Factors influencing the effectiveness of remote patient monitoring interventions: a realist review

Acceptability and usability of a nurse-assisted remote patient monitoring intervention for the post-hospital follow-up of patients with long-term illness: A qualitative study

Background

Patients living with long-term chronic illnesses often need ongoing medical attention, lifestyle adjustments, and psychosocial support beyond the initial diagnosis and treatment phases. Many experience illness deterioration and subsequently require hospitalisation, especially in the transition period after hospital discharge. A promising strategy for managing long-term conditions is promoting self-management. eHealth interventions involving remote patient monitoring have the potential to promote self-management and offer a more seamless bridge between the hospital and the patient´s home environment. However, such interventions can only significantly impact health and health care if they are effective, accepted and adopted by users, normalised into routine practice and everyday life, and able to be widely implemented. Feasibility studies are used to determine whether an intervention is suitable for the target population and effective in achieving its intended goal. They may also provide critical information about an intervention´s acceptability and usability.

Objectives

We aimed to evaluate the acceptability and usability of a nurse-assisted remote patient monitoring intervention for the post-hospital follow-up of patients with long-term illnesses by use of the core constructs of normalisation process theory.

Design

A descriptive and explanatory qualitative approach was used, with patients observed during training and semi-structured interviews conducted with patients and nurses after study completion.

Settings

Participants were recruited from two university hospitals in Norway between December 2021 and February 2023.

Participants

Ten patients were observed during training, and 27 patients and eight nurses were interviewed after study completion.

Methods

Structured and overt observations were made while the patients received training to operate the remote patient monitoring service, guided by an observation guide. Semi-structured interviews were conducted with patients and nurse navigators about their experiences of remote follow-up care, guided by open ended questions. Data analysis followed a stepwise deductive inductive method.

Results

`Achieving acceptance and usability through digital social interaction´ emerged as a unifying theme that bridged the experiences of patients with long-term illnesses and the nurse navigators. This overarching theme was illustrated by four sub-themes, which all reflected the usability and acceptability of the nurse-assisted remote patient monitoring service in various ways.

Conclusion

Acceptability and usability are critical factors to consider when evaluating remote patient monitoring interventions. In this study, the most important feature for promoting acceptability and usability was the interaction between patients and nurse navigators. Therefore, the intervention´s feasibility and implementation potential rested upon the relationship between its deliverer and receiver.

Patient Characteristics Associated With Disparities in Engagement With and Experience of COVID-19 Remote Home Monitoring Services: A Mixed-Methods Evaluation

INTRODUCTION

The adoption of remote healthcare methods has been accelerated by the COVID-19 pandemic, but evidence suggests that some patients need additional support to engage remotely, potentially increasing health disparities if needs are not met. This study of COVID-19 remote home monitoring services across England explores experiences of and engagement with the service across different patient groups.

METHODS

This was a mixed-methods study with survey and interview data collected from 28 services across England between February and June 2021. Surveys were conducted with staff and patients and carers receiving the service. Interviews with staff service leads, patients and carers were conducted in 17 sites. Quantitative data were analysed using univariate and multivariate methods, and qualitative data were analysed using thematic analysis.

FINDINGS

Survey responses were received from 292 staff and 1069 patients and carers. Twenty-three staff service leads, 59 patients and 3 carers were interviewed. Many service leads reported that they had considered inclusivity when adapting the service for their local population; strategies included widening the eligibility criteria, prioritising vulnerable groups and creating referral pathways. However, disparities were reported across patient groups in their experiences and engagement. Older patients reported the service to be less helpful (p = 0.004), were more likely to report a problem (p < 0.001) and had more difficulty in understanding information (p = 0.005). Health status (p = 0.004), ethnicity (p < 0.001), gender (p < 0.001) and employment (p = 0.007) were associated with differential engagement with monitoring, and minority ethnic groups reported more difficulty understanding service information (p = 0.001). Qualitative data found illness severity to be an important factor in the support required, and patients' living situation and social network affected whether they found the service reassuring.

CONCLUSION

Addressing health disparities must be a key focus in the design and delivery of remote care. Services should be tailored to match the needs of their local population, encourage access through collaboration and referral pathways with other services and monitor their inclusiveness. Involving patients and staff in service design can illuminate the diversity of patients' needs and experiences of care.

PATIENT OR PUBLIC CONTRIBUTION

The study team met with service user and public members of the BRACE PPI group and patient representatives from RSET in a series of workshops. Workshops informed study design, data collection tools, data interpretation and dissemination activities. Study documents (such as consent forms, topic guides, surveys and information sheets) were reviewed by PPI members; patient surveys and interview guides were piloted, and members also commented on the manuscript.

Hospital Staff Perspectives on the Drivers and Challenges in Implementing a Virtual Rehabilitation Ward: Qualitative Study

Background

Over the past decade, the adoption of virtual wards has surged. Virtual wards aim to prevent unnecessary hospital admissions, expedite home discharge, and enhance patient satisfaction, which are particularly beneficial for the older adult population who faces risks associated with hospitalization. Consequently, substantial investments are being made in virtual rehabilitation wards (VRWs), despite evidence of varying levels of success in their implementation. However, the facilitators and barriers experienced by virtual ward staff for the rapid implementation of these innovative care models remain poorly understood.

Objective

This paper presents insights from hospital staff working on an Australian VRW in response to the growing demand for programs aimed at preventing hospital admissions. We explore staff's perspectives on the facilitators and barriers of the VRW, shedding light on service setup and delivery.

Methods

Qualitative interviews were conducted with 21 VRW staff using the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework. The analysis of data was performed using framework analysis and the 7 domains of the NASSS framework.

Results

The results were mapped onto the 7 domains of the NASSS framework. (1) Condition: Managing certain conditions, especially those involving comorbidities and sociocultural factors, can be challenging. (2) Technology: The VRW demonstrated suitability for technologically engaged patients without cognitive impairment, offering advantages in clinical decision-making through remote monitoring and video calls. However, interoperability issues and equipment malfunctions caused staff frustration, highlighting the importance of promptly addressing technical challenges. (3) Value proposition: The VRW empowered patients to choose their care location, extending access to care for rural communities and enabling home-based treatment for older adults. (4) Adopters and (5) organizations: Despite these benefits, the cultural shift from in-person to remote treatment introduced uncertainties in workflows, professional responsibilities, resource allocation, and intake processes. (6) Wider system and (7) embedding: As the service continues to develop to address gaps in hospital capacity, it is imperative to prioritize ongoing adaptation. This includes refining the process of smoothly transferring patients back to the hospital, addressing technical aspects, ensuring seamless continuity of care, and thoughtfully considering how the burden of care may shift to patients and their families.

Conclusions

In this qualitative study exploring health care staff's experience of an innovative VRW, we identified several drivers and challenges to implementation and acceptability. The findings have implications for future services considering implementing VRWs for older adults in terms of service setup and delivery. Future work will focus on assessing patient and carer experiences of the VRW.

