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Home monitoring of coronavirus disease 2019 patients in different phases of disease

Medicine and Health

Home monitoring of coronavirus disease 2019 patients in different phases of disease

K. Majoor and A. D. M. Vorselaars

Discover how Kalle Majoor and Adriane D M Vorselaars delve into the world of home monitoring programs launched during the COVID-19 pandemic. This review scrutinizes their effectiveness and cost-effectiveness across different phases of disease management, offering insights that could reshape patient care models at home.

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Playback language: English
Introduction
The COVID-19 pandemic significantly challenged healthcare systems globally. To mitigate the strain on hospitals and prevent virus transmission, the World Health Organization (WHO) promoted home monitoring. This approach facilitated communication between patients and healthcare professionals remotely. Prior to the pandemic, home monitoring had demonstrated effectiveness in managing various diseases, including heart failure, and during the pandemic its use saw a significant increase. This review focuses on home monitoring in three COVID-19 phases: 1. **Prehospital:** Monitoring asymptomatic or mildly symptomatic patients at home to prevent unnecessary hospital admissions and allow for early detection of deterioration. 2. **Hospital Care at Home (Virtual Wards):** Enabling early discharge of recovering patients with oxygen and medication support while under continued remote monitoring. 3. **Monitoring Recovery:** Post-discharge monitoring to detect any relapse and prevent readmission. The review will discuss the safety, effectiveness, and cost-effectiveness of home monitoring initiatives during these different phases, considering the various challenges and requirements involved.
Literature Review
The review draws on numerous studies conducted in various countries, including the UK, US, Netherlands, and Australia. These studies employed different approaches to home monitoring, utilizing various technologies (pulse oximeters, mobile applications, wearable sensors) and methodologies (retrospective observational studies, randomized controlled trials). The reviewed literature includes studies assessing the impact of home monitoring on hospitalization rates, mortality, length of stay, cost-effectiveness, and patient satisfaction. The review considers the varying intensity of monitoring, patient populations (age, comorbidities), and the context of the healthcare system during different pandemic phases, specifically highlighting the effects of vaccination and evolving treatment protocols.
Methodology
The review is a narrative synthesis of existing literature, focusing on home monitoring initiatives for COVID-19 patients across different stages of the illness. The authors searched for relevant publications in major medical databases, including studies that explored prehospital monitoring, virtual wards, and post-discharge monitoring. The studies included in the review used various methodologies, including retrospective observational studies, randomized controlled trials (RCTs), and retrospective cohort analyses. The data collected across these studies encompassed various outcomes such as hospitalization rates, ICU admission rates, mortality rates, length of hospital stay, patient satisfaction, and cost-effectiveness of the interventions. The included studies varied in terms of population characteristics (age, gender, comorbidities), intensity of monitoring (frequency of vital sign measurements, type of communication with healthcare providers), and the specific technologies utilized (pulse oximeters, mobile applications, wearable sensors). Propensity score matching was employed in some studies to address potential confounding factors. The review discusses the strengths and limitations of each study design and the potential biases that could influence the results. The authors synthesized the findings from the included studies to provide a comprehensive overview of the effectiveness, safety, and challenges associated with home monitoring of COVID-19 patients.
Key Findings
**Prehospital Monitoring:** Several studies demonstrated the effectiveness of prehospital home monitoring in reducing hospitalization, ICU admissions, and mortality in COVID-19 patients, particularly those with mild symptoms and few comorbidities. The Oximetry@home program in the UK and other similar programs in the US and Australia showed positive outcomes. However, many studies were retrospective and lacked robust control groups. **Hospital Care at Home (Virtual Wards):** Early discharge to virtual wards with home monitoring, oxygen, and medication appeared safe, potentially reducing hospital stays. Some studies showed reductions in hospital length of stay; however, RCTs did not consistently demonstrate statistically significant benefits. This may have been influenced by factors such as small sample sizes and the tendency for control patients to also receive early discharge with oxygen. **Monitoring Recovery:** Findings on post-discharge monitoring were less conclusive. While some studies suggested reductions in emergency department visits and hospitalizations, a large UK study showed increased hospitalization duration in hospitals using virtual wards. This discrepancy may stem from variations in monitoring practices, patient populations, and data collection methods. **Home Monitoring Requirements:** Successful home monitoring necessitates regular clinical assessments, combining objective vital signs (oxygen saturation, heart rate, respiratory rate, temperature) with subjective symptom reporting. Mobile apps and various remote monitoring devices played a significant role. Oxygen saturation was consistently highlighted as a crucial indicator, particularly concerning the phenomenon of 'silent hypoxemia' (low oxygen saturation without corresponding shortness of breath). However, a systematic review questioned the added benefit of oxygen saturation measurements compared to standard consultations. **Overall:** Home monitoring programs showed safety and high patient satisfaction, but effectiveness varied based on patient populations, monitoring intensity, and the pandemic stage. Studies often focused on low-risk patients, limiting generalizability. Future research should focus on high-risk individuals and the development of predictive algorithms to optimize resource allocation and intervention timing.
Discussion
The findings of this review highlight the potential benefits and challenges of home monitoring for COVID-19 patients. While several studies demonstrated the effectiveness of home monitoring in reducing hospitalizations, ICU admissions, and mortality, especially in the pre-hospital phase, there is a need for larger, more rigorously designed studies with better control groups to confirm these findings. The inconsistent results regarding the impact of home monitoring on hospital length of stay in the post-discharge phase emphasize the need for further research to better understand the factors that influence the effectiveness of home monitoring strategies. The review's findings also emphasize the importance of carefully selecting appropriate patient populations for home monitoring, as the effectiveness of this approach may be limited in high-risk patients. The development of predictive algorithms and risk stratification tools could improve the efficiency and efficacy of home monitoring programs. The impact of evolving treatments and vaccination strategies on the need for home monitoring should also be considered in future research.
Conclusion
Home monitoring programs proved safe and well-received by COVID-19 patients, across different disease phases. The optimal strategy depends on the patient's condition and disease phase. Prehospital monitoring effectively reduced hospitalization, while early discharge with oxygen support may shorten hospital stays, albeit extending care under hospital responsibility. Post-discharge monitoring offers support but demonstrated limited impact on hospitalization. The effectiveness of home monitoring is contingent on pandemic stage and patient selection. Future systems should adapt to changing needs, focusing on high-risk groups, preparing for future pandemics, and integrating with other home monitoring programs for various diseases.
Limitations
The review primarily relied on existing literature, which itself contained limitations. Many studies were retrospective, lacked robust control groups, and often included predominantly low-risk patient populations, limiting generalizability. The heterogeneity of study designs, patient populations, and monitoring protocols makes direct comparisons challenging. The review acknowledges that the dynamic nature of the COVID-19 pandemic, including the impact of vaccination and treatment advancements, affects the interpretation of study findings across different time points.
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