key: cord-0937318-vzqv7znj
authors: Gruwez, Henri; Bakelants, Emma; Dreesen, Pauline; Broekmans, Jolien; Criel, Maarten; Thomeer, Michiel; Vandervoort, Pieter; Ruttens, David
title: Remote patient monitoring in COVID-19: a critical appraisal
date: 2022-02-03
journal: Eur Respir J
DOI: 10.1183/13993003.02697-2021
sha: b4510018fc2b9d0b48f6811d7f22bc9b2f260c34
doc_id: 937318
cord_uid: vzqv7znj

Is there any evidence for #telemonitoring in #COVID19? Read more: https://bit.ly/3p1YXBi

At the beginning of the COVID-19 pandemic in Belgium in April 2020, we implemented an RPM programme to facilitate early discharge of patients admitted to the pulmonology ward with a COVID-19 infection, with or without previous intensive care unit (ICU) stay. Invitation to the RPM programme was left to the discretion of the clinician. The invited patient population consisted of patients ready for discharge requiring prolonged oxygen therapy or suffering anxiety to return home. The RPM programme allowed monitoring patients' vital parameters at home, registering symptoms with a standardised questionnaire, and allowing interaction with the monitoring team through a "free text box" or telephone. Patients or family were instructed to measure their heart rate, blood pressure, respiratory rate, blood oxygen saturation and body temperature three times daily using an automated blood pressure monitor, a portable fingertip saturation probe and a thermometer. The patient registered their parameters on a secure hospital server which they could access with a personal login and password. At each registration, patients were asked to grade their dyspnoea on a Borg scale (0 "no dyspnoea", to 10 "maximal dyspnoea"), to report whether they had fever during the last 24 h, and to comment on their general condition (better, unchanged, worse). Patients could also pose questions to the telemonitoring team in a free text box at any moment. The RPM data were read and interpreted by specialised telemonitoring nurses who contacted the patient by phone if a deterioration of vital signs or symptoms was noted or if the patient wrote remarks or questions in the free text box. Whenever deemed necessary, the nurse consulted with the pulmonologist. Prior experience of our hospital RPM team was mainly in the field of cardiology and gynaecology [10, 11] . Patients were allowed to self-manage the duration of their RPM. They were asked to return the pulse oximeter when they felt better and re-engaged in their daily activities. Patients who stopped recording measurements for 2 days were asked to return the equipment or to continue recording.

We included all COVID-19 patients discharged with RPM from the hospital Ziekenhuis Oost-Limburg, Genk, Belgium, during the first wave between 8 April and 9 May, 2020 (30 days). Statistical analysis of this data was performed using the statistical program SPSS version 27.0 (Chicago, IL, USA). As appropriate, comparisons were made using one-way analysis of variance, the Kruskall-Wallis H-test or the Pearson's chi-squared test. Statistical significance was always set at a two-tailed probability level of <0.05. The study complied with the Declaration of Helsinki and was approved by the ethical review board of Ziekenhuis Oost-Limburg (Genk, Belgium).

During this period, 181 patients hospitalised for a COVID-19 infection were discharged home. 47 patients were discharged with RPM, and 134 patients were discharged without RPM. The mean±SD age was 56±13 years in the RPM group compared to 73±14 years in all other patients ( p<0.001). Thus, patients who received RPM were younger and suffered less chronic lung disease and chronic kidney disease than those without RPM. The baseline characteristics of both groups are shown in table 1. There was no difference in hospital or ICU stay duration, oxygen therapy during hospitalisation, or oxygen therapy at discharge between both groups. The median (interquartile range) length of stay in the RPM group was 9 (4-14) days, 30% were hospitalised in the ICU, and 4% had been intubated. 34% required oxygen therapy at discharge at a mean flow of 1±1 L·min −1 in this group. After discharge, all patients that engaged in the RPM programme performed at least three measurements. The median RPM time (time between discharge and last RPM measurement) was 10 (5-36) days. Compliance was highest during the first days of RPM patients. From day one to day four, 91% of the patients performed at least one daily measurement, and 68% performed all three. After day 5, compliance declined significantly. The longest RPM time was 75 days. A total of 1259 measurements were registered, of which 5% triggered a phone call by a specialised nurse and 2% triggered a phone call by a physician. During the first month after discharge or during the entire RPM time, 4% of patients were readmitted and 9% visited an emergency department in the RPM group, compared to 10% and 15% in the unmonitored group, respectively ( p=0.20 and p=0.27). These results should be interpreted with great caution since this is not a randomised controlled trial. Patients in the RPM were younger and tended to have fewer comorbidities than COVID-19 patients who were not included in the RPM programme. Therefore, the RPM population is a subgroup of the COVID-19 patients. This causes a potential bias when comparing RPM results with unmonitored COVID-19 patients.

In the studies of GRUTTERS et al. [1] and O'CARROLL et al. [8] , the clinical characteristics of the RPM groups were very similar to our RPM group for age and comorbidities, but the characteristics of unmonitored COVID-19 patients were not disclosed in these studies. The inclusion of elderly patients in RPM trials is essential since this high-risk group might benefit the most. In our experience, 19% of the RPM patients were older than 65 years, and the oldest patient was 84 years. Digital literacy is a critical threshold that should be overcome by simplifying the RPM programme and allowing relatives to assist in the RPM tasks. In the study of GRUTTERS et al. [1] , the conclusion that RPM reduces hospital stay of COVID-19 patients by 5 days is premature, since there was no control group to benchmark these results. In our observational study, we did not see a significant difference in hospital length of stay. Also, the trend towards fewer emergency department visits and readmissions in the RPM group was not statistically significant. Again, the same reservations apply; this was not a randomised controlled trial. This project was not designed to evaluate the benefit of RPM but was instead a modality to facilitate the discharge of COVID-19 patients during an acute healthcare crisis.

However, we share the vision of GRUTTERS et al. [1] that RPM has the potential to reduce the hospital length of stay of COVID-19 patients and possibly reduces emergency visits and readmission rates. We believe RPM is an essential tool to cope with the shortage of hospital beds, especially when the health system is challenged. This study demonstrates that RPM can facilitate a safe discharge home after a short or prolonged hospitalisation for COVID-19 and can assist patients in tapering home oxygen therapy. However, the assumed benefits of RPM (shorter hospitalisations, fewer readmissions, and safe tapering of home oxygen therapy) should be confirmed in randomised controlled trials before developing reimbursement strategies for RPM by healthcare payers [12] .

In conclusion, our experience demonstrates that an RPM programme, monitoring vital parameters and symptoms, implemented at a moment of sanitary crisis, facilitated discharge and tapering of home oxygen therapy with few readmissions in COVID-19 patients. In addition, this paper puts the results of other RPM programmes in similar patient cohorts in perspective and stresses the need for randomised controlled trials to evaluate the benefit of RPM.

Henri Gruwez 1,2,3,4 , Emma Bakelants 4,5 , Pauline Dreesen 1 , Jolien Broekmans 4 , Maarten Criel 5 , Michiel Thomeer 1,5 , Pieter Vandervoort 1,2 and David Ruttens 1,5

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