By Jay Furst
More than two years after it began, the COVID-19 pandemic continues to have a profound impact on how health care is delivered worldwide. Among the major changes in the U.S. is the pace at which telemedicine and virtual care has expanded.
Mayo Clinic and other health care organizations rapidly adapted established remote patient monitoring (RPM) programs to care for patients with confirmed COVID-19 infection who are at risk for severe disease. The RPM programs use technologies, including mobile apps, devices such as iPads with preconfigured questionnaires for symptom tracking, and automated text messaging for centralized care management on a real-time basis.
The programs also use peripheral medical devices for monitoring physiologic data, including vital signs and oxygen saturation, as well as phone or video telehealth visits, to support patients while they isolate and recover at home.
In addition to providing care for patients, RPM assists in limiting the spread of infection, and it enables health care systems to manage critical resources more efficiently at a time when hospitals and emergency departments have been filled to capacity and staff are stretched to the limit.
The COVID-19 RPM program has been well accepted by patients, and according to new research in Mayo Clinic Proceedings, high-risk patients with COVID-19 who were enrolled and engaged in the RPM program had lower rates of hospitalization and mortality than those who were enrolled but did not engage with the technology. The programs also were associated with lower total cost of care.
"Those who were engaged with the RPM program had better outcomes on a number of key measures, and their overall cost of care was lower than those who were not engaged with the technology," says Tufia Haddad, M.D., a medical oncologist at Mayo Clinic and medical director of Digital Product and Platform Strategy in the Center for Digital Health. "These findings are encouraging and have potential policy and reimbursement implications for extension and wider use of this acute care delivery model. They also highlight the need to better understand why some patients do not engage with the RPM technology platform."
The retrospective analysis included patients diagnosed with COVID-19 and at risk of severe disease who were enrolled in Mayo's RPM program in the Midwest between March 2020 and October 2021. Among 5,796 patients enrolled in the RPM program, 80% engaged with the technology, which included a cellular-enabled tablet and Bluetooth-enabled medical devices. Patients completed vital sign measurements and symptom assessment questions two to four times per day, and a virtually centralized team of RPM registered nurses responded to technology-generated alerts and involved physicians and advanced care providers for escalation of care as needed. Clinical support was provided 24 hours per day, seven days per week.
Those patients who engaged with the program had a significantly lower mortality rate — the all-cause, 30-day mortality rate was 0.5% for those who were engaged with the program and 1.7% who did not. Patients who were engaged also had a significantly lower rate of one or more hospitalizations, prolonged hospitalization and ICU admission.
"The findings suggest that the RPM program enabled health care staff to detect adverse health trends earlier, respond quickly with supportive care interventions and alter the trajectory of the disease," Dr. Haddad says.
Incidence of one or more emergency department visits were similar for engaged and nonengaged patients, though engaged patients were more likely to experience two or more visits, an anticipated result of close, round-the-clock monitoring and the RPM program's protocol of directing patients to the emergency department if health indicators changed.
The in-home technology package was provided at no cost to patients. Those who engaged with the RPM program experienced a significantly lower cost of care than the nonengaged patients, with an average cost savings of $1,259 during the 30-day follow-up period, due primarily to lower rates of hospitalization and shorter lengths of stay in hospital.
"The total cost savings for the 1,128 patients who were engaged in the RPM program was about $1.4 million," Dr. Haddad says. "The findings suggest that a well-engaged RPM program not only results in better patient outcomes and better management of hospital capacity, but also substantial cost savings for patients and health care systems. The benefits of the program directly address the triple aim of health care."
Another promising finding in the Mayo research is that racial and ethnic minority patients were as likely as non-Hispanic white patients to engage with the RPM technology and program.
"This was an important and unexpected observation," Dr. Haddad says. "Many other studies have demonstrated lower rates of telehealth adoption in Black and Hispanic patients. If further research were to show consistent engagement of this kind, it is feasible that RPM programs could help improve outcomes in these populations that have been disproportionately impacted by the pandemic."
According to a related editorial in Proceedings, the COVID-19 pandemic has intensified the existing health disparities in people at higher risk. Studies cited in the article have shown an increase in excess mortality among Black patients as a result of the pandemic, due to many factors that include higher frequency of COVID-19 infections, less access to health care and other socioeconomic factors. The authors examine the pandemic's impact on cardiovascular death in the U.S. and find a 300% higher rate of excess cardiovascular death among Black people compared with non-Hispanic whites.
Among the strengths cited in the Mayo research is that it included underrepresented minority populations, as well as older patients and those who live in rural areas. These underserved populations also have been disproportionately affected by inequities in health care, and RPM programs can be especially valuable to reach those patients, according to the article.
More research is needed to understand why 20% of patients who enrolled in the program did not engage with the technology, and this highlights the need for further research to improve digital health literacy and program adoption.
"Remote patient monitoring enables the health care team to help at-risk patients recover at home, ideally remaining out of the hospital or reducing the time they spend in the hospital," Dr. Haddad says. "It also may enable us to reach patient populations who have been hardest hit by COVID-19, and there appear to be cost savings as well. These are all reasons to continue exploring this acute care delivery model beyond the pandemic."