Dr. Div Patel discusses diagnosis and treatment of arrhythmias and how digital tools can assist in future care.
Um Thanks Eric for the introduction. So I'm just gonna talk about digital health and cardiology. It's a little different than our usual topics uh that we talk about in E P structural heart um intervention prevention or imaging. In that I think it involves more consumer and goods and things like that. So on the left, you can see on the top left, you can see the apple watch on the bottom left, you can see what's Z patch that many of us are familiar with. On the right, we have the cardia which was U usual uh digital health for recording EKG S um with two leads and on the bottom is one you may not be familiar with, especially if you're not in electrophysiology, which is a Metronic app which goes on the patient's cell phone uh with the newer Azure systems that looks at Bluetooth and the patient can look up their device. So we'll go through all of this and see how digital health is evolving. I think in the next 5 to 10 years, even maybe sooner. I think digital health will play a bigger role in our practice in day to day management So here are my disclosures. Um So I'd like to start off just by thanking um most of you and um especially these five individuals. So, Matt Eric and Jeff, I know very well from the Cleveland Clinic. And I'm fortunate in that um they invited me down to interview and I enjoyed the practice. And then Phil and Ron along with the rest of the cardiology and E P group, I'm fortunate they gave me the opportunity to work for them and hopefully I haven't let them down yet. So here's the grand rounds outlined. So the first part is diagnosing and treatment of arrhythmias and how digital tools can help us in going forward with these. The second part is bringing cardiac implantable electronic devices up to speed because one of the important parts is as we move in 2023 patients have access to their data. But one of the things you may not know is they don't have access until recently with their data about their devices. So manufacturers have access to their devices. Um their physicians may remote monitoring companies may have access to their data, but until recently, patients have not had access. And I think that's gonna be more and more important as we move forward. And then the third part, which I think is a health system we need to look at and see how other hospital systems are divide. Uh designing care is novel care pathways and clinics of the future, which may not be in person physician to, to patient or provider or a P P to patient. But it may involve reviewing a chart and deciding what the best management of a patient may be. So here um is just a slide to give you a framework on how it's changing. You can see here is the traditional model of how we've looked at devices or medicines or tests. Basically a physician or scientist working with industry or pharmaceutical companies back in the day would develop a medication in the lab tested on animals, develop devices that would be tested and then you run a clinical trial. So then after the clinical trials ran and the FDA is sufficiently satisfied, they give the approval for the device at which point it's released and marketed and then health care providers um release that product to patients. So that is the traditional model. But now we have what's called direct to consumer products. And a lot of these which I'll be talking about, which is that you have companies that are tech and industry driven with entrepreneurs and with venture capital funding that develop wearables, they develop health care apps and then they do small studies and some may not even do studies. I think as we go forward, studies will be important. But then there's the divide between FDA clearance and FDA approval. So this wearable may be released to the public but they may not have FDA clearance and it's an important distinction because clearance means that it's been, it's, it's already being marketed, but it's indicated for the use of, for example, an apple launch could be indicated for detecting atrial fibrillation where whereas FDA approval requires a product to before it's released to be approved by the FDA. And so I think we're seeing a shift in the design of trials in that all of these products are already released. Uh But then we're shifting towards studying them after the release as opposed to before the release. And so one of the first examples I'll bring up is the Z patch. And I'll start off with saying I don't endorse or um disagree with any of the products. I'm just going into how we can develop framework for studying these products. So the Z patch was one of the first inventions of thought of as digital health because it's a small patch that sits on the skin, it gives recordings of up to two weeks and easily generates reports and clear signals. And you can see this as sample recording. This is what the ire patch looks like and you get a report like this, which looks great. So you get the fastest V T fastest S V T, you get the slowest um and it's been really utilized well um in a lot of indications