Patient Perceptions of Emergency Department Observation Care at Home

Introduction: The Virtual Observation Unit (VOU) utilizes telehealth and community paramedicine to provide observation-level care in patients' homes. Patients' experience of this novel program has not been reported. Methods: A phone-based patient experience survey was administered to the patients who were admitted to the VOU at an urban, academic Emergency Department in the Northeast United States. The survey asked about patient's perception of the program's quality of care (0 = worst care possible, 10 = best care possible). t Tests with a Bonferroni adjustment assessed for differences between patient demographic groups. Results: The survey response rate was 40% (124/307). Overall mean scores for perceived quality of care were very high (9.51 ± 1.19). There were no significant differences in patient's perception of quality of care between demographic cohorts of age, gender, race, or ethnicity. Conclusions: Patient experience with a novel VOU program was very positive and did not differ significantly by demographic cohort. Further research is warranted.

Key features in telehealth-delivered cardiac rehabilitation required to optimize cardiovascular health in coronary heart disease: a systematic review and realist synthesis

Telehealth-delivered cardiac rehabilitation (CR) programmes can potentially increase participation rates while delivering equivalent outcomes to facility-based programmes. However, key components of these interventions that reduce cardiovascular risk factors are not yet distinguished. This study aims to identify features of telehealth-delivered CR that improve secondary prevention outcomes, exercise capacity, participation, and participant satisfaction and develop recommendations for future telehealth-delivered CR. The protocol for our review was registered with the Prospective Register of Systematic Reviews (#CRD42021236471). We systematically searched four databases (PubMed, Scopus, EMBASE, and Cochrane Database) for randomized controlled trials comparing telehealth-delivered CR programmes to facility-based interventions or usual care. Two independent reviewers screened the abstracts and then full texts. Using a qualitative review methodology (realist synthesis), included articles were evaluated to determine contextual factors and potential mechanisms that impacted cardiovascular risk factors, exercise capacity, participation in the intervention, and increased satisfaction. We included 37 reports describing 26 randomized controlled trials published from 2010 to 2022. Studies were primarily conducted in Europe and Australia/Asia. Identified contextual factors and mechanisms were synthesized into four theories required to enhance participant outcomes and participation. These theories are as follows: (i) early and regular engagement; (ii) personalized interventions and shared goals; (iii) usable, accessible, and supported interventions; and (iv) exercise that is measured and monitored. Providing a personalized approach with frequent opportunities for bi-directional interaction was a critical feature for success across telehealth-delivered CR trials. Real-world effectiveness studies are now needed to complement our findings.

Filling the Gaps in the Pandemic Response: Impact of COVID-19 on Telehealth in the Military Health System

Introduction: As a result of the COVID-19 pandemic, telehealth use became widespread, allowing for continued health care while minimizing COVID-19 transmission risk for patients and providers. This rapid scale-up highlighted shortcomings of the current telehealth infrastructure in many health systems. We aimed to identify and address gaps in the United States Military Health System (MHS) response to the COVID-19 pandemic related to the implementation and utilization of telehealth. Methods: We conducted semistructured key informant interviews of MHS stakeholders, including policymakers, program managers, and health care providers. We recruited respondents using purposive and snowball sampling until we reached thematic saturation. Interviews were conducted virtually from December 2022 to March 2023 and coded by deductive thematic analysis using NVivo. Results: We interviewed 28 key informants. Several themes emerged from the interviews and were categorized into four defined areas of obstacles to the effective utilization of telehealth: administrative, technical, organizational, and quality issues. While respondents had positive perceptions of telehealth, issues such as billing, licensure portability, network connectivity and technology, and ability to monitor health outcomes represent major barriers in the current system, preventing the potential for further expansion. Conclusions: While the shift to telehealth during the COVID-19 pandemic demonstrated robust potential within the MHS, it highlighted shortcomings that impair the utility and expansion of telehealth on a level comparable to that of other large health systems. Future focus should be directed toward generating and implementing actionable recommendations that target these identified challenges in the MHS.

Challenges and Facilitators in Implementing Remote Patient Monitoring Programs in Primary Care

BACKGROUND

The COVID-19 pandemic resulted in greater use of remote patient monitoring (RPM). However, the use of RPM has been modest compared to other forms of telehealth.

OBJECTIVE

To identify and describe barriers to the implementation of RPM among primary care physicians (PCPs) that may be constraining its growth.

DESIGN

We conducted 20 semi-structured interviews with PCPs across the USA who adopted RPM. Interview questions focused on implementation facilitators and barriers and RPM's impact on quality. We conducted thematic analysis of semi-structured interviews using both inductive and deductive approaches. The analysis was informed by the NASSS (non-adoption and abandonment and challenges to scale-up, spread, and sustainability) framework.

PARTICIPANTS

PCPs who practiced at least 10 h per week in an outpatient setting, served adults, and monitored blood pressure and/or blood glucose levels with automatic transmission of data with at least 3 patients.

KEY RESULTS

While PCPs generally agreed that RPM improved quality of care for their patients, many identified barriers to adoption and maintenance of RPM programs. Challenges included difficulties handling the influx of data and establishing a manageable workflow, along with digital and health literacy barriers. In addition to these barriers, many PCPs did not believe RPM was profitable.

CONCLUSIONS

To encourage ongoing growth of RPM, it will be necessary to address implementation barriers through changes in payment policy, training and education in digital and health literacy, improvements in staff roles and workflows, and new strategies to ensure equitable access.

Patient and Staff Experience of Remote Patient Monitoring-What to Measure and How: Systematic Review

BACKGROUND

Patient and staff experience is a vital factor to consider in the evaluation of remote patient monitoring (RPM) interventions. However, no comprehensive overview of available RPM patient and staff experience-measuring methods and tools exists.

OBJECTIVE

This review aimed at obtaining a comprehensive set of experience constructs and corresponding measuring instruments used in contemporary RPM research and at proposing an initial set of guidelines for improving methodological standardization in this domain.

METHODS

Full-text papers reporting on instances of patient or staff experience measuring in RPM interventions, written in English, and published after January 1, 2011, were considered for eligibility. By "RPM interventions," we referred to interventions including sensor-based patient monitoring used for clinical decision-making; papers reporting on other kinds of interventions were therefore excluded. Papers describing primary care interventions, involving participants under 18 years of age, or focusing on attitudes or technologies rather than specific interventions were also excluded. We searched 2 electronic databases, Medline (PubMed) and EMBASE, on February 12, 2021.We explored and structured the obtained corpus of data through correspondence analysis, a multivariate statistical technique.

RESULTS

In total, 158 papers were included, covering RPM interventions in a variety of domains. From these studies, we reported 546 experience-measuring instances in RPM, covering the use of 160 unique experience-measuring instruments to measure 120 unique experience constructs. We found that the research landscape has seen a sizeable growth in the past decade, that it is affected by a relative lack of focus on the experience of staff, and that the overall corpus of collected experience measures can be organized in 4 main categories (service system related, care related, usage and adherence related, and health outcome related). In the light of the collected findings, we provided a set of 6 actionable recommendations to RPM patient and staff experience evaluators, in terms of both what to measure and how to measure it. Overall, we suggested that RPM researchers and practitioners include experience measuring as part of integrated, interdisciplinary data strategies for continuous RPM evaluation.

CONCLUSIONS

At present, there is a lack of consensus and standardization in the methods used to measure patient and staff experience in RPM, leading to a critical knowledge gap in our understanding of the impact of RPM interventions. This review offers targeted support for RPM experience evaluators by providing a structured, comprehensive overview of contemporary patient and staff experience measures and a set of practical guidelines for improving research quality and standardization in this domain.

