patients included Hemoglobin A1c (HbA1c), diet, exercise, and lipids.
Telemedicine assists in the management of proatherogenic dyslipidemia and postprandial glucose variability in patients with type 2 diabetes mellitus: a cross-sectional study.
Personalized information and data among patients allowed clinicians to change therapeutic titrations and prescriptions according to the updated metrics they received from patients,
A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus.
On a system-wide level, some telehealth interventions were shown to increase coordination with primary care centers and engage sometimes under-utilized advanced practice providers to share the clinical management of their patients.
Increased cooperation and communication between clinicians, their colleagues, and their patients likely contributed to the observed overall positive to neutral outcomes.
Facilitators to delivering telehealth services
Current facilitators to telehealth services for lipid management exist in the categories of multidisciplinary approach to care, patient-centered programs, funding support.
Multidisciplinary approach to care
Telehealth interventions were shown to promote the utilization of multidisciplinary healthcare professionals to care for patients with complex medical conditions. A virtual telehealth clinic allowed professionals across multiple specialties to coordinate care, without the burdens of excess scheduling, travel, and other related obstacles that typically prevent coordinated specialty care.
Telemedicine diabetes consultations are cost-effective, and effects on essential diabetes treatment parameters are similar to conventional treatment: 7-year results from the Svendborg Telemedicine Diabetes Project.
Many of the telehealth interventions analyzed in this study used professionals from multiple areas of practice, including nutritionists, registered nurses, dieticians, psychiatrists, pharmacists, and cardiologists, to coach, counsel, and treat patients with chronic health conditions in a remote setting.
Telemedicine diabetes consultations are cost-effective, and effects on essential diabetes treatment parameters are similar to conventional treatment: 7-year results from the Svendborg Telemedicine Diabetes Project.
Specifically, patient-centered interventions that thoughtfully considered patient education level, possible language barriers, and comfort-level with technology yielded high patient satisfaction marks.
Social impact analysis of the effects of a telemedicine intervention to improve diabetes outcomes in an ethnically diverse, medically underserved population: findings from the IDEATel Study.
Culturally appropriate telehealth interventions that facilitated care in a timely manner also demonstrated evidence of a patient-centered design to telehealth interventions.
Social impact analysis of the effects of a telemedicine intervention to improve diabetes outcomes in an ethnically diverse, medically underserved population: findings from the IDEATel Study.
Patients across studies enjoyed the flexibility in scheduling their own telehealth appointments with the freedom of attending appointments from wherever they pleased, which minimized their travel burden and associated costs.
Telemedicine diabetes consultations are cost-effective, and effects on essential diabetes treatment parameters are similar to conventional treatment: 7-year results from the Svendborg Telemedicine Diabetes Project.
Many of the telehealth interventions practiced among the studies in this review encouraged self-empowerment and self-management principles that enabled patients to take ownership of their health and create strong habits. Telehealth interventions that emphasized self-efficacy in one's health facilitated a boost in patients’ internal locus of health control.
While cost currently exists as a barrier to delivering telehealth services, some studies revealed that the costs associated with technology installation, training, and hardware were covered by publicly funded health care systems, which promoted the delivery of telehealth services at reduced to no cost for patients in several studies.
Social impact analysis of the effects of a telemedicine intervention to improve diabetes outcomes in an ethnically diverse, medically underserved population: findings from the IDEATel Study.
This suggests that government funding could facilitate the delivery of future telehealth interventions in the U.S., as technology costs was reported as a barrier to implementation of telehealth services in studies conducted in the U.S.
A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus.
Only a few studies in our analysis analyzed potential cost-savings for health systems, which yielded mixed results. Telehealth interventions could marginally reduce the cost of ward admissions and consultations.
Interestingly, one study found that the cost-effectiveness of telehealth interventions for health systems depends on the nature of the disease in question, as cost-effectiveness was achieved for patients with cardiovascular disease risk, but was not achieved for patients living with depression.
An evidence-based approach to the use of telehealth in long-term health conditions: development of an intervention and evaluation through pragmatic randomised controlled trials in patients with depression or raised cardiovascular risk.
Current barriers to telehealth services for lipid management exist in the categories of technology, patient experience, clinician experience, and health systems.
Technological barriers
In several studies, technology was identified as the most significant barrier to delivering telehealth services. Technology dexterity and comfortability varied across patient age ranges,
and if technological issues existed before or during a telehealth appointment, the infrastructure must exist for patients and/or providers to navigate this issue or obtain appropriate support.