for monitoring that people don't want to wear bulky holter monitors or things like that. So, one of the case studies I'll discuss uh and this involves the structural heart group. Um Is we see it a lot used in post cardiac surgery and actually structural heart. So this is a patient, a 66 year old who underwent SAPIEN S3 implantation. And he had a right bundle of pre pre um ta and then he had complete heart block and required a temporary paster afterwards. Monitored over the weekend, he required no pacing. But I think the structural heart team did the right thing in discharging the patient with the Z because these are patients who were high risk. Um And you could see from the Zire report that the patient had an intermittent, complete heart block and was having dizziness and passing out at home. Um So the recording went away. Uh The recording was recorded, the patient was notified and we put on a left bundle pacer um with an excellent result in the patient. So I bring this up because we actually studied this um at the Cleveland Clinic. Um Caldo, who I've done a lot of my research with who now works for Metronic. Uh We looked at Brady Tar study. Basically, we put a Z patch on patients pre tavern, we put a op patch on patients post A and then we said our patients having delayed conduction abnormalities, 2 to 3 months post tar that we're not detecting. And so we did 100 patient study. And I think the importance of all of the, a lot of these studies is this was funded by I rhythm technologies. And so we worked closely with industry to try to develop uh ways to study these because we think it can increase the implementation and it can increase um patients and physicians um satisfaction with this. So 96 patients preta we put a Z patch on, we couldn't detect anything that basically from the Z would say that you would need a, you would need a pacemaker afterwards. Most of those patients under one successful tas 10 patients required um C I E D implantation during the hospitalization. And then we put xy patches post have in 81 patients without the patients who had pacemakers afterwards. And we detected three patients who underwent C ID in implantation. So a couple of patients had long pauses that required that a patient had complete heart block. But you can see here zero, underwent C I E D implantation 2 to 3 months post Taber. So the importance of this study was we found out that same stuff that pre tar predicts pacemaker implantation, right bundle branch block wide NQ R S predicted at post. But I think it's reasonable in higher risk patients to put a Z I O on because you can pick up 3 to 4% of patients will need a pacemaker or some kind of device afterwards. And so patients who are higher risk deserve a Z patch. I think the delayed 13 months out, we're not seeing those patients requiring um any pacemaker needs afterwards. So now shift to atrial fibrillation and talking about these devices. So a fib remains the most common arrhythmia that we see in clinical practice, it's difficult to detect unless it's symptomatic and, and because we don't get 12 leads on patients who are doing fine. The third part is expensive treatment. So anti coagulation, antiarrhythmics, monitoring for these things are expensive and there are lots of consequences if left untreated. So if we don't detect a fib and patients with high chat vast, the risk of stroke is very high. And you can see on this graph either from the Minnesota study or nationwide study, the prevalence of a fib is only gonna increase over time as patients live longer and comorbid it is increase. So here's the gold standard, it's a 12 lead EKG. Um And you can see from this 12 lead, you have atrial fibrillation. The problem with the 12 lead EKG is you require an emergency room visit to detect or an in office visit and we know the burdensome um issues with ordering on Epic. If a patient calls your office and says I have symptomatic a fib, you say, OK, I'll order 12 EKG on Epic. They have to come to clinic or they have to go to an urgent care or go to the emergency room. They have to get an EKG which requires the use of your time, the patient's time. Um And it, it's an ineffective use of resources because of this, the US preventative task force has which makes recommendations on things such as screening. Um So they make recommendations on prostate cancer screening, lung cancer screening. They say in asymptomatic adults, 50 or older, there's insufficient evidence to assess the balance of benefits and harm for screening for AFI and so they're saying we need more data. And so that's for our part as a community come up with more data, they're saying that there's randomized data which shows that there's no benefit of usual care versus screening patients for a fib. Because as much benefit as you may get from detecting a fib and putting them on anti regulation, you may also get some harm. And so one of the things they ask is understanding the risk of stroke associated with subclinical A F which we don't really have great data on. Because until the digital health era, I would argue that subclinical A F has been hard to