A Delphi Study on Identifying Competencies in Virtual Healthcare for Healthcare Professionals

BACKGROUND

Virtual care adoption accelerated during the COVID-19 pandemic, highlighting the need for healthcare professionals to develop relevant competencies. However, limited evidence exists on the core competencies required for quality virtual care delivery.

OBJECTIVE

This study aimed to identify the critical competencies physicians, nurses, and other health professionals need for adequate virtual care provision in Saudi Arabia using a Delphi method.

METHODS

A 3-round Delphi technique was applied with a panel of 42 experts, including policymakers, healthcare professionals, academicians, and telehealth specialists. In Round 1, an open-ended questionnaire elicited competencies needed for virtual care. The competencies were distilled and rated for importance in Rounds 2 and 3 until consensus was achieved.

RESULTS

Consensus emerged on 151 competencies across 33 domains. The most prominent domains were communication (15 competencies), professionalism (13), leadership (12), health informatics (5), digital literacy (5), and clinical expertise (11).

Experiences with telemedicine-based follow-up of chronic conditions: the views of patients and health personnel enrolled in a pragmatic randomized controlled trial

BACKGROUND

Telemedicine is often promoted as a possible solution to some of the challenges healthcare systems in many countries face, and an increasing number of studies evaluate the clinical effects. So far, the studies show varying results. Less attention has been paid to systemic factors, such as the context, implementation, and mechanisms of these interventions.

METHODS

This study evaluates the experiences of patients and health personnel enrolled in a pragmatic randomized controlled trial comparing telemedicine-based follow-up of chronic conditions with usual care. Patients in the intervention group received an individual treatment plan together with computer tablets and home telemonitoring devices to report point-of-care measurements, e.g., blood pressure, blood glucose or oxygen saturation, and to respond to health related questions reported to a follow-up service. In response to abnormal measurement results, a follow-up service nurse would contact the patient and consider relevant actions. We conducted 49 interviews with patients and 77 interviews with health personnel and managers at the local centers. The interview data were analyzed using thematic analysis and based on recommendations for conducting process evaluation, considering three core aspects within the process of delivering a complex intervention: (1) context, (2) implementation, and (3) mechanisms of impact.

RESULTS

Patients were mainly satisfied with the telemedicine-based service, and experienced increased safety and understanding of their symptoms and illness. Implementation of the service does, however, require dedicated resources over time. Slow adjustment of other healthcare providers may have contributed to the absence of reductions in the use of specialized healthcare and general practitioner (GP) services. An evident advantage of the service is its flexibility, yet this may also challenge cost-efficiency of the intervention.

CONCLUSIONS

The implementation of a telemedicine-based service in primary healthcare is a complex process that is sensitive to contextual factors and that requires time and dedicated resources to ensure successful implementation.

TRIAL REGISTRATION

The trial was registered in www.

CLINICALTRIALS

gov (NCT04142710). Study start: 2019-02-09, Study completion: 2021-06-30, Study type: Interventional, Intervention/treatment: Telemedicine tablet and tools to perform measurements. Informed and documented consent was obtained from all subjects and next of kin participating in the study.

Telenursing and Remote Patient Monitoring in Cardiovascular Health

Background: Since the decline in death rates from cardiovascular diseases has slowed down recently, promoting cardiovascular health in patients and the general public has become more important than ever, particularly for elder and rural patients. This study is a collaborative effort between a regional health network in Virginia and associated organizations to implement and assess telenursing and remote patient monitoring (RPM) to help home care patients better manage their own cardiovascular related diseases and promote sustainable health delivery options. Method: Eighty cardiovascular patients with diabetes, congestive heart failure, or both who had a recent disease-related hospital stay were enrolled in the RPM program to receive services, including care coordination, coaching, referral for behavioral health, and aging-related services for 90+ days. The program used telenursing and RPM through home care monitoring equipment to coach patients on effective measures to stay compliant with posthospitalization regimens, track and evaluate readmissions, and assess physiological status and mental health. Result: There was a decline in hospital admissions of 65%, 85% for observations and related inpatient services for enrolled CVD patients in the RPM program. In addition, the longer the patient was enrolled the less likely they were to readmit. The program saved ∼$615,127 in patient claims costs and had net savings of $390,296, ∼173% of the total program expenses. Discussion: Evidence showed that 90+ day enrollments are sufficient for realization of readmissions and Emergency Department reductions, increased health care access, and lower costs. This resulted from consistent monitoring using the technology to alert nurses and care coordinators who were able to respond and facilitate patients accessing care in the most helpful and generally less costly care environment. Conclusion: The study has confirmed that care coordination and RPM are effective in supporting self-management of chronic conditions and cost reductions through telenursing and RPM.

Pragmatic randomized controlled trial comparing a complex telemedicine-based intervention with usual care in patients with chronic conditions

This study evaluates a complex telemedicine-based intervention targeting patients with chronic health problems. Computer tablets and home telemonitoring devices are used by patients to report point-of-care measurements, e.g., blood pressure, blood glucose or oxygen saturation, and to answer health-related questions at a follow-up center. We designed a pragmatic randomized controlled trial to compare the telemedicine-based intervention with usual care in six local centers in Norway. The study outcomes included health-related quality of life (HRQoL) based on the EuroQol questionnaire (EQ-5D-5L), patient experiences, and utilization of healthcare. We also conducted a cost-benefit analysis to inform policy implementation, as well as a process evaluation (reported elsewhere). We used mixed methods to analyze data collected during the trial (health data, survey data and interviews with patients and health personnel) as well as data from national health registers. 735 patients were included during the period from February 2019 to June 2020. One year after inclusion, the effects on the use of healthcare services were mixed. The proportion of patients receiving home-based care services declined, but the number of GP contacts increased in the intervention group compared to the control group. Participants in the intervention group experienced improved HRQoL compared to the control group and were more satisfied with the follow-up of their health. The cost-benefit of the intervention depends largely on the design of the service and the value society places on improved safety and self-efficacy.

INNOVATIONS IN DIGITAL HEALTH TO IMPROVE CARE DELIVERY: THE BJC HEALTHCARE/WASHINGTON UNIVERSITY SCHOOL OF MEDICINE HEALTHCARE INNOVATION LAB

The Healthcare Innovation Lab, established by BJC HealthCare and Washington University School of Medicine, has catalyzed care delivery innovations since 2017. Focusing on digital health to enhance care delivery and patient outcomes, the Lab emphasizes predictive analytics, digital point-of-care tools, and remote patient monitoring. The Lab identifies innovative ideas that align with the health system mission and deliver empiric value to its patients and care teams. Since its inception, the Lab has vetted 507 ideas, piloting 98, with a success rate of 40%. Examples include a predictive model to improve palliative care referrals and goal-of-care discussions, a digital approach to non-emergent medical transportation that enhances access and equity, and a COVID-19 home monitoring program that proved essential during the pandemic. These initiatives underscore the importance of integrating digital technology with health care, balancing innovation with practical application, and using a data-informed approach to innovation selection and assessment.

Patients' and GPs' views and expectations of home monitoring with a pulse oximeter: a mixed-methods process evaluation of a pilot randomised controlled trial

BACKGROUND

Research on how home monitoring with a pulse oximeter is executed and experienced by patients with an acute illness such as COVID-19 and their GPs is scarce.

