Our objective is to evaluate clinical and implementation outcomes of COVID Watch, an automated, text message-based remote monitoring intervention for home-dwelling adults diagnosed with COVID-19, especially among Black and Latino patients. This project identifies an adaptation to healthcare delivery that may positively improve COVID-19 care for vulnerable populations.
The clinical guidance for 90 percent of infected COVID-19 adult patients who do not meet eligibility for home care or inpatient admission is to self-isolate. To support these patients, alternatives to in-person care are needed to manage an unpredictable clinical course; identify and intercept patients rapidly deteriorating at home, prevent viral spread during in-person visits; and minimize future surges in emergency departments (EDs). In addition, fingertip pulse oximeters have been proposed to improve in-home early detection of respiratory deteriorations but are untested and the operational infrastructure to support large-scale monitoring is limited.
While telemedicine has been widely adopted during the pandemic as an alternative to conventional outpatient care, limited telemedicine access may be exacerbating observed disparities for Black and Latino patients. In our health system, Black and Latino patients used video-visits 15 percent less often than white patients. Text messaging and phone calls may improve healthcare access for communities of color, but the evidence for these telecommunication modalities to be effective and improve equity are limited.
The University of Pennsylvania Health System (UPHS) developed and deployed COVID Watch to improve access to health care for COVID-19 patients who are self-isolating at home. COVID Watch sends twice-daily, scheduled text messages to assess patients for shortness of breath using a clinical algorithm to determine whether patients need an urgent escalation to a team of dedicated, on-call nurses within one hour. These nurses are supported by an on-call team of clinicians who can conduct urgent phone or video assessments. Patients can also trigger the algorithmic assessment independent of the scheduled messages. To date, COVID Watch has managed 3,628 COVID-19 patients at home, of which 1,295 are confirmed COVID-19 positive; of these, 61 percent are Black or Latino, higher than the proportion of all UPHS COVID-19 positive patients that are Black or Latino (55 percent).
Our hybrid effectiveness-implementation study is significant because it will evaluate the potential for novel remote monitoring programs to improve COVID-19 care and has an important focus on Black and Latino patients. COVID Watch also provides an operational infrastructure for distributing and evaluating the added benefit of dispensing pulse oximeters to COVID-19 patients at home. The proposal’s specific aims are to:
Aim 1. Conduct a retrospective quantitative evaluation using secondary data (obtained via Electronic Medical Records and the National Death Index) to evaluate clinical outcomes for COVID Watch patients, particularly for Black and Latino patients. Hypotheses: Compared with patients tested for COVID-19 in locations where COVID Watch enrollment had not yet been implemented, COVID Watch enrollment will be associated with a higher number of Days Alive and Out of Hospital in the overall population (H1a), and among Black and Latino patients (H1b).
Aim 2. Conduct a pragmatic randomized controlled trial to determine the incremental benefit of providing home pulse oximetry for patients enrolled in COVID Watch. Hypotheses: Provision of pulse oximetry will lead to a higher number of Days Alive and Out of Hospital (H2a) in the overall population, and among Black and Latino patients (H2b).
Aim 3. Use a mixed methods approach to quantify uptake, trajectories, and predictors of COVID Watch activity and query health system leaders, clinicians, and patients to understand contextual factors related to COVID Watch referral, program engagement, and health care access.
Overall study design:
- Hybrid effectiveness-implementation study design using quasi-experimental analyses, a pragmatic randomized controlled trial, surveys, and qualitative interviews.
The Intervention and Comparator(s):
- Intervention: An automated home monitoring program for COVID-19 patients with and without home pulse oximetry
- Comparator: Usual care for COVID-19 patients, including telemedicine visits and ED visits
- Patients 18 years and older who test positive for COVID-19
Primary and Secondary Outcomes:
- Primary: A composite endpoint of Days Alive and Out of Hospital
- Secondary: Automated remote monitoring implementation facilitators and barriers
- 30-day follow-up for the primary outcome