detect and then A F detected with use of consumer devices and how that risk varies with duration or burden of A F. And I think on the next preventive task force, we'll see that change uh to may be beneficial as we move forward. So here's the first device um that sort of came out was the Cardia Mobile. So it's a two lead EKG. It was founded in 2010 as a first iphone application. Um And unlike other companies, I think it was one of the first that said that, you know, we need to prove this efficacy through trials. So if you look at other watches or blood pressure detection of a fib, they've never really um used trials as a way to convince consumers or physicians whether the thing works. So whether if you look at blood pressure cuffs or watches before the iphone or cardia, um they never proved with the positive predictive value or sensitivity or specificity, any of these technologies. So, here's uh one of the first studies that Dr Bumgarner and Doctor Tarai, one of um Eric's co fellows and one of our co fellows at Cleveland did and which they use the cardio mobile and patients coming in for cardioversion. So this is patients who arrive um into the hospital for cardioversion and they use the app to know. OK. Is this patient sinus rhythm or are they, are they in atrial fibrillation? And what was the sensitivity and specificity? So, the app algorithm they use uh what's they use the R R variability in the Q S? So if it notices it's irregularly irregular, it calls it atrial fibrillation. Um And if it knows that it's regularized, um it calls it sinus rhythm. They've now made changes to that algorithm to detect flutter as well. Uh But this was the original algorithm and you can see the app only algorithm does pretty well, 66% accuracy. And compared to a 12 lead as 93% sensitivity and 84 speci percent specificity, the physician only looking at the recording does better. So 87% with similar sensitivity and specificity. But when the physician reviewing the app tracing with the recordings looks at both together, you can see that 100% of the results are spec um are interpretable and the sensitivity is 100% with 80 specificity. So a lot of these apps have a better refined algorithm. But once you combine the physician interpreting the algorithm with the recording sensitivity and specificity only goes up. And I think that's one of the important points which is that as good as algorithms become, I think a physician overreading them is gonna be important until the modeling is as good as perfect. So here's another interesting paper by the Mayo group. So the Mayo group has Mayo Clinic is very unique in that all of their patient data is in a research data bank. So their EKG S every patient that walks in basically gets put into the um the Mayo Clinic EKG database. And so they have about 600,000 millions of EKG S. And what they said was, can we use an A I enabled neural network um to measure a Q T interval using a mobile electrocardiogram device. And so doctor Ackerman, who's one of the world's experts on one Q T syndrome. Um With Paul Friedman studied this. Um and you could see they had about 600,000 patients with two million EKG S in their study. And they basically developed a training data set and a testing data set. So they trained on 250,000 patients, they test in 100 and 8000 data uh patients and then they randomized it to using the cardio mobile app to measure Q T interval um versus a 12 lead EKG. And you can see from this A U C, the main important point to see is that the A U C was 9.5, which if you do most studies, anything above 0.6 is considered robust. Um Anything above 0.8 is considered very good and 0.95 is almost excellent. Um And so the, the app with the Cardia Mobile, the algorithm was successfully able to tell if your Q T was going to be greater than 500. And so it, it becomes a question of novel care pathways moving forward. Can you solo load someone as an outpatient, have them do a cardio mobile and send you a recording in the morning or two hours after their dose. Can you do a tiki and load um at home with these newer algorithms? And I think that's gonna be more important as we shift care from inside the hospital to outside the hospital. And so the editorial from Rosenberg, it says it seems almost magical to see a computer interpret in EKG a technique that for a human requires many years of training as well as continued practice in less than a second. Um And I think over time we're gonna see better and better algorithms develop for these technologies. So here's the one you may be familiar with. And I was most excited about um when it came out was the Apple Watch. So it was introduced in 2014 by Tim Cook as the most revolutionary product since the iphone by Apple, they added an EKG feature in series four using the crystals on the crown. So where it could, first of all, it would notify you if it thought you were an A fib and then it would ask you to take a recording and you hold your finger close to the crown of your watch um and to record. So it knows and then it interprets it whether it thinks it's in sinus rhythm or in atrial fibrillation. It's