AIM

To examine the process of structured home monitoring with a pulse oximeter for patients with COVID-19, their caregivers, and their GPs.

DESIGN AND SETTING

This was a mixed-method process evaluation alongside a pilot feasibility randomised controlled trial. Patients drawn from a general practice setting, with COVID-19, and aged ≥40 years with cardiovascular comorbidities were included.

METHOD

Quantitative trial data from 21 intervention group participants (age 63.2 years) were used, plus qualitative data from semi-structured interviews with 15 patients (age 62.9 years), eight informal caregivers, and 10 GPs.

RESULTS

Adherence to the intervention was very high; 97.6% of protocolised peripheral oxygen saturation (SpO2) measurements in the first 14 days until admission to hospital were recorded (677/694, median daily per patient 2.7). Three identified themes from the interviews were: (a) user-friendliness of home monitoring: easy use of the pulse oximeter and patient preference of a three times daily measurement scheme; (b) patient empowerment: pulse oximeter use enhanced patient self-assurance and empowered patients and informal caregivers in disease management; and (c) added value to current clinical decision making. GPs perceived the pulse oximeter as a useful diagnostic tool and did not experience any additional workload. They felt more secure with remote monitoring with a pulse oximeter than only phone-based monitoring, but emphasised the need to keep an overall view on the patient's condition.

CONCLUSION

Structured home monitoring by pulse oximetry supports patients and their informal caregivers in managing, and GPs in monitoring, acute COVID-19 disease. It appears suitable for use in acutely ill patients in general practice.

Cost-effectiveness of remote patient monitoring for First Nations peoples living with diabetes in regional Australia

The aim of this study was to determine the cost-effectiveness of remote patient monitoring (RPM) with First Nations peoples living with diabetes. This study was set at the Goondir Health Service (GHS), an Aboriginal and Torres Strait Islander Community-Controlled Health in South-West Queensland. Electronic medical records and RPM data were provided by the GHS. Clinical effectiveness was determined by comparing mean HbA1c before and after enrolment in the RPM service. Our analysis found no statistically significant effect between the mean HbA1c before and after enrolment, so this analysis focused on net-benefit and return on investment for costs from the perspective of the GHS. The 6-month RPM service for 84 clients cost AUD $67,841 to cover RPM equipment, ongoing technology costs, and a dedicated Virtual Care Manager, equating to $808 per client. There were 199 additional client-clinician interactions in the period after enrolment resulting in an additional $4797 revenue for the GHS. Therefore, the program cost the GHS $63,044 to deliver, representing a return on investment of around 7 cents for every dollar they spent. Whilst the diabetes RPM service was equally effective as usual care and resulted in increased interactions with clients, the cost for the service was substantially more than the additional revenue generated from increased interactions. This evidence highlights the need for alternative funding models for RPM services and demonstrates the need to focus future research on long-term clinical effects and the extra-clinical benefits resulting from services of this type.

Patient and staff experiences of using technology-enabled and analogue models of remote home monitoring for COVID-19 in England: A mixed-method evaluation

OBJECTIVE

To evaluate patient and staff experiences of using technology-enabled ('tech-enabled') and analogue remote home monitoring models for COVID-19, implemented in England during the pandemic.

METHODS

Twenty-eight sites were selected for diversity in a range of criteria (e.g. pre-hospital or early discharge service, mode of patient data submission). Between February and May 2021, we conducted quantitative surveys with patients, carers and staff delivering the service, and interviewed patients, carers, and staff from 17 of the 28 services. Quantitative data were analysed using descriptive statistics and both univariate and multivariate analyses. Qualitative data were interpreted using thematic analysis.

RESULTS

Twenty-one sites adopted mixed models whereby patients could submit their symptoms using either tech-enabled (app, weblink, or automated phone calls) or analogue (phone calls with a health professional) options; seven sites offered analogue-only data submission (phone calls or face-to-face visits with a health professional). Sixty-two patients and carers were interviewed, and 1069 survey responses were received (18 % response rate). Fifty-eight staff were interviewed, and 292 survey responses were received (39 % response rate). Patients who used tech-enabled modes tended to be younger (p = 0.005), have a higher level of education (p = 0.011), and more likely to identify as White British (p = 0.043). Most patients found relaying symptoms easy, regardless of modality, though many received assistance from family or friends. Staff considered the adoption of mixed delivery models beneficial, enabling them to manage large patient numbers and contact patients for further assessment as needed; however, they suggested improvements to the functionality of systems to better fit clinical and operational needs. Human contact was important in all remote home monitoring options.

CONCLUSIONS

Organisations implementing tech-enabled remote home monitoring at scale should consider adopting mixed models which can accommodate patients with different needs; focus on the usability and interoperability of tech-enabled platforms; and encourage digital inclusivity for patients.

Remote monitoring for long-term physical health conditions: an evidence and gap map

Background

Remote monitoring involves the measurement of an aspect of a patient's health without that person being seen face to face. It could benefit the individual and aid the efficient provision of health services. However, remote monitoring can be used to monitor different aspects of health in different ways. This evidence map allows users to find evidence on different forms of remote monitoring for different conditions easily to support the commissioning and implementation of interventions.

Objectives

The aim of this map was to provide an overview of the volume, diversity and nature of recent systematic reviews on the effectiveness, acceptability and implementation of remote monitoring for adults with long-term physical health conditions.

Data sources

We searched MEDLINE, nine further databases and Epistemonikos for systematic reviews published between 2018 and March 2022, PROSPERO for continuing reviews, and completed citation chasing on included studies.

Review methods

(Study selection and Study appraisal): Included systematic reviews focused on adult populations with a long-term physical health condition and reported on the effectiveness, acceptability or implementation of remote monitoring. All forms of remote monitoring where data were passed to a healthcare professional as part of the intervention were included. Data were extracted on the characteristics of the remote monitoring intervention and outcomes assessed in the review. AMSTAR 2 was used to assess quality. Results were presented in an interactive evidence and gap map and summarised narratively. Stakeholder and public and patient involvement groups provided feedback throughout the project.

Results

We included 72 systematic reviews. Of these, 61 focus on the effectiveness of remote monitoring and 24 on its acceptability and/or implementation, with some reviews reporting on both. The majority contained studies from North America and Europe (38 included studies from the United Kingdom). Patients with cardiovascular disease, diabetes and respiratory conditions were the most studied populations. Data were collected predominantly using common devices such as blood pressure monitors and transmitted via applications, websites, e-mail or patient portals, feedback provided via telephone call and by nurses. In terms of outcomes, most reviews focused on physical health, mental health and well-being, health service use, acceptability or implementation. Few reviews reported on less common conditions or on the views of carers or healthcare professionals. Most reviews were of low or critically low quality.

Limitations

Many terms are used to describe remote monitoring; we searched as widely as possible but may have missed some relevant reviews. Poor reporting of remote monitoring interventions may mean some included reviews contain interventions that do not meet our definition, while relevant reviews might have been excluded. This also made the interpretation of results difficult.

Conclusions and future work

The map provides an interactive, visual representation of evidence on the effectiveness of remote monitoring and its acceptability and successful implementation. This evidence could support the commissioning and delivery of remote monitoring interventions, while the limitations and gaps could inform further research and technological development. Future reviews should follow the guidelines for conducting and reporting systematic reviews and investigate the application of remote monitoring in less common conditions.