Despite patients achieving internet access to their telehealth appointment, challenges may have persisted, including faulty video access and time spent attempting to troubleshoot.
These technological issues can sometimes hinder telehealth appointments from facilitating the best patient care.
Patient-related barriers
Patients may provide direct or indirect resistance to using telehealth services. Many patients did not provide accurate or updated contact information in their records, and were difficult to reach for scheduling and conducting telehealth appointments,
Impact of ENHANCED (diEtitiaNs Helping pAtieNts CarE for Diabetes) Telemedicine Randomized Controlled Trial on Diabetes Optimal Care Outcomes in Patients with Type 2 Diabetes.
Long-term, telephone-based follow-up after stroke and TIA improves risk factors: 36-month results from the randomized controlled NAILED stroke risk factor trial.
Lastly, various interstate licensure requirements restrict providers from being able to continue providing telehealth services to patients who move out of state.
A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus.
Historically, telehealth providers received limited reimbursement from insurances, yet as telehealth increased in prevalence when the COVID-19 pandemic began in 2020, federal and state agencies in the U.S. and other stakeholders modified their policies and procedures to grant more clinicians the capability to provide telehealth services and to receive reimbursement from agencies such as the CMS.
However, cost remains a significant barrier to providing quality telehealth services. These costs include: telehealth software; technology required to facilitate telehealth appointments;
A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus.
A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus.
Furthermore, insurance policies limited clinicians on their ability to bill equally for in-person and telehealth visits, which culminates in missed earnings and may discourage clinicians from pursuing telehealth interventions.
A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus.
Specifically within telehealth interventions, individual state policies dictate reimbursement across telephone-only and video telehealth interventions in the U.S., which creates inconsistencies in billing practices and may further isolate elderly patients or patients without access to video streaming services.
Clinician feedback on utility of telehealth services
Clinician attitudes toward telehealth services for lipid management remain unclear in the literature. Some clinicians expressed concern about licensing restrictions and reimbursement policies regarding telehealth services.
Telemedicine diabetes consultations are cost-effective, and effects on essential diabetes treatment parameters are similar to conventional treatment: 7-year results from the Svendborg Telemedicine Diabetes Project.
Telemedicine diabetes consultations are cost-effective, and effects on essential diabetes treatment parameters are similar to conventional treatment: 7-year results from the Svendborg Telemedicine Diabetes Project.
Future utility of telehealth services for lipid management
One consequence of the COVID-19 pandemic is the emerging interest in telehealth to deliver care.41As this interest grows, best practices for telehealth interventions regarding lipid management should be further explored. Many studies in this review suggested that future use of telehealth should include both in-person and virtual consultations.
Specifically, a complimentary hybrid model of both occasional telehealth and in-person consultations could optimize care for the management of proatherogenic dyslipidemias in diabetic patients.
Telemedicine assists in the management of proatherogenic dyslipidemia and postprandial glucose variability in patients with type 2 diabetes mellitus: a cross-sectional study.
Future telehealth interventions may focus on medication management and adherence to lifestyle modifications to prevent ASCVD, while in-person consultations could focus on obtaining lipid metrics and other screening measures.
Lipid-lowering therapies could be better adjusted and prescribed through telehealth interventions, as some telehealth interventions increased statin use and medication adjustment.
Lipid treatment in ethnically diverse underserved older adults with diabetes mellitus: statin use, goal attainment, and health disparities in the informatics for diabetes education and telemedicine project.
Additionally, studies in this review suggested that telehealth visits, when paired with self-monitoring devices, can be used to help increase patients’ self-efficacy, which has been shown to improve patient outcomes.
Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: the IDEATel project.
Telehealth provides opportunities to further enrich the patient-centered focus of healthcare, which can be beneficial to providing lipid management care. If telehealth visits became more ubiquitous, this would be more convenient for patients, as they can take less time off work, eliminate travel time, and reduce time spent for transportation coordination.
If patients believe they are managing their ASCVD risk well and have ample opportunities to check-in with their provider about their lipids, then this may lead to overall reductions in ASCVD risk for patients with dyslipidemia. Future telehealth practice should focus on integrating patients better when developing telehealth lipid management care plans, to not only help adopt this self-efficacy approach, but also to improve patient engagement.