not been approved for patients with underlying atrial fibrillation because you may get um mis detection, especially when you have PAC S uh which are hard to detect for these algorithms. So sinus with PAC S may be misinterpreted as a fib. And so this was the largest scale study um done by the Sanford Group uh by Mtu Tara and Marco Perez. And one of the important parts of this study was how they enrolled patients. And they use the very digitally health um way of enrolling, which is when you got the Apple Watch and you opened your Apple phone, you were given an option of enrolling in the trial. And so the trial, basically, there was no person to person visit. There was no, uh there was an I R B but there was no coordinator. It was just all done through the app to fast forward and make it um large scale trial. So they studied over 400,000 patients. And you can see from this patients who are older greater in 65 had a higher chance of having atrial fibrillation. Males had a higher chance of having atrial fibrillation. You can see from this notification subgroup, 43 um of the 929 patients were diagnosed with atrial fibrillation and some were started on anticoagulation and warfarin. So I think the important part of this study uh was that they used a large scale study um enrolling patients with a fib and they were able to change their management looking at it. The specificity was 84%. And so it's important to remember that none of these trials are gonna have 100% specificity or sensitivity um for the diagnosis of atrial fibrillation. So the next thing is embolic stroke of unknown significance. So I think it represents 17% of all ischaemic stroke patients undergo monitoring um with holders they undergo echocardiogram to look for P F OS or other kinds of shunts. And a lot of patients I've been referred to for loop recorder implantation. The problem with loops are it requires an incision in the body. Um It requires hospital bill. Um And you can see some of these devices are pretty big. So here's one that looks 8.8 cm, there's a small 1, 4.5, but any of these things are invasive. Um So I'll go into a case of where the Apple watch may be able to help. So this was a case uh that we saw in clinic. Actually, a patient was 70 years old. She had an embolic cerebellar stroke. Her chances vasco was for her, she had echocardiogram which showed no uh no evidence of shunt or P F O. Um And she had 30 day monitoring which didn't show atrial fibrillation. The patient was very tech savvy. Um And she's like, uh I'm gonna go and buy an apple watch because she heard that maybe atrial fibrillation may have caused her stroke. So the patient was notified um at, at home that on October 31, Hey, you have an irregular rhythm notification. So she said, OK, I'm gonna record my rhythm and you could see here it recorded it and you could see nicely that the patient had atrial fibrillation. And the al algorithm successfully told her what it was and told her to go see a doctor. She came to our clinic for a loop recorder, implantation appointment. And we saw this recording and said, you don't need the loop. Here's a prescription for an anticoagulation. Um So it bypassed the whole loop and we were able to diagnose her and start it earlier, um which was a huge benefit to the patient, avoiding the hospitalization, avoiding the cost of the of the loop. And so this I think will be important as we think about the React A F trial. So right now, Watchman is becoming importantly um is an important device especially and we'll see what the champion and option data show. But patients who are younger don't want to take blood thinners. So these are patients who are active, who want to ski, who want to do extreme sports or may want to not take blood thinner and their chance vast may be on the border line where it may be two or three and you say, and they may have parasal a fib or they may not have the classic risk risk factors. So those patients may be candidates for Watchmen or one of the things you can consider is a digital health trial. And so Rod Passman who's at Northwestern is really looking at this. So he's doing a trial sponsored by the N I H. It's a $37 million trial. And so one of the things he writes is about pill in the pocket anticoagulation for a fib fiction factor foolish. So he's designing this trial. Basically, what happens is the patient's not on the anticoagulation, but their apple watch tells them, hey, you have a FIB. And so the patient records a rhythm and the EKG shows signs of a FIB. The watch tells them you have atrial fibrillation. The patient starts taking their anticoagulation for 30 days and then stops it because they're now in sinus rhythm and then they don't have to take it until their next event of a fib. So it's gonna be a randomized trial. Um It's gonna be 100 US sites. It's they're planning on enrolling 5500 patients, which is great because it's you need a power high enough to detect bleeding and stroke. With that many patients half will always be on anticoagulation and half will be on this smart watch based anticoagulation where their watch tells them to take