Review registration

A protocol was registered on the OSF registry (https://doi.org/10.17605/OSF.IO/6Q7P4).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Services and Delivery Research programme (NIHR award ref: NIHR135450) as part of a series of evidence syntheses under award NIHR130538. For more information, visit https://fundingawards.nihr.ac.uk/award/NIHR135450 and https://fundingawards.nihr.ac.uk/award/NIHR130538. The report is published in full in Health and Social Care Delivery Research; Vol. 11, No. 22. See the NIHR Funding and Awards website for further project information.

Effects of Remote Patient Monitoring Use on Care Outcomes Among Medicare Patients With Hypertension : An Observational Study

BACKGROUND

Remote patient monitoring (RPM) is a promising tool for improving chronic disease management. Use of RPM for hypertension monitoring is growing rapidly, raising concerns about increased spending. However, the effects of RPM are still unclear.

OBJECTIVE

To estimate RPM's effect on hypertension care and spending.

DESIGN

Matched observational study emulating a longitudinal, cluster randomized trial. After matching, effect estimates were derived from a regression analysis comparing changes in outcomes from 2019 to 2021 for patients with hypertension at high-RPM practices versus those at matched control practices with little RPM use.

SETTING

Traditional Medicare.

PATIENTS

Patients with hypertension.

INTERVENTION

Receipt of care at a high-RPM practice.

MEASUREMENTS

Primary outcomes included hypertension medication use (medication fills, adherence, and unique medications received), outpatient visit use, testing and imaging use, hypertension-related acute care use, and total hypertension-related spending.

RESULTS

192 high-RPM practices (with 19 978 patients with hypertension) were matched to 942 low-RPM control practices (with 95 029 patients with hypertension). Compared with patients with hypertension at matched low-RPM practices, patients with hypertension at high-RPM practices had a 3.3% (95% CI, 1.9% to 4.8%) relative increase in hypertension medication fills, a 1.6% (CI, 0.7% to 2.5%) increase in days' supply, and a 1.3% (CI, 0.2% to 2.4%) increase in unique medications received. Patients at high-RPM practices also had fewer hypertension-related acute care encounters (-9.3% [CI, -20.6% to 2.1%]) and reduced testing use (-5.9% [CI, -11.9% to 0.0%]). However, these patients also saw increases in primary care physician outpatient visits (7.2% [CI, -0.1% to 14.6%]) and a $274 [CI, $165 to $384]) increase in total hypertension-related spending.

LIMITATION

Lacked blood pressure data; residual confounding.

CONCLUSION

Patients in high-RPM practices had improved hypertension care outcomes but increased spending.

PRIMARY FUNDING SOURCE

National Institute of Neurological Disorders and Stroke.

Hospitalisations related to nervous-system diseases in Australia, 1998-2019: a secular trend analysis

OBJECTIVE

The burden of neurological disease-related disabilities and deaths is one of the most serious issues globally. We aimed to examine the hospitalisation profile related to nervous system diseases in Australia for the duration between 1998 and 2019.

DESIGN

A secular trend analysis using a population-based dataset.

SETTING

This analysis used a population-based study of hospitalised patients in Australia. Hospitalisation data were extracted from the National Hospital Morbidity Database, which collects sets of episode-level information for Australian patients admitted to all private and public hospitals.

PARTICIPANTS

All patients who were hospitalised in all private and public hospitalisations.

PRIMARY OUTCOME MEASURE

Hospitalisation rates related to nervous system diseases.

RESULTS

Hospitalisation rates increased by 1.04 times (from 650.36 (95% CI 646.73 to 654.00) in 1998 to 1328.90 (95% CI 1324.44 to 1333.35) in 2019 per 100 000 persons, p<0.01). Overnight-stay episodes accounted for 57.0% of the total number of hospitalisations. Rates of the same-day hospitalisation for diseases of the nervous system increased by 2.10-fold (from 219.74 (95% CI 217.63 to 221.86) in 1998 to 680.23 (95% CI 677.03 to 683.43) in 2019 per 100 000 persons). Rates of overnight-stay hospital admission increased by 42.7% (from 430.62 (95% CI 427.66 to 433.58) in 1998 to 614.70 (95% CI 611.66 to 617.75) in 2019 per 100 000 persons). 'Episodic and paroxysmal disorders' were the most prevalent reason for hospitalisation, which accounted for 49.0% of the total number of episodes. Female hospitalisation rates increased by 1.13-fold (from 618.23 (95% CI 613.24 to 623.22) in 1998 to 1316.33 (95% CI 1310.07 to 1322.58) in 2019 per 100 000 persons). Male hospitalisation rates increased by 86.4% (from 682.95 (95% CI 677.67 to 688.23) in 1998 to 1273.18 (95% CI 1266.98 to 1279.37) in 2019 per 100 000 persons).

CONCLUSION

Hospitalisation rates for neurological disorders in Australia are high, potentially owing to the ageing of the population. Males had greater rates of hospitalisation than females.

Segmenting Patients With Diabetes With the Navigator Service in Primary Care and a Description of the Self-Acting Patient Group: Cross-Sectional Study

BACKGROUND

The aim of patient segmentation is to recognize patients with similar health care needs. The Finnish patient segmentation service Navigator segregates patients into 4 groups, including a self-acting group, who presumably manages their everyday life and coordinates their health care. Digital services could support their self-care. Knowledge on self-acting patients' characteristics is lacking.

OBJECTIVE

The study aims are to describe how Navigator assigns patients with diabetes to the 4 groups at nurses' appointments at a health center, the self-acting patient group's characteristics compared with other patient groups, and the concordance between the nurse's evaluation of the patient's group and the actual group assigned by Navigator (criterion validity).

METHODS

Patients with diabetes ≥18 years old visiting primary care were invited to participate in this cross-sectional study. Patients with disability preventing informed consent for participation were excluded. Nurses estimated the patients' upcoming group results before the appointment. We describe the concordance (%) between the evaluation and actual groups. Nurses used Navigator patients with diabetes (n=304) at their annual follow-up visits. The self-acting patients' diabetes care values (glycated hemoglobin [HbA1c], urine albumin to creatinine ratio, low-density lipoprotein cholesterol, blood pressure, BMI), chronic conditions, medication, smoking status, self-rated health, disability (World Health Organization Disability Assessment Schedule [WHODAS] 2.0), health-related quality of life (EQ-5D-5L), and well-being (Well-being Questionnaire [WBQ-12]) and the patients' responses to Navigator's question concerning their digital skills as outcome variables were compared with those of the other patients. We used descriptive statistics for the patients' distribution into the 4 groups and demographic data. We used the Mann-Whitney U test with nonnormally distributed variables, independent samples t test with normally distributed variables, and Pearson chi-square tests with categorized variables to compare the groups.

RESULTS

Most patients (259/304, 85.2%) were in the self-acting group. Hypertension, hyperlipidemia, and joint ailments were the most prevalent comorbidities among all patients. Self-acting patients had less ischemic cardiac disease (P=.001), depression or anxiety (P=.03), asthma or chronic obstructive pulmonary disease (P<.001), long-term pain (P<.001), and related medication. Self-acting patients had better self-rated health (P<.001), functional ability (P<.001), health-related quality of life (P<.001), and general well-being (P<.001). All patients considered their skills at using electronic services to be good.

