Population-level management of Type 1 diabetes via continuous glucose monitoring and algorithm-enabled patient prioritization: Precision health meets population health

OBJECTIVE: To develop and scale algorithm-enabled patient prioritization to improve population-level management of type 1 diabetes (T1D) in a pediatric clinic with fixed resources, using telemedicine and remote monitoring of patients via continuous glucose monitor (CGM) data review. RESEARCH DESIGN AND METHODS: We adapted consensus glucose targets for T1D patients using CGM to identify interpretable clinical criteria to prioritize patients for weekly provider review. The criteria were constructed to manage the number of patients reviewed weekly and identify patients who most needed provider contact. We developed an interactive dashboard to display CGM data relevant for the patients prioritized for review. RESULTS: The introduction of the new criteria and interactive dashboard was associated with a 60% reduction in the mean time spent by diabetes team members who remotely and asynchronously reviewed patient data and contacted patients, from 3.2 ± 0.20 to 1.3 ± 0.24 min per patient per week. Given fixed resources for review, this corresponded to an estimated 147% increase in weekly clinic capacity. Patients who qualified for and received remote review (n = 58) have associated 8.8 percentage points (pp) (95% CI = 0.6–16.9 pp) greater time-in-range (70–180 mg/dl) glucoses compared to 25 control patients who did not qualify at 12 months after T1D onset. CONCLUSIONS: An algorithm-enabled prioritization of T1D patients with CGM for asynchronous remote review reduced provider time spent per patient and was associated with improved time-in-range

Effect of the COVID-19 Pandemic on Patient Volumes, Acuity, and Outcomes in Pediatric Emergency Departments: A Nationwide Study

Objectives The aim of this study was to quantify the effect of the COVID-19 pandemic on pediatric emergency department (ED) utilization and outcomes. Methods This study is an interrupted-Time-series observational study of children presenting to 11 Canadian tertiary-care pediatric EDs. Data were grouped into weeks in 3 study periods: prepandemic (January 1, 2018-January 27, 2020), peripandemic (January 28, 2020-March 10, 2020), and early pandemic (March 11, 2020-April 30, 2020). These periods were compared with the same time intervals in the 2 preceding calendar years. Primary outcomes were number of ED visits per week. The secondary outcomes were triage acuity, hospitalization, intensive care unit (ICU) admission, mortality, length of hospital stay, ED revisits, and visits for trauma and mental health concerns. Results There were 577,807 ED visits (median age, 4.5 years; 52.9% male). Relative to the prepandemic period, there was a reduction [-58%; 95% confidence interval (CI),-63% to-51%] in the number of ED visits during the early-pandemic period, with concomitant higher acuity. There was a concurrent increase in the proportion of ward [odds ratio (OR), 1.39; 95% CI, 1.32-1.45] and intensive care unit (OR, 1.20; 95% CI, 1.01-1.42) admissions, and trauma-related ED visits among children less than 10 years (OR, 1.51; 95% CI, 1.45-1.56). Mental health-related visits in children declined in the early-pandemic period (in \u3c10 years,-60%; 95% CI,-67% to-51%; in children ≥10 years:-56%; 95% CI,-63% to-47%) relative to the pre-COVID-19 period. There were no differences in mortality or length of stay; however, ED revisits within 72 hours were reduced during the early-pandemic period (percent change:-55%; 95% CI,-61% to-49%; P \u3c 0.001). Conclusions After the declaration of the COVID-19 pandemic, dramatic reductions in pediatric ED visits occurred across Canada. Children seeking ED care were sicker, and there was an increase in trauma-related visits among children more than 10 years of age, whereas mental health visits declined during the early-pandemic period. When faced with a future pandemic, public health officials must consider the impact of the illness and the measures implemented on children\u27s health and acute care needs

Public Perspectives on Exposure Notification Apps: A Patient and Citizen Co-Designed Study

Canada deployed a digital exposure notification app (COVID Alert) as a strategy to support manual contact tracing. Our aims are to (1) assess the use, knowledge, and concerns of the COVID Alert app, (2) identify predictors of app downloads, and (3) develop strategies to promote social acceptability. A 36-item questionnaire was co-designed by 12 citizens and patients partnered with 16 academic researchers and was distributed in the province of Québec, Canada, from May 27 to 28 June 2021. Of 959 respondents, 43% had downloaded the app. Messaging from government sources constituted the largest influence on app download. Infrequent social contacts and perceived app inefficacy were the main reasons not to download the app. Cybersecurity, data confidentiality, loss of privacy, and geolocation were the most frequent concerns. Nearly half of the respondents inaccurately believed that the app used geolocation. Most respondents supported citizen involvement in app development. The identified predictors for app uptake included nine characteristics. In conclusion, this project highlights four key themes on how to promote the social acceptability of such tools: (1) improved communication and explanation of key app characteristics, (2) design features that incentivize adoption, (3) inclusive socio-technical features, and (4) upstream public partnership in development and deployment