their blood thinner. And so I think patient centered care has to evolve uh with the use of these digital technologies. So questions remaining for digital health um in atrial fibrillation and detection arrhythmia. What's the best tool for the patient given comorbidities? So if you have an affluent patient who's very tech savvy, younger patient, they may benefit uh from a Cardio mobile or an Apple Watch. Uh but if they have an underlying diagnosis of a fib because the Apple watch may give more misdiagnosis, they may benefit from a higher lead placement or something like cardias six lead EKG which might may have higher sensitivity and specificity. So finding patients with, with the right comorbidities for the right device. And then the second part, which has been an important part uh since the cardio mense thing is how do we manage more data from patients? So if you have cardia recordings coming in, if you have a whole clinic of cardio recordings, how do you manage that data um from the patients? Do you have a nurse practitioner? Do you have a nurse? Do you have a physician? Do you? Is the A I algorithm good enough? Or that sensitivity and specificity will be so high that you don't need any oversight. The third part which is important is who will pay for the use of digital technology. So these products are a $100,400 500 um which is still cheaper than the invasive monitoring. But insurance companies yet are not covering these devices. And I think that'll change with time and then how much evidence is needed before recommending the use of digital technologies. And I think it's an important point to make that before we used to have FDA approval after the data. Now, these health tools are becoming in be, becoming increasingly used before um before FDA approval or clearance is made. So I'll go into a little bit about devices. So here's the stat news headline. Um looking at call it Data Liberation Day patients can now access all their health records digitally. So as you've noticed over time in epic patients can view their encounters, they can view your notes, they can view their imaging studies, they may even see the echo results uh before you're able to review them as soon as they're released. And so one of the things that's always been a sticking point is cardiac implantable electronic devices. So if you get a pacemaker or defibrillator, your doctor may have access to it. Your company may have access to it. But until recently, you as the patient do not have access to it. And I think that'll change with time because patients want to know about their devices. But I think one of the important parts is we did this study to look at what, what do patients know and what did they desire to know about their devices? And we did a multiple choice survey in about 400 patients where we these are patients with devices already implanted. We asked them basic questions that they should know. Like who makes your device? How many times have you been shocked? Why did you get the device? What type of device was? It was a pacemaker defibrillator? Do you know what your device does? Does it pace? Does it shock you? Does it? And then how many wires do you have? And what is the estimated battery life? And I think these are very basic questions that you may think that patient should know. These were multiple choice questions with three responses. And you can see from this patients still don't know a lot about their devices. So they don't know why they got their device implanted. They don't know what type of device they had. 25% of patients thought they had a defibrillator when they had a pacemaker, uh which is a quarter which is surprisingly high. They don't know all the functions of the devices. Some patients thought their defibrillator would. Uh they, some patients thought their pacemaker would shock them when it was a pacemaker, not a defibrillator, they don't know how many wires they have and they were way off on their battery life, but they have a desire to learn. So if you look on the right, we ask them, what would you want to know? And they, they want to know about their battery life, they want to know about their activity levels, their atrial arrhythmias. They want to know if they're in sinus rhythm, they wanna know their fluid status. They're not worried much about sensing and impedance, but the other stuff, patients actually have a desire to learn. And so as you can imagine this got a lot of press. Um and so a lot of news stories covered that patients often lack basic knowledge about their implanted devices. Uh T C T MD, we spend tons of time talking to patients trying to educate them, but I guess we're not meeting them where they live uh this was another study in cardiology today about patients knowledge of devices being suboptimal. Um And then another story showing that survey shows big need for patient education on their devices. And so the blue Sync study was a Metronic sponsored study which gave access to patients, their devices and patients could transmit data using their smartphone. So you can see here this is a manual transmission of a remote technology. This