CONCLUSIONS

The patients in the self-acting group had several comorbidities. However, their functional ability was not yet diminished compared with patients in the other groups. Therefore, to prevent diabetic complications and disabilities, support for patients' self-management should be emphasized in their integrated care services. Digital services could be involved in the care of patients willing to use them. The study was performed in 1 health center, the participants were volunteers, and most patients were assigned to self-acting patient group. These facts limit the generalizability of our results.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/20570.

Upscaling telemonitoring in Dutch University Medical Centres: A baseline measurement

INTRODUCTION AND OBJECTIVE

The Dutch university medical centres (UMC's) are on the forefront when it comes to validation, implementation and research of telemonitoring. To aid the UMC's in their effort, the Dutch Government has supported the UMC's by fostering the 'Citrien eHealth program'. This program aims at nationwide implementation and upscaling of telemonitoring via a collaborative network. To quantify the success of this program, this study aims to provide insights into the current adoption of telemonitoring by health care professionals (HCP) within Dutch UMC's.

METHODS

Based on the evaluation framework as adapted from the Normalization Process Theory (NPT) a cross-sectional study was conducted in all Dutch UMC's. Thirty healthcare professionals (HCPs) per UMC were invited to complete the 23-item Normalization MeAsure Development (NoMAD) questionnaire, a tool to assess the degree of normalisation of telemonitoring.

RESULTS

The over-all response rate was 52.4% (124/240). Over 80% of respondents agreed or strongly agreed that they understand how telemonitoring affects the nature of their work, with a mean score of 1.49 (N = 117, SD 0.74). HCPs reported to believe telemonitoring will become a normal part of their work in the near future (N = 124, mean = 8.67, SD = 1.38). Using the Wilcoxon signed-rank test, the difference between current practise and future use of telemonitoring predicts to be statistically significant (Z =  - 7.505, p ≤ 0.001). Mean scores for appropriate training and sufficient resources are relatively low (2.39 and 2.70 respectively), indicating a barrier for collective action.

CONCLUSION

This is the first study to assess the implementation of telemonitoring as standard practise across Dutch UMCs. The HCPs in this study are the frontrunners, believing that telemonitoring will become standard practise in the future despite the fact that it is currently not. Based on the results of this study, both educational and implementation strategies including practical skills training are highly recommended in order to scale up telemonitoring widely.

Interface of Clinical Nurse Specialist Practice and Healthcare Technology

PURPOSE

This article demonstrates the leadership role of the clinical nurse specialist in developing and implementing healthcare technology across the continuum of care.

DESCRIPTION

Three virtual nursing practices-facilitated self-care, remote patient monitoring, and virtual acute care nursing-illustrate how the clinical nurse specialist is well suited to transform traditional practice models to ones that use healthcare technology effectively. These 3 practices use interactive healthcare technology to gather patient data and allow communication and coordination with the healthcare team to meet patient-specific needs.

OUTCOME

Use of healthcare technology in virtual nursing practices led to early care team intervention, optimized care team processes, proactive patient outreach, timely access to care, and reduction in healthcare-associated errors and near-miss events.

CONCLUSION

Clinical nurse specialists are well positioned to develop innovative, effective, accessible, and high-quality virtual nursing practices. Integrating healthcare technology with nursing practice augments care for various patients, ranging from those with low illness severity in the outpatient setting to acutely ill patients in the inpatient hospital environment.

A rapid mixed-methods evaluation of remote home monitoring models during the COVID-19 pandemic in England

Background

Remote home monitoring services were developed and implemented for patients with COVID-19 during the pandemic. Patients monitored blood oxygen saturation and other readings (e.g. temperature) at home and were escalated as necessary.

Objective

To evaluate effectiveness, costs, implementation, and staff and patient experiences (including disparities and mode) of COVID-19 remote home monitoring services in England during the COVID-19 pandemic (waves 1 and 2).

Methods

A rapid mixed-methods evaluation, conducted in two phases. Phase 1 (July-August 2020) comprised a rapid systematic review, implementation and economic analysis study (in eight sites). Phase 2 (January-June 2021) comprised a large-scale, multisite, mixed-methods study of effectiveness, costs, implementation and patient/staff experience, using national data sets, surveys (28 sites) and interviews (17 sites).

Results

Phase 1 Findings from the review and empirical study indicated that these services have been implemented worldwide and vary substantially. Empirical findings highlighted that communication, appropriate information and multiple modes of monitoring facilitated implementation; barriers included unclear referral processes, workforce availability and lack of administrative support. Phase 2 We received surveys from 292 staff (39% response rate) and 1069 patients/carers (18% response rate). We conducted interviews with 58 staff, 62 patients/carers and 5 national leads. Despite national roll-out, enrolment to services was lower than expected (average enrolment across 37 clinical commissioning groups judged to have completed data was 8.7%). There was large variability in implementation of services, influenced by patient (e.g. local population needs), workforce (e.g. workload), organisational (e.g. collaboration) and resource (e.g. software) factors. We found that for every 10% increase in enrolment to the programme, mortality was reduced by 2% (95% confidence interval: 4% reduction to 1% increase), admissions increased by 3% (-1% to 7%), in-hospital mortality fell by 3% (-8% to 3%) and lengths of stay increased by 1.8% (-1.2% to 4.9%). None of these results are statistically significant. We found slightly longer hospital lengths of stay associated with virtual ward services (adjusted incidence rate ratio 1.05, 95% confidence interval 1.01 to 1.09), and no statistically significant impact on subsequent COVID-19 readmissions (adjusted odds ratio 0.95, 95% confidence interval 0.89 to 1.02). Low patient enrolment rates and incomplete data may have affected chances of detecting possible impact. The mean running cost per patient varied for different types of service and mode; and was driven by the number and grade of staff. Staff, patients and carers generally reported positive experiences of services. Services were easy to deliver but staff needed additional training. Staff knowledge/confidence, NHS resources/workload, dynamics between multidisciplinary team members and patients' engagement with the service (e.g. using the oximeter to record and submit readings) influenced delivery. Patients and carers felt services and human contact received reassured them and were easy to engage with. Engagement was conditional on patient, support, resource and service factors. Many sites designed services to suit the needs of their local population. Despite adaptations, disparities were reported across some patient groups. For example, older adults and patients from ethnic minorities reported more difficulties engaging with the service. Tech-enabled models helped to manage large patient groups but did not completely replace phone calls.

Limitations

Limitations included data completeness, inability to link data on service use to outcomes at a patient level, low survey response rates and under-representation of some patient groups.

Future work

Further research should consider the long-term impact and cost-effectiveness of these services and the appropriateness of different models for different groups of patients.

Conclusions

We were not able to find quantitative evidence that COVID-19 remote home monitoring services have been effective. However, low enrolment rates, incomplete data and varied implementation reduced our chances of detecting any impact that may have existed. While services were viewed positively by staff and patients, barriers to implementation, delivery and engagement should be considered.

Study registration

This study is registered with the ISRCTN (14962466).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (RSET: 16/138/17; BRACE: 16/138/31) and NHSEI and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 13. See the NIHR Journals Library website for further project information. The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health and Care Research or the Department of Health and Social Care.

