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BackgroundThe adoption of remote methods of care has been accelerated by the COVID-19 pandemic, but concerns exist relating to the potential impact on health disparities. This evaluation explores the implementation of COVID-19 remote home monitoring services across England, focussing on patients experiences and engagement with the service. MethodsThe study was a rapid, multi-site, mixed methods evaluation. Data were collected between January and June 2021. We conducted qualitative interviews with staff service leads, and patients and carers receiving the service. We conducted quantitative surveys with staff delivering the service, and patients and carers receiving the service across 28 sites in England, UK. Qualitative data were analysed using thematic analysis and quantitative data were analysed using univariate and multivariate methods. FindingsMany sites designed their service to be inclusive to the needs of their local population. Strategies included widening eligibility criteria, prioritising vulnerable groups, and creating referral pathways. Many sites also adapted their services according to patient needs, including providing information in different languages or more accessible formats, offering translation services, offering non-digital options, or providing face-to-face assessments. Despite these adaptions, disparities were reported across patient groups (e.g. age, health status, ethnicity, level of education) in their experience of and engagement with the service. InterpretationServices must determine how best to design and implement remote monitoring services to be of value to all populations. National guidance should play a role in supporting services to best serve the needs of their populations, and patients and staff must play an active role in service design. FundingThis is independent research funded by the National Institute for Health Research, Health Services & Delivery Research programme (RSET Project no. 16/138/17; BRACE Project no. 16/138/31) and NHSEI. NJF is an NIHR Senior Investigator. The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSEvidence shows COVID-19 has a disproportionate impact on certain population groups, such as ethnic minority groups, older adults and those with comorbidities. The rapid adoption and spread of remote home monitoring services in England must be accompanied by evaluations at a local level to monitor the impact on health disparities in local populations. Added value of this studyThis rapid mixed methods evaluation of COVID-19 home monitoring services adopted across 28 sites in England aimed to increase understanding of how services have been designed and delivered to address local population needs to increase accessibility to the service and facilitate engagement with the service. We add to the literature by identifying a range of local service adaptations which aim to increase reach and facilitate patient engagement, and consider their potential impact on health disparities. We found strategies included prioritising vulnerable groups, creating referral pathways, offering translation services, offering non-digital options, or providing face-to-face assessments. Despite efforts to adapt services to meet local needs, disparities across patient groups in their experience of, and engagement with, the service (related to age, health status, ethnicity, and level of education) were reported. Implications of the available evidenceAt both a national and local level, and particularly given the increasing use of remote home monitoring schemes, lessening health disparities must be a primary focus in the design and delivery of remote monitoring models for COVID-19 and other conditions. Future research should focus on how best to design and evaluate remote monitoring services, for a range of conditions, especially for patients residing in areas where significant health disparities persist, as well as addressing the effectiveness of any strategies on specific population groups.
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BackgroundThere was a national roll out of COVID Virtual Wards (CVW) during Englands second COVID-19 wave (Autumn 2020 - Spring 2021). These services used remote pulse oximetry monitoring for COVID-19 patients following discharge from hospital. A key aim was to enable rapid detection of patient deterioration. It was anticipated that the services would support early discharge and avoid readmissions, reducing pressure on beds. This study is an evaluation of the impact of the CVW services on hospital activity. MethodsUsing retrospective patient-level hospital admissions data, we built multivariate models to analyse the relationship between the implementation of CVW services and hospital activity outcomes: length of COVID-19 related stays and subsequent COVID-19 readmissions within 28 days. We used data from more than 98% of recorded COVID-19 hospital stays in England, where the patient was discharged alive between mid-August 2020 and late February 2021. FindingsWe found a longer length of stay for COVID-19 patients discharged from hospitals where a CVW was available, when compared to patients discharged from hospitals where there was no CVW (adjusted IRR 1{middle dot}05, 95% CI 1{middle dot}01 to 1{middle dot}09). We found no evidence of a relationship between the availability of CVW and subsequent rates of readmission for COVID-19 (adjusted OR 0{middle dot}95, 95% CI 0{middle dot}89 to 1{middle dot}02). InterpretationWe found no evidence of early discharges or reduced readmissions associated with the roll out of COVID Virtual Wards across England. Our analysis made pragmatic use of national-scale hospital data, but it is possible that a lack of specific data (for example, on which patients were enrolled) may have meant that true impacts, especially at a local level, were not ultimately discernible. FundingThis is independent research funded by the National Institute for Health Research, Health Services & Delivery Research programme and NHSEI. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSPost-hospital virtual wards have been found to have a positive impact on patient outcomes when focussed on patients with specific diseases, for example those with heart disease. There has been less evidence of impact for more heterogenous groups of patients. While these services have been rolled out at scale in England, there has been little evidence thus far that post-hospital virtual wards (using pulse oximetry monitoring) have helped to reduce the length of stay of hospitalised COVID-19 patients, or rates of subsequent readmissions for COVID-19. Added value of this studyThis national-scale study provides evidence that the rollout of post-hospital discharge virtual ward services for COVID-19 patients in England did not reduce lengths of stay in hospital, or rates of readmission. Implications of all the available evidenceWhile there is currently an absence of evidence of positive impacts for COVID-19 patients discharged to a virtual ward, our study emphasises the need for quality data to be collected as part of future service implementation.