Health and healthcare disparities associated with the digital divide

The prioritization of telehealth in response to the COVID-19 pandemic may accelerate progress to virtual integrated care at scale. However, disparities in healthcare and health outcomes may widen if telehealth is not accessible to the underserved communities that are most in need. Providers faced with practical constraints have already defaulted into a two-tiered system of telehealth: technology-driven, integrated care for those with the requisite resources; and phone-based, ad-hoc care, possibly less effective, for those without. Insights based on data from federal organizations offer a starting point for primary care providers to understand common structural barriers to telehealth access, identify interventions they can implement to increase equity in their virtual care practice, and advocate for their patients.http://deepblue.lib.umich.edu/bitstream/2027.42/166083/1/Digital Divide and Health Disparities_01.27.2021JH.pdfDescription of Digital Divide and Health Disparities_01.27.2021JH.pdf : Main ArticleSEL

Considerations for the Design and Implementation of COVID-19 Contact Tracing Apps: Scoping Review

BackgroundGiven the magnitude and speed of SARS-CoV-2 transmission, achieving timely and effective manual contact tracing has been a challenging task. Early in the pandemic, contact tracing apps generated substantial enthusiasm due to their potential for automating tracing and reducing transmission rates while enabling targeted confinement strategies. However, although surveys demonstrate public interest in using such apps, their actual uptake remains limited. Their social acceptability is challenged by issues around privacy, fairness, and effectiveness, among other concerns. ObjectiveThis study aims to examine the extent to which design and implementation considerations for contact tracing apps are detailed in the available literature, focusing on aspects related to participatory and responsible eHealth innovation, and synthesize recommendations that support the development of successful COVID-19 contact tracing apps and related eHealth technologies. MethodsSearches were performed on five databases, and articles were selected based on eligibility criteria. Papers pertaining to the design, implementation, or acceptability of contact tracing apps were included. Articles published since 2019, written in English or French, and for which the full articles were available were considered eligible for analysis. To assess the scope of the knowledge found in the current literature, we used three complementary frameworks: (1) the Holistic Framework to Improve the Uptake and Impact of eHealth Technologies, (2) the Montreal model, and (3) the Responsible Innovation in Health Assessment Tool. ResultsA total of 63 articles qualified for the final analysis. Less than half of the selected articles cited the need for a participatory process (n=25, 40%), which nonetheless was the most frequently referenced item of the Framework to Improve the Uptake and Impact of eHealth Technologies. Regarding the Montreal model, stakeholder consultation was the most frequently described level of engagement in the development of contact tracing apps (n=24, 38%), while collaboration and partnership were cited the least (n=2, 3%). As for the Responsible Innovation in Health framework, all the articles (n=63, 100%) addressed population health, whereas only 2% (n=1) covered environmental considerations. ConclusionsMost studies lacked fundamental aspects of eHealth development and implementation. Our results demonstrate that stakeholders of COVID-19 contact tracing apps lack important information to be able to critically appraise this eHealth innovation. This may have contributed to the modest uptake of contact tracing apps worldwide. We make evidence-informed recommendations regarding data management, communication, stakeholder engagement, user experience, and implementation strategies for the successful and responsible development of contact tracing apps

Public perspectives on exposure notification apps: A patient and citizen co-designed study

Canada deployed a digital exposure notification app (COVID Alert) as a strategy to support manual contact tracing. Our aims are to (1) assess the use, knowledge, and concerns of the COVID Alert app, (2) identify predictors of app downloads, and (3) develop strategies to promote social acceptability. A 36-item questionnaire was co-designed by 12 citizens and patients partnered with 16 academic researchers and was distributed in the province of Québec, Canada, from May 27 to 28 June 2021. Of 959 respondents, 43% had downloaded the app. Messaging from government sources constituted the largest influence on app download. Infrequent social contacts and perceived app inefficacy were the main reasons not to download the app. Cybersecurity, data confidentiality, loss of privacy, and geolocation were the most frequent concerns. Nearly half of the respondents inaccurately believed that the app used geolocation. Most respondents supported citizen involvement in app development. The identified predictors for app uptake included nine characteristics. In conclusion, this project highlights four key themes on how to promote the social acceptability of such tools: (1) improved communication and explanation of key app characteristics, (2) design features that incentivize adoption, (3) inclusive socio-technical features, and (4) upstream public partnership in development and deployment