Telehealth Use to Address Cardiovascular Disease and Hypertension in the United States: A Systematic Review and Meta-Analysis, 2011-2021

Background

The use of telehealth for the management and treatment of hypertension and cardiovascular disease (CVD) has increased across the United States (U.S.), especially during the COVID-19 pandemic. Telehealth has the potential to reduce barriers to accessing health care and improve clinical outcomes. However, implementation, outcomes, and health equity implications related to these strategies are not well understood. The purpose of this review was to identify how telehealth is being used by U.S. health care professionals and health systems to manage hypertension and CVD and to describe the impact these telehealth strategies have on hypertension and CVD outcomes, with a special focus on social determinants of health and health disparities.

Methods

This study comprised a narrative review of the literature and meta-analyses. The meta-analyses included articles with intervention and control groups to examine the impact of telehealth interventions on changes to select patient outcomes, including systolic and diastolic blood pressure. A total of 38 U.S.-based interventions were included in the narrative review, with 14 yielding data eligible for the meta-analyses.

Results

The telehealth interventions reviewed were used to treat patients with hypertension, heart failure, and stroke, with most interventions employing a team-based care approach. These interventions utilized the expertise of physicians, nurses, pharmacists, and other health care professionals to collaborate on patient decisions and provide direct care. Among the 38 interventions reviewed, 26 interventions utilized remote patient monitoring (RPM) devices mostly for blood pressure monitoring. Half the interventions used a combination of strategies (e.g., videoconferencing and RPM). Patients using telehealth saw significant improvements in clinical outcomes such as blood pressure control, which were comparable to patients receiving in-person care. In contrast, the outcomes related to hospitalizations were mixed. There were also significant decreases in all-cause mortality when compared to usual care. No study explicitly focused on addressing social determinants of health or health disparities through telehealth for hypertension or CVD.

Conclusions

Telehealth appears to be comparable to traditional in-person care for managing blood pressure and CVD and may be seen as a complement to existing care options for some patients. Telehealth can also support team-based care delivery and may benefit patients and health care professionals by increasing opportunities for communication, engagement, and monitoring outside a clinical setting.

Rapid Roll Out of a Pacemaker Home Monitoring Programme: A Patient Perspective

OBJECTIVE

To assess the safety, efficacy, and patient acceptability of a pacemaker home monitoring (HM) service.

METHODS

All patients receiving a new Biotronik (Biotronik, Berlin, Germany) pacemaker between March 2020 and February 2021 were contacted for participation. Participants were surveyed on their experience of pacemaker HM. HM alerts and remote wound monitoring rates were also assessed.

RESULTS

Of the patients contacted, 77% responded, with a mean age of 80.6±9.9 years. Of these, 95.8% agreed that the home monitoring (HM) has been beneficial. Two thirds preferred HM to face-to-face follow-up and two thirds felt safe with HM. Three themes were identified from the comments: reassurance, technology and data security. Forty-one percent (41%) of respondents would like more reassurance that their HM is working, 18% mentioned technology with mixed responses, and 4.7% cited cybersecurity or the use of their personal data as a concern. The average one-way patient journey saved was 24.3±16.7 km (15.1±10.4 miles). One in three HM alerts required action but only 3.4% were urgent. Remote wound review was successful in 59%.

CONCLUSIONS

The majority of patients prefer HM and almost all think it has been beneficial. It saves significant travel time and provides actionable alerts. The patient experience could be improved by reassuring patients that their device is being monitored.

Economic evaluation and costs of remote patient monitoring for cardiovascular disease in the United States: a systematic review

BACKGROUND

Remote patient monitoring (RPM) has emerged as a viable and valuable care delivery method to improve chronic disease management. In light of the high prevalence and substantial economic burden of cardiovascular disease (CVD), this systematic review examines the cost and cost-effectiveness of using RPM to manage CVD in the United States.

METHODS

We systematically searched databases to identify potentially relevant research. Findings were synthesized for cost and cost-effectiveness by economic study type with consideration of study perspective, intervention, clinical outcome, and time horizon. The methodological quality was assessed using the Joanna Briggs Institute Checklist for Economic Evaluations.

RESULTS

Thirteen articles with fourteen studies published between 2011 and 2021 were included in the final review. Studies from the provider perspective with a narrow scope of cost components identified higher costs and similar effectiveness for the RPM group relative to the usual care group. However, studies from payer and healthcare sector perspectives indicate better clinical effectiveness of RPM relative to usual care, with two cost-utility analysis studies suggesting that RPM relative to usual care is a cost-effective tool for CVD management even at the conservative $50,000 per Quality-Adjusted Life-Year threshold. Additionally, all model-based studies revealed that RPM is cost-effective in the long run.

CONCLUSIONS

Full economic evaluations identified RPM as a potentially cost-effective tool, particularly for long-term CVD management. In addition to the current literature, rigorous economic analysis with a broader perspective is needed in evaluating the value and economic sustainability of RPM.

Design and development of a smartphone app for hypertension management: An intervention mapping approach

Background

Several research studies have demonstrated the potential of mobile health apps in supporting health management. However, the design and development process of these apps are rarely presented.

Objective

We present the design and development of a smartphone-based lifestyle app integrating a wearable device for hypertension management.

Methods

We used an intervention mapping approach for the development of theory- and evidence-based intervention in hypertension management. This consisted of six fundamental steps: needs assessment, matrices, theoretical methods and practical strategies, program design, adoption and implementation plan, and evaluation plan. To design the contents of the intervention, we performed a literature review to determine the preferences of people with hypertension (Step 1) and necessary objectives toward the promotion of self-management behaviors (Step 2). Based on these findings, we implemented theoretical and practical strategies in consultation with stakeholders and researchers (Steps 3), which was used to identify the functionality and develop an mHealth app (Step 4). The adoption (Step 5) and evaluation (Step 6) of the mHealth app will be conducted in a future study.

Results

Through the needs analysis, we identified that people with hypertension preferred having education, medication or treatment adherence, lifestyle modification, alcohol and smoking cessation and blood pressure monitoring support. We utilized MoSCoW analysis to consider four key elements, i.e., education, medication or treatment adherence, lifestyle modification and blood pressure support based on past experiences, and its potential benefits in hypertension management. Theoretical models such as (i) the information, motivation, and behavior skills model, and (ii) the patient health engagement model was implemented in the intervention development to ensure positive engagement and health behavior. Our app provides health education to people with hypertension related to their condition, while utilizing wearable devices to promote lifestyle modification and blood pressure management. The app also contains a clinician portal with rules and medication lists titrated by the clinician to ensure treatment adherence, with regular push notifications to prompt behavioral change. In addition, the app data can be reviewed by patients and clinicians as needed.

Conclusions

This is the first study describing the design and development of an app that integrates a wearable blood pressure device and provides lifestyle support and hypertension management. Our theory-driven intervention for hypertension management is founded on the critical needs of people with hypertension to ensure treatment adherence and supports medication review and titration by clinicians. The intervention will be clinically evaluated in future studies to determine its effectiveness and usability.