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BackgroundRemote home monitoring of people testing positive for COVID-19 using pulse oximetry was implemented across England during the Winter of 2020/21 to identify falling blood oxygen saturation levels at an early stage. This was hypothesised to enable earlier hospital admission, reduce the need for intensive care and improve survival. This study is an evaluation of the clinical effectiveness of the pre-hospital monitoring programme, COVID oximetry @home (CO@h). MethodsWe analysed relationships at a geographical area level between the extent to which people aged 65 or over were enrolled onto the programme and outcomes over the period between November 2020 to February 2021 FindingsFor every 10% increase in coverage of the programme, mortality was reduced by 2% (95% confidence interval: -4% to 1%), admissions increased by 3% (-1% to 7%), in-hospital mortality fell by 3% (-8% to 3%) and lengths of stay increased by 1{middle dot}8% (-1{middle dot}2% to 4{middle dot}9%). None of these results are statistically significant. InterpretationThere are several possible explanations for our findings. One is that the CO@h did not have the hypothesised impact. Another is that the low rates of enrolment and incomplete data in many areas reduced the chances of detecting any impact that may have existed. Also, CO@h has been implemented in many different ways across the country and these may have had varying levels of effect. FundingThis is independent research funded by the National Institute for Health Research, Health Services & Delivery Research programme (RSET Project no. 16/138/17; BRACE Project no. 16/138/31) and NHSEI. NJF is an NIHR Senior Investigator. The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care. Research in ContextO_ST_ABSEvidence before this studyC_ST_ABSExisting evidence before this study and the search strategy used to obtain this evidence has been published previously by the authors in a systematic review. Previous quantitative studies have assessed remote oximetry monitoring services for COVID-19 patients mostly at individual sites and focussed on their safety. However, their effectiveness has been little studied. This may reflect the challenges of identifying reliable counterfactuals during a rapidly evolving pandemic. Added value of this studyThis study is part of a wider mixed methods evaluation that followed the rapid implementation of remote monitoring across the English NHS during the Winter of 2020/21. It adds to the evidence of the effectiveness of such programmes at a national level. Implications of the available evidenceThere is some existing evidence that remote monitoring of COVID-19 patients can be locally effective although we have not been able to replicate such findings at a wider level. Missing data and lower coverage of the service than expected may have influenced our results, and the effectiveness of some local programmes could have been lost among the analysis of national data. Future implementation requires better data collection strategies which could be focussed within fewer local areas, and effective learning from areas that have achieved better population coverage.
