key: cord-0074557-2p1jazfx
authors: Eimer, Micah J.
title: Patient Care Extra-Aedificium: The Time is Now
date: 2022-02-05
journal: Jt Comm J Qual Patient Saf
DOI: 10.1016/j.jcjq.2022.02.002
sha: b24411df10c0f0f79ab630ee0ff5f4434fb033ad
doc_id: 74557
cord_uid: 2p1jazfx

nan

There is little doubt that COVID-19 will result in lasting changes in health care delivery. Early in the pandemic, the Department of Health and Human Services relaxed in-person requirements for many services and also declared that federal healthcare programs would reimburse providers for out of office visits. 1 The realities of the pandemic "fast-tracked" certain aspects of patient care outside the building (extra-aedificium), and the uptake by patients and practitioners has been enthusiastic.

As providers, we have been forced to innovate, think on the fly, and try things that have not been done before. Many of these changes were not new ideas, but old ideas that lacked the buy-in from stakeholders to implement. Some of that buy-in related to reimbursement and some to a change in the philosophy of practitioners-for example, during my medical training it was sacrilegious to suggest that patient care could be delivered without a face-to-face interaction.

Add the general reluctance of patients to come to the office during the pandemic, at various times mandated by local governments, and combine this with a serious shortage of health care workers. Something had to change. The ongoing health care needs of the community certainly do not pause during a pandemic and are instead added to the health care challenges of the pandemic itself.

In considering aspects of patient care that could be conducted extra-aedificium, patient education seems an area ripe for exploration. In this issue of The Joint Commission Journal on Quality and Patient Safety, Price and Ansell study the feasibility of conducting virtual education of patient self-testing (PST) for monitoring warfarin therapy at home. 2 The authors examined data from 33,683 patients enrolled in the Allere home monitoring system. The patients were aged approximately 70 years, and the majority were prescribed warfarin for atrial fibrillation or prosthetic heart valves.

The investigators conducted a retrospective analysis of pre-pandemic patients who had their PST education in person (13,568 patients) vs. post-pandemic patients (20,115 patients) who had the education completed virtually (via video conferencing). The statistic most commonly used to measure quality in a warfarin clinic is time in therapeutic range (TTR), which was compared among the in-person and virtual groups. Patients in the virtual education group had a small but statistically significant higher rate of TTR (66.78% vs. 64.19%, p < 0.01) compared to patients in the in-person group. A secondary outcome, the percentage of readings in a critical range (defined as internal normalized ratio (INR) < 1.5 or > 5) was statistically lower in the virtual group compared to the in-person patients (5.03% vs. 4.08%, p < 0.001).

The authors do acknowledge that there may be some unmeasurable but important differences between the two groups. It would be legitimate to ask if patients who were offered and accepted virtual training were more health literate in general and likely to do better with warfarin management regardless of the PST approach. One might also wonder whether the patients who switched to PST post-pandemic had more stable TTRs prior to joining the PST program. Moreover, the patients in the virtual group did slightly more frequent INR testing compared to the in-person group, which would be expected to improve TTR (11.82 vs. 12.27 p < 0.01). A limitation of the study is that the authors do not provide any information on the quality of the training in either group or the duration of training, stating only that it was at least 60 minutes.

Regardless, this study suggests that virtual training in self-testing for warfarin is at least as effective as in-person training. The success of this program likely stems from the fact that a very clear set of objectives had to be met to consider the patient safe for home testing. While not explicitly discussed in this study, appropriate patient selection is also paramount to establish reliability and medical stability prior to being considered for at-home testing.

The Centers for Medicare and Medicaid 2021 Physician Fee Schedule contains reimbursable codes for Remote Patient Monitoring (RPM) which will further encourage health care practitioners to provide certain aspects of medical care outside of the office-for example, patient recording and review of blood pressure, blood sugars, spirometry, weights, oxygen saturations, and so on. The ability to transition certain patient care tasks extra-aedificium is a clear win for patients and the over-burdened health care system. I look forward to the innovation that will result from this shift in practice and hope to see more studies such as the one by Price and Ansell to verify that quality is not compromised in the pursuit of convenience.

Micah J. Eimer, MD, is Cardiologist and Medical Director, Northwestern Medicine, Glenview, Illinois. Please address correspondence to Micah J. Eimer, meimer@nm.org.

Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency (CMS-1744-IFC)

Virtual education for patient self-testing for warfarin therapy is effective during the COVID-19 pandemic