Implementing a COVID-19 Virtual Observation Unit in Emergency Medicine: Frontline Clinician and Staff Experiences

The COVID-19 pandemic pushed hospitals to deliver care outside of their four walls. To successfully scale virtual care delivery, it is important to understand how its implementation affects frontline workers, including their teamwork and patient-provider interactions. We conducted in-depth interviews of 17 clinicians and staff involved with the COVID-19 Virtual Observation Unit (CVOU) in the emergency department (ED) of an academic hospital. The program leveraged remote patient monitoring and mobile integrated health care. In the CVOU (vs. the ED), participants observed increases in interactions among clinicians and staff, patient participation in care delivery, attention to nonmedical factors, and involvement of coordinators and paramedics in patient care. These changes were associated with unintended, positive consequences for staff, namely, feeling heard, experience of meaningfulness, and positive attitudes toward virtual care. This study advances research on reconfiguration of roles following implementation of new practices using digital tools, virtual work interactions, and at-home care delivery.

Virtual wards: a rapid evidence synthesis and implications for the care of older people

BACKGROUND

Virtual wards are being rapidly developed within the National Health Service in the UK, and frailty is one of the first clinical pathways. Virtual wards for older people and existing hospital at home services are closely related.

METHODS

In March 2022, we searched Medline, CINAHL, the Cochrane Database of Systematic Reviews and medRxiv for evidence syntheses which addressed clinical-effectiveness, cost-effectiveness, barriers and facilitators, or staff, patient or carer experience for virtual wards, hospital at home or remote monitoring alternatives to inpatient care.

RESULTS

We included 28 evidence syntheses mostly relating to hospital at home. There is low to moderate certainty evidence that clinical outcomes including mortality (example pooled RR 0.77, 95% CI 0.60-0.99) were probably equivalent or better for hospital at home. Subsequent residential care admissions are probably reduced (example pooled RR 0.35, 95% CI 0.22-0.57). Cost-effectiveness evidence demonstrated methodological issues which mean the results are uncertain. Evidence is lacking on cost implications for patients and carers. Barriers and facilitators operate at multiple levels (organisational, clinical and patient). Patient satisfaction may be improved by hospital at home relative to inpatient care. Evidence for carer experience is limited.

CONCLUSIONS

There is substantial evidence for the clinical effectiveness of hospital at home but less evidence for virtual wards. Guidance for virtual wards is lacking on key aspects including team characteristics, outcome selection and data protection. We recommend that research and evaluation is integrated into development of virtual ward models. The issue of carer strain is particularly relevant.

Facilitators and barriers to blood pressure telemonitoring: A mixed-methods study

Background

Telemonitoring of blood pressure (BP) may improve BP control. However, many patients are not using BP telemonitoring due to personal, technological, and health system barriers. Individuals are required to have electronic health literacy (e-HL), defined as knowledge and skills to use technology services effectively, such as BP telemonitoring.

Objective

The objective was to determine the facilitators and barriers experienced by patients with hypertension in telemonitoring of BP using the e-HL framework (e-HLF).

Methods

This study was a prospective mixed-methods study using a convergent design. We recruited a convenience sample of 21 patients with hypertension. The qualitative section was online or phone individual in-depth interviews based on the e-HLF, which has seven domains. The quantitative section was an online survey consisting of demographics, an e-HL questionnaire, and patient-provider communication preferences. A joint display was used in the mixed-methods analysis.

Results

Five themes including knowledge, motivation, skills, systems, and behaviors along with 28 subthemes comprising facilitators or barriers of BP telemonitoring were identified. The mixed-methods results showed concordance between the participants' e-HL status and their experiences in the ability to actively engage with BP monitoring and managing digital services (domain 3) of the e-HLF. Other e-HL domains showed discordance.

Conclusion

Patients may engage with BP telemonitoring when they feel the usefulness of concurrent access to telemonitoring services that suit their needs.

Definition of a Method for the Evaluation of Telemedicine Platforms in the Italian Context

Background: The COVID-19 outbreak led to the diffusion of several telemedicine solutions. The choice of the correct platform is crucial for ensuring the release of effective assistance. However, there is a lack of an objective method for the assessment of technical features. Objective: This study proposes a methodology for the evaluation of functional requirements of telemedicine platforms. This approach also permits the comparison of solutions in the Italian market by means of defined parameters, thus directing the choice of health care professionals. Methods: The study is divided into three phases. First, a mapping of the telemedicine platforms operating in Italy is performed. Then, the available platforms are selected based on the offered telemedicine activity. Finally, a method for evaluating the investigated platforms is defined. Results: Thirty-three (n = 33) technological systems were identified through an accurate investigation on the web and interviews with IT companies. Fifteen parameters were defined and organized into three categories: (1) usability of the telemedicine platform, (2) security, and (3) technological and organizational aspects. A score between 1 and 4 was assigned to each parameter, proportionally to the completeness of the platform. In particular, 62.96% of platforms reached an average score between 3.01 and 4 points; 33.33% of them had scores between 2.01 and 3, while the remaining 3.70% of solutions obtained a result between 1.01 and 2. Conclusions: The study provides an evaluation approach that is easily usable by health professionals to select the most suitable platform. The number of solutions and quality of information could be updated to obtain a complete tool.

Environmental Benefits of Sleep Apnoea Detection in the Home Environment

Sleep Apnoea (SA) is a common chronic illness that affects nearly 1 billion people around the world, and the number of patients is rising. SA causes a wide range of psychological and physiological ailments that have detrimental effects on a patient’s wellbeing. The high prevalence and negative health effects make SA a public health problem. Whilst the current gold standard diagnostic procedure, polysomnography (PSG), is reliable, it is resource-expensive and can have a negative impact on sleep quality, as well as the environment. With this study, we focus on the environmental impact that arises from resource utilisation during SA detection, and we propose remote monitoring (RM) as a potential solution that can improve the resource efficiency and reduce travel. By reusing infrastructure technology, such as mobile communication, cloud computing, and artificial intelligence (AI), RM establishes SA detection and diagnosis support services in the home environment. However, there are considerable barriers to a widespread adoption of this technology. To gain a better understanding of the available technology and its associated strength, as well as weaknesses, we reviewed scientific papers that used various strategies for RM-based SA detection. Our review focused on 113 studies that were conducted between 2018 and 2022 and that were listed in Google Scholar. We found that just over 50% of the proposed RM systems incorporated real time signal processing and around 20% of the studies did not report on this important aspect. From an environmental perspective, this is a significant shortcoming, because 30% of the studies were based on measurement devices that must travel whenever the internal buffer is full. The environmental impact of that travel might constitute an additional need for changing from offline to online SA detection in the home environment.

Remote Monitoring for Prediction and Management of Acute Exacerbations in Chronic Obstructive Pulmonary Disease (AECOPD)

The progression of chronic obstructive pulmonary disease (COPD) is characterized by episodes of acute exacerbation (AECOPD) of symptoms, decline in respiratory function, and reduction in quality-of-life increasing morbi-mortality and often requiring hospitalization. Exacerbations can be triggered by environmental exposures, changes in lifestyle, and/or physiological and psychological factors to greater or lesser extents depending on the individual’s COPD phenotype. The prediction and early detection of an exacerbation might allow patients and physicians to better manage the acute phase. We summarize the recent scientific data on remote telemonitoring (TM) for the prediction and management of acute exacerbations in COPD patients. We discuss the components of remote monitoring platforms, including the integration of environmental monitoring data; patient reported outcomes collected via interactive Smartphone apps, with data from wearable devices that monitor physical activity, heart rate, etc.; and data from medical devices such as connected non-invasive ventilators. We consider how telemonitoring and the deluge of data it potentially generates could be combined with electronic health records to provide personalized care and multi-disease management for COPD patients.