COVID-19 Outbreak in Italy: Report on the First 124 Consecutive Patients Treated at Home

Remote Patient Monitoring at Home in Patients With COVID-19: Narrative Review

BACKGROUND

During the pandemic, health care providers implemented remote patient monitoring (RPM) for patients experiencing COVID-19. RPM is an interaction between health care professionals and patients who are in different locations, in which certain patient functioning parameters are assessed and followed up for a certain duration of time. The implementation of RPM in these patients aimed to reduce the strain on hospitals and primary care.

OBJECTIVE

With this literature review, we aim to describe the characteristics of RPM interventions, report on patients with COVID-19 receiving RPM, and provide an overview of outcome variables such as length of stay (LOS), hospital readmission, and mortality.

METHODS

A combination of different searches in several database types (traditional databases, trial registers, daily [Google] searches, and daily PubMed alerts) was run daily from March 2020 to December 2021. A search update for randomized controlled trials (RCTs) was performed in April 2022.

RESULTS

The initial search yielded more than 4448 articles (not including daily searches). After deduplication and assessment for eligibility, 241 articles were retained describing 164 telemonitoring studies from 160 centers. None of the 164 studies covering 248,431 patients reported on the presence of a randomized control group. Studies described a "prehosp" group (96 studies) with patients who had a suspected or confirmed COVID-19 diagnosis and who were not hospitalized but closely monitored at home or a "posthosp" group (32 studies) with patients who were monitored at home after hospitalization for COVID-19. Moreover, 34 studies described both groups, and in 2 studies, the description was unclear. In the prehosp and posthosp groups, there were large variations in the number of emergency department (ED) visits (0%-36% and 0%-16%, respectively) and no convincing evidence that RPM leads to less or more ED visits or hospital readmissions (0%-30% and 0%-22%, respectively). Mortality was generally low, and there was weak to no evidence that RPM is associated with lower mortality. Moreover, there was no evidence that RPM shortens previous LOS. A literature update identified 3 small-scale RCTs, which could not demonstrate statistically significant differences in these outcomes. Most papers claimed savings; however, the scientific base for these claims was doubtful. The overall patient experiences with RPM were positive, as patients felt more reassured, although many patients declined RPM for several reasons (eg, technological embarrassment, digital literacy).

CONCLUSIONS

Based on these results, there is no convincing evidence that RPM in COVID-19 patients avoids ED visits or hospital readmissions and shortens LOS or reduces mortality. On the other hand, there is no evidence that RPM has adverse outcomes. Further research should focus on developing, implementing, and evaluating an RPM framework.

Managing Patients With COVID-19 in Armenia Using a Remote Monitoring System: Descriptive Study

BACKGROUND

The COVID-19 pandemic has imposed immense stress on global health care systems, especially in low- and middle-income countries (LMICs). Armenia, a middle-income country in the Caucasus region, contended with the pandemic and a concurrent war, resulting in significant demand on its already strained health care infrastructure. The COVID@home program was a multi-institution, international collaboration to address critical hospital bed shortages by implementing a home-based oxygen therapy and remote monitoring program.

OBJECTIVE

The objective of this study was to describe the program protocol and clinical outcomes of implementing an early discharge program in Armenia through a collaboration of partner institutions, which can inform the future implementation of COVID-19 remote home monitoring programs, particularly in LMICs or low-resource settings.

METHODS

Seven hospitals in Yerevan participated in the COVID@home program. A web app based on OpenMRS was developed to facilitate data capture and care coordination. Patients meeting eligibility criteria were enrolled during hospitalization and monitored daily while on oxygen at home. Program evaluation relied on data extraction from (1) eligibility and enrollment forms, (2) daily monitoring forms, and (3) discharge forms.

RESULTS

Over 11 months, 439 patients were screened, and 221 patients were managed and discharged. Around 94% (n=208) of participants safely discontinued oxygen therapy at home, with a median home monitoring duration of 26 (IQR 15-45 days; mean 32.33, SD 25.29) days. Women (median 28.5, mean 35.25 days) had similar length of stay to men (median 26, mean 32.21 days; P=.75). Despite challenges in data collection and entry, the program demonstrated feasibility and safety, with a mortality rate below 1% and low re-admission rate. Opportunities for operational and data quality improvements were identified.

CONCLUSIONS

This study contributes practical evidence on the implementation and outcomes of a remote monitoring program in Armenia, offering insights into managing patients with COVID-19 in resource-constrained settings. The COVID@home program's success provides a model for remote patient care, potentially alleviating strain on health care resources in LMICs. Policymakers can draw from these findings to inform the development of adaptable health care solutions during public health crises, emphasizing the need for innovative approaches in resource-limited environments.

Updated Surveillance Metrics and History of the COVID-19 Pandemic (2020-2023) in Europe: Longitudinal Trend Analysis

BACKGROUND

In this study, we built upon our initial research published in 2020 by incorporating an additional 2 years of data for Europe. We assessed whether COVID-19 had shifted from the pandemic to endemic phase in the region when the World Health Organization (WHO) declared the end of the public health emergency of international concern on May 5, 2023.