Lipid management telehealth services should also place a strong focus on increasing communication between provider and patient, as this can help underserved patients with adherence and reduce their overall ASCVD risk.
Regardless of proposed mechanisms related to the future utility of telehealth for lipid conditions, implementation science will play a role in ensuring telehealth's uptake into clinical practice.
This scoping review was performed to assess and describe the current landscape of telehealth utility for the practice of lipid management. The major strength of this study is that it provides a thorough understanding of the current state, barriers, and facilitators related to telehealth use for clinical lipidology, adding a lipid-specific focus to the rapidly growing field of telehealth. Two weaknesses present in this study include the inherent weakness that this is a scoping review, rather than an original project, in addition to the fact that only one author performed manuscript screening (Figure 1). However, by synthesizing the facilitators and barriers of telehealth use in lipid management with a detailed current state understanding, other groups may be able to better design, implement, and evaluate novel telehealth interventions for use in clinical lipidology.
Conclusion
Telehealth services for lipid management have expanded during the COVID-19 pandemic. By addressing current barriers to telehealth for lipid management, such as technology dexterity, and leveraging existing facilitators, like access to multidisciplinary specialty care, health systems, clinicians, and patients alike may benefit from this modernized approach to lipid care. Further research is needed to discover best practices for optimizing lipid management via telehealth interventions.
CRediT authorship contribution statement
Tyler J. Schubert: Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing. Katarina Clegg: Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing. Dean Karalis: Conceptualization, Data curation, Formal analysis, Methodology, Writing – review & editing. Nihar R. Desai: Conceptualization, Data curation, Formal analysis, Methodology, Writing – review & editing. Joel C. Marrs: Data curation, Conceptualization, Formal analysis, Methodology, Writing – review & editing. Catherine McNeal: Conceptualization, Data curation, Formal analysis, Methodology, Writing – review & editing. Guy L. Mintz: Conceptualization, Data curation, Formal analysis, Methodology, Writing – review & editing. Katrina M. Romagnoli: Conceptualization, Data curation, Formal analysis, Methodology, Writing – review & editing. Laney K. Jones: Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Writing – original draft, Writing – review & editing.
References
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Razzak J.
Telemedicine in the United States: An Introduction for Students and Residents.
2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
Telemedicine assists in the management of proatherogenic dyslipidemia and postprandial glucose variability in patients with type 2 diabetes mellitus: a cross-sectional study.
A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus.
Telemedicine diabetes consultations are cost-effective, and effects on essential diabetes treatment parameters are similar to conventional treatment: 7-year results from the Svendborg Telemedicine Diabetes Project.
Social impact analysis of the effects of a telemedicine intervention to improve diabetes outcomes in an ethnically diverse, medically underserved population: findings from the IDEATel Study.
An evidence-based approach to the use of telehealth in long-term health conditions: development of an intervention and evaluation through pragmatic randomised controlled trials in patients with depression or raised cardiovascular risk.
Impact of ENHANCED (diEtitiaNs Helping pAtieNts CarE for Diabetes) Telemedicine Randomized Controlled Trial on Diabetes Optimal Care Outcomes in Patients with Type 2 Diabetes.
Long-term, telephone-based follow-up after stroke and TIA improves risk factors: 36-month results from the randomized controlled NAILED stroke risk factor trial.
Lipid treatment in ethnically diverse underserved older adults with diabetes mellitus: statin use, goal attainment, and health disparities in the informatics for diabetes education and telemedicine project.
Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: the IDEATel project.
The sustained effects of extending cardiac rehabilitation with a six-month telemonitoring and telecoaching programme on fitness, quality of life, cardiovascular risk factors and care utilisation in CAD patients: The TeleCaRe study.
Conflict of interest: Tyler J. Schubert has no disclosures. Katarina Clegg has no disclosures. Dean Karalis is a consultant for Amgen and Novartis and speaker for Esperion. Nihar R. Desai works under contract with the Centers for Medicare and Medicaid Services to develop and maintain performance measures used for public reporting and pay for performance programs. He reports research grants and consulting for Amgen, Astra Zeneca, Bayer, Boehringer Ingelheim, Cytokinetics, Relypsa, Novartis, SCPharmaceuticals, and Vifor. Joel C. Marrs has no disclosures. Catherine McNeal has no disclosures. Guy L. Mintz is a consultant for Esperion and Janssen. Katrina M. Romagnoli has no disclosures. Laney K. Jones is a consultant for Novartis.
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