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ObjectiveTo describe changes in NHS outpatient activity connected to the Covid-19 pandemic DesignNationwide population-based retrospective study SettingEngland, UK, 31 December 2018 to 25 October 2020 Data sourceOutpatient Hospital Episode Statistics data ResultsBetween early March and late October 2020, there was a total reduction of 16.6 million outpatient attendances compared to the same period in 2019, equivalent to a 27% decline. The largest weekly drop of 48% relative to 2019 occurred the week beginning 30 March. Activity recovered more slowly than it fell, and by the end of the study period remained 16% lower than the equivalent week in 2019. Changes in patterns of attendances were broadly similar across most patient characteristic groups. There was a substantial increase in the proportion of attendances taking place remotely, peaking at more than one in three during April and May 2020. Differences were observed in trends of remote consultations between age and sex categories, ethnic groups, and proxy deprivation levels. There was also substantial variation in overall activity and use of remote consultations by clinical specialty. ConclusionsThe large increase in remote outpatient consultations during the early Covid-19 period, variations in remote care use by specialty as well as proxy deprivation and ethnic groups all suggest a need to evaluate the impact of these changes particularly in light of national policy to encourage greater use of remote consultations. SUMMARY BOXO_ST_ABSWhat is already known on this topicC_ST_ABSO_LINumbers of outpatient attendances in England have increased substantially over recent years. C_LIO_LIHistorically, the vast majority of attendances have been face-to-face, with remote consultations accounting for [~]4% of all attendances. C_LIO_LIThe emergence of the Covid-19 pandemic in 2020 had a large impact on outpatient services in English hospitals, and on health services more generally in England and around the world. C_LI What this study addsO_LIThere were significant differences by clinical specialty in changes to patterns of attendances and remote consultations. C_LIO_LIChanges in the volume of outpatient attendances as a result of responses to the pandemic were broadly similar across patient groups. C_LIO_LIHowever, there were marked differences across patient groups in trends in remote consultations. C_LI
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BackgroundThere is a paucity of evidence for the implementation of remote home monitoring for COVID-19 infection. The aims of this study were to identify the key characteristics of remote home monitoring models for COVID-19 infection, explore the experiences of staff implementing these models, understand the use of data for monitoring progress against outcomes, and document variability in staffing and resource allocation. MethodsThis was a multi-site mixed methods study that combined qualitative and quantitative approaches to analyse the implementation and impact of remote home monitoring models during the first wave of the COVID-19 pandemic (July to September 2020) in England. The study combined interviews (n=22) with staff delivering these models across eight sites in England with the collection and analysis of data on staffing models and resource allocation. FindingsThe models varied in relation to the healthcare settings and mechanisms used for patient triage, monitoring and escalation. Implementation was embedded in existing staff workloads and budgets. Good communication within clinical teams, culturally-appropriate information for patients/carers and the combination of multiple approaches for patient monitoring (app and paper-based) were considered facilitators in implementation. The mean cost per monitored patient varied from {pound}400 to {pound}553, depending on the model. InterpretationIt is necessary to provide the means for evaluating the effectiveness of these models, for example, by establishing comparator data. Future research should also focus on the sustainability of the models and patient experience (considering the extent to which some of the models exacerbate existing inequalities in access to care). FundingThe study was funded by the National Institute for Health Research-NIHR (Health Services and Delivery Research, 16/138/17 - Rapid Service Evaluation Research Team; or The Birmingham, RAND and Cambridge Evaluation (BRACE) Centre Team (HSDR16/138/31).
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ObjectivesThe aim of this review was to analyse the implementation and impact of remote home monitoring models (virtual wards) during COVID-19, identifying their main components, processes of implementation, target patient populations, impact on outcomes, costs and lessons learnt. DesignA rapid systematic review to capture an evolving evidence base. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. SettingThe review included models led by primary and secondary care across seven countries. Participants27 articles were included in the review. Main outcome measuresImpact of remote home monitoring on virtual length of stay, escalation, emergency department attendance/reattendance, admission/readmission and mortality. ResultsThe aim of the models was to maintain patients safe in the right setting. Most models were led by secondary care and confirmation of COVID-19 was not required (in most cases). Monitoring was carried via online platforms, paper-based systems with telephone calls or (less frequently) through wearable sensors. Models based on phone calls were considered more inclusive. Patient/carer training was identified as a determining factor of success. We could not reach substantive conclusions regarding patient safety and the identification of early deterioration due to lack of standardised reporting and missing data. Economic analysis was not reported for most of the models and did not go beyond reporting resources used and the amount spent per patient monitored. ConclusionsFuture research should focus on staff and patient experiences of care and inequalities in patients access to care. Attention needs to be paid to the cost-effectiveness of the models and their sustainability, evaluation of their impact on patient outcomes by using comparators, and the use of risk-stratification tools. Protocol registrationThe review protocol was published on PROSPERO (CRD: 42020202888). RESEARCH IN CONTEXTO_ST_ABSEvidence before this studyC_ST_ABSRemote home monitoring models for other conditions have been studied, but their adaptation to monitor COVID-19 patients and the analysis of their implementation constitute gaps in research. Added value of this studyThe review covers a wide range of remote home monitoring models (pre-hospital as well as step-down wards) implemented in primary and secondary care sectors in eight countries and focuses on their implementation and impact on outcomes (including costs). Implications of all the available evidenceThe review provides a rapid overview of an emerging evidence base that can be used to inform changes in policy and practice regarding the home monitoring of patients during COVID-19. Attention needs to be paid to the cost-effectiveness of the models and their sustainability, evaluation of their impact on patient outcomes by using comparators, and the use of risk-stratification tools.