OBJECTIVE

We first aimed to measure whether there was an expansion or contraction in the pandemic in Europe at the time of the WHO declaration. Second, we used dynamic and genomic surveillance methods to describe the history of the pandemic in the region and situate the window of the WHO declaration within the broader history. Third, we provided the historical context for the course of the pandemic in Europe in terms of policy and disease burden at the country and region levels.

METHODS

In addition to the updates of traditional surveillance data and dynamic panel estimates from the original study, this study used data on sequenced SARS-CoV-2 variants from the Global Initiative on Sharing All Influenza Data to identify the appearance and duration of variants of concern. We used Nextclade nomenclature to collect clade designations from sequences and Pangolin nomenclature for lineage designations of SARS-CoV-2. Finally, we conducted a 1-tailed t test for whether regional weekly speed was greater than an outbreak threshold of 10. We ran the test iteratively with 6 months of data across the sample period.

RESULTS

Speed for the region had remained below the outbreak threshold for 4 months by the time of the WHO declaration. Acceleration and jerk were also low and stable. While the 1-day and 7-day persistence coefficients remained statistically significant, the coefficients were moderate in magnitude (0.404 and 0.547, respectively; P<.001 for both). The shift parameters for the 2 weeks around the WHO declaration were small and insignificant, suggesting little change in the clustering effect of cases on future cases at the time. From December 2021 onward, Omicron was the predominant variant of concern in sequenced viral samples. The rolling t test of speed equal to 10 became insignificant for the first time in April 2023.

CONCLUSIONS

While COVID-19 continues to circulate in Europe, the rate of transmission remained below the threshold of an outbreak for 4 months ahead of the WHO declaration. The region had previously been in a nearly continuous state of outbreak. The more recent trend suggested that COVID-19 was endemic in the region and no longer reached the threshold of the pandemic definition. However, several countries remained in a state of outbreak, and the conclusion that COVID-19 was no longer a pandemic in Europe at the time is unclear.

Home-based initiatives for acute management of COVID-19 patients needing oxygen: differences across The Netherlands

OBJECTIVE

During the COVID-19 pandemic new collaborative-care initiatives were developed for treating and monitoring COVID-19 patients with oxygen at home. Aim was to provide a structured overview focused on differences and similarities of initiatives of acute home-based management in the Netherlands.

METHODS

Initiatives were eligible for evaluation if (i) COVID-19 patients received oxygen treatment at home; (ii) patients received structured remote monitoring; (iii) it was not an 'early hospital discharge' program; (iv) at least one patient was included. Protocols were screened, and additional information was obtained from involved physicians. Design choices were categorised into: eligible patient group, organization medical care, remote monitoring, nursing care, and devices used.

RESULTS

Nine initiatives were screened for eligibility; five were included. Three initiatives included low-risk patients and two were designed specifically for frail patients. Emergency department (ED) visit for an initial diagnostic work-up and evaluation was mandatory in three initiatives before starting home management. Medical responsibility was either assigned to the general practitioner or hospital specialist, most often pulmonologist or internist. Pulse-oximetry was used in all initiatives, with additional monitoring of heart rate and respiratory rate in three initiatives. Remote monitoring staff's qualification and authority varied, and organization and logistics were covered by persons with various backgrounds. All initiatives offered remote monitoring via an application, two also offered a paper diary option.

CONCLUSIONS

We observed differences in the organization of interprofessional collaboration for acute home management of hypoxemic COVID-19 patients. All initiatives used pulse-oximetry and an app for remote monitoring. Our overview may be of help to healthcare providers and organizations to set up and implement similar acute home management initiatives for critical episodes of COVID-19 (or other acute disorders) that would otherwise require hospital care.

A 98-Year-Old Male With Paroxysmal Atrial Fibrillation Treated for COVID-19 at Home

In the absence of evidenced-based guidelines for early home treatment of COVID-19, some Italian groups of volunteer physicians (both general practitioners (GPs) and hospital doctors) virtually gathered themselves to discuss the best available evidence and develop shared schemes of therapy. We present the case of a 98-year-old unvaccinated male on chronic anticoagulant therapy with dabigatran for paroxysmal atrial fibrillation (AF), who has been successfully treated for COVID-19 at home, according to one of the multidrug treatments proposed, since hospital admission was not feasible. At the very beginning of symptoms, anti-inflammatory drugs, vitamin D, and adjuvant dietary supplements (quercetin, vitamin C, zinc, and vitamin K2) were administered, followed by dexamethasone and antibiotic therapy, according to the evolving clinical conditions. Gastroprotection with omeprazole was added. Eventually, our patient fully recovered, thus suggesting that careful home assistance under strict medical supervision can be successful, even in a very old subject with comorbidities, particularly if early treatment simultaneously addressing inflammation, hypercoagulation, and viral replication is started.