A remote monitoring program for patients with COVID-19 worked, but was less successful for Black patients, according to the results of a recent study.1
“The structure of the program was to let people infected with COVID, who didn’t need to be hospitalized and had mild enough illness to stay home, to be continually checked to make sure they were continuing to improve,” says Thomas M. Maddox, MD, MSc, study co-author and professor of medicine at Washington University School of Medicine (WUSM) and vice president of digital products and innovation at BJC HealthCare in St. Louis.
Remote Evaluations
Nurses and medical assistants reviewed patients’ data daily. If a patient’s condition was worsening, medical assistants would call the patient and evaluate whether he or she should go to the hospital.
“We could manage it with 15 medical assistants and three nurses,” Maddox says. “The medical assistant would go through the questionnaire and record the answers.”
If patients said they were struggling more than before, the medical assistants would send their case to a nurse.
The remote monitoring program lasted 14 days. It followed more than 7,500 patients from April 2020 to early December 2020. Patients downloaded a medical record app that sent them a daily symptom questionnaire about their breathing, fatigue, and other COVID-19 symptoms. The program gave patients thermometers and pulse oximeters. Patients without smartphones or a data plan could enroll in the phone program. They would still receive the thermometer and oximeter but would be called daily by a medical assistant.
“They’d verbally ask [the patients] the same questions as the app questionnaire,” Maddox explains. “If [the patients] looked like they were doing fine, [the medical assistant] would call back the next day.”
Sixty-two percent of patients enrolled in both the phone arm and the app questionnaire arm completed the 14-day monitoring period and stayed engaged.
“In the phone arm, there was a higher retention of 70%, while the app’s retention was 54%,” Maddox says. “Roughly half the people chose the app, and half chose the telephone.”
Retention Differed by Race
Maddox and colleagues found retention in the app arm differed by race. Retention was lower for Black enrollees than white enrollees — 49% and 55%, respectively. But retention with the phone call arm was similar: 69% for Black enrollees and 71% for white enrollees. Overall, 14% of enrollees required ED intervention, and 7% needed a hospital admission within 30 days.
Although the program was studied in a population with COVID-19 infection, it could work similarly for patients with chronic illnesses, such as diabetes, congestive heart failure, and COPD.
“Before the pandemic, we were monitoring patients with heart failure, diabetes, COPD, and hypertension,” Maddox says. “We provided them with technology at home to measure their sugar levels, oxygen levels, and whatever they needed.”
The data were sent to care teams that could triage patients who needed more help. “All of those kinds of programs are much more acceptable and more standard now, post-pandemic,” Maddox says. “We’re so much more used to remote now.”
The pandemic accelerated the use of remote monitoring. It also gave case management teams experience and practice in remote monitoring processes. They could adapt as they learned what worked and what did not.
“It’s thinking about our care teams and their work process,” Maddox says. “They need time set aside. They need medical assistants and panels to look at the data and reach out to patients.”
The Human Connection
Organizations need to develop the work processes and put the right people in place to work with patients and monitor them remotely. They also need to develop multiple modalities to consider patients with different technological skills and access.
“Many people didn’t have money for a smartphone or data plan, and there were plenty of people who just preferred to talk with someone,” Maddox explains. “They were isolated and worried about the pandemic, and even if they could handle an app, they preferred a voice — a human connection.”
It is important to embed human connection in any remote monitoring program. Some patients are scared and may need someone to talk to because it is difficult to communicate purely with technology.
“That’s what we learned,” Maddox says. “Out of necessity, we needed to build up our technology platforms, but we also needed multiple ways for people to engage.”
Technology helped facilitate remote monitoring, but it does not replace the human element of healthcare, he adds.
The study results highlighted the importance of the phone call arm of the program, particularly for some populations. “We found that people who were Black or people living in poorer neighborhoods tended to opt for the phone program, and it’s likely that if we didn’t have a phone arm, a number of people wouldn’t have participated,” Maddox says. “We wanted to understand both groups of race and income, and the main thing we found was that retention in the program was higher for Black patients in the phone arm. Those who participated in the phone arm and are Black tended to complete the program.”
That community also was more engaged with the phone program, he adds.
Maddox and colleagues also compared the rates of ED evaluations and hospitalizations between COVID-19 patients and matched controls who did not have COVID-19. They found patients with COVID-19 visited the ED more frequently.
“It suggested that the COVID patients had a higher risk for needing more acute care because of the disease,” Maddox explains.
Through the monitoring program, someone was in contact with the COVID-19 patients daily and had more opportunity to intervene, which also could have led to more ED visits.
“Someone at home [without monitoring] may start feeling worse, but says, ‘I don’t want to go into the ED,’ and so they may be less likely to present to the ED or to be hospitalized,” Maddox says.
REFERENCE
- Fritz BA, Ramsey B, Taylor D, et al. Association of race and neighborhood disadvantage with patient engagement in a home-based COVID-19 remote monitoring program. J Gen Intern Med 2022;37:838-846.
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