is what most patients have, which is a wireless console that sits in their home, um which they're able to transmit remotely every quarter. So every three months they're able to transmit to us their recordings. You could see the transmission success rates are between anywhere from 70 to 90%. Um looking at these two newer technologies and the Bluetooth App group was much higher. So 95% and patients had access about their device so they could just pull out their phone, go on the app and you could see, ok, I have a Metronic Azure that was implanted in 2020. Here's the transmissions I've done when I've done them, it tracks their vitals so it tracks their heart rates. The patient can log their symptoms, they have education about their device and their physical activity. There's also a thing about battery life as you go through the the menu of options. And I think patients who are smartphone savvy are really looking for this because ultimately, it's their device that we are implanting and participating in their care. And there's no reason they shouldn't have access um to their data. And I think a lot of manufacturers will fall as soon as more and more. Uh people get on apps and digital health. So I'll shift a little bit um for the last part of the talk on using novel care pathways um and using digital health of you in different modalities. So this was a study that we did um after the COVID pandemic where we asked patients, are you satisfied with the virtual visit? We know that um we've tried doing virtual visits, but I think E P has to be at the forefront of virtual visits uh because we don't really um we need to look at the heart rhythm more um so than looking at physical exam findings. And so E P has been in the forefront of virtual visits, looking at telemetry, looking at EKG S and then asking the patient how they feel whether they have symptoms. And so it's prime for virtual visits. So we did this study asking our patients actually satisfied with virtual visits. And you can see from the left where they were satisfied with scheduling the virtual visit, they were fine seeing the patient. But one of the things they were uh not so happy about was paying for the cost of a virtual visit. Um And so they, they like the care they received, asking all the questions, but the cost of these things of digital technologies, of insurance companies or health care systems. Picking it up has to be important as we move forward. You can see on the right for physicians rating, the ability to communicate, accessing, monitoring data and overall level sa satisfaction physicians themselves were satisfied as well. This was a novel care pathway and that Cameron Lambert, one of our co fellows um and me working with Caldo Tarai used where we looked at patients postablation. So what we did was instead of postablation, patients calling your office and saying, I think I'm back in a fib and you ordering an EKG, the new smartphone thing was we gave him a cardia mobile home three months after the ablation and said, you know, if you think you're in a fib, just send us a recording and go forward. So 50 patients in each home were randomized and you, you can see here freedom from a fib recurrence was the same which it's not, it doesn't affect the ablation e effectiveness. But from the right, what you can see is the number of additional EKG S or cardiac rhythm monitors was significantly higher in the control group. So 13 verse three with a P value of point oh four, meaning it was able to reduce costs and it saved time. So you ordering the EKG you ordering extended rhythm monitoring with a patch or a halter monitor is way more time consuming and way more costlier than the patient just having your cardio mobile at home and they can record them whenever. So it decreased the need for extended monitoring. Um So I think it, it was a novel pathway in that postablation. A lot of patients feel they're back in a fib, they may have anxiety, they may be anxious that their PAC S or something and we have to order stuff. But if they already have smartphone capable cardio mobile, they're able to send us a recording and we're able to help them with their anxiety. So the last two studies, I wanna show you about outside of E P and how care pathways can evolve in digital health. So this was a study done at the Brigham by one of my cores on Ke Bo which looked at virtual optimization of guideline, directed medical therapy and ho hospitals. I patients with heart failure with reduced ejection fraction, the implement H F pilot study. So the the bigger results from this study will come out at AC C 2023 in New Orleans as a light breaker. But the premise of this study was you have 118 patients 29 get usual care, which is you have a cardiologist who sees them. You have people rounding on the patient, you have a medicine team managing their patient. They're trying to put them on guideline directed medical therapy. So these are patients with newly reduced low ejection fraction. They put them on guideline directed medical therapy. That's usual care what we do in the hospital. Basically a patient, they call a consult. You try to add a beta blocker, you try to add an ace inhibitor. The intervention group was 89 patients where a virtual pharmacist and cardiologist review charts. So they never saw or examined the patient ever in the usual intervention arm, but they could review the chart. Look at labs, look at blood pressure, look at hemodynamics and say, you know what, I'm gonna change your beta blocker dosing. I'm gonna write a note in Epic that says you should go from 12.5 of carve to 25 of Carol. You should add um you should add cubital valsartan, you should add um S G L T two. And so what you can see at the end of the study. So this is usual care, admission discharge, 30 days, post discharge, not much difference at the top in the control groups, all the bars, basically this stay the same. But you can see it on guideline directed the intervention group, everything went up. So beta blocker use went up from 72% to almost 100%. The army rates went up, the M R A spiral lacto rates went up, the S G L T two rates went up. The triple therapy of being on guideline directed medical therapy went up and the quad therapy uh arm went up compared to usual care which was zero started with I think seven patients at the end. So it increased guideline, directed medical therapy optimization score, all all therapies increased and more patients were on target doses. And you can know from national data, looking at uh studies from the U C L A group or the Duke um group that being on more heart failure, medications increases left ventricular ejection fraction and in and improves mortality. So designing a novel care pathway where you use virtual care instead of going rounding um to the river building or the Kaufman building and seeing the patient examining them, it's much more effective um to put these patients on and patients will live longer because of that. And I expect the late breaker to show this to be even um to be even true in a much bigger population. This was a study also done. Um one of my cores who's at the Brigham um AJ blood, which is he deliver remote care um hypertension and lipid program in more than 10,000 patients across a diverse health network. So they use the Mass General and Brigham study and they said if we deliver just remote care, can we make care more equitable? So, one of the things we struggle with, especially on the peninsula is care is not equitable um across the network of hospital systems in centro or in any nationwide study. So affluent patients have better care um across the country. Uh patients who are minorities get worse care. And so if you make stuff digital, can you improve care and can you make it equitable where it doesn't depend on income? It doesn't depend on race, it doesn't depend on gender. And so they studied 10,000 patients where they manage their blood pressure and hypertension without ever seeing the patient. So they would get recordings digitally and they would make adjustments on medications. And so the objective was can a remote only blood pressure program help ensure equal access to care, blood pressure management. With meds, they had a reduction in 10, 10 points across the board lipids. They had a reduction in 35 in LDL. And the the important conclusion was they had similar rates of enrollment and reductions in B P and lipids across different racial ethnic and primary language groups. So digital health was able to remove barriers to care across the platform. So the questions remaining for designing virtual care is will patients prefer virtual visits even after pandemic is in rear view? Does digital health increase health utilization? I think we as providers worry that you know, if we give patients more access to cardias or digital digital tools, they'll increase it more and they'll be calling your office more or in or increasing hospitalization or er visits and how to have health systems a adopt novel care pathways without increasing costs. I think this is one for the administrator, administrators of how to prevent patients from being in the hospital. Uh but do uh delivering care that's safe and equitable. And so the conclusions are digital health is rapidly evolving and cardiology is in the forefront. I think us as a field have a lot to be proud of. One is we study everything to randomized trial uh whether it's fitbits or watches or anything um compared to other fields. Uh The second point is consumer, digital health must be tested via research and clinical trials. If a patient comes to you and the tool is not really studied, you can't as a provider make recommendations on whether you should use it or not. And then I think the last point, it is an important one is care deliveries changing from in office visit to virtual digital care in order to increase access to care and increase equity across groups of patients. So as patients may live far away, this is an issue on the eastern shore or the outer banks where they may not have access to our care, we can still provide I think excellent care virtually or digitally reviewing their chart. Um And doing a virtual visit.
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