Patient and staff experiences of using technology-enabled and analogue models of remote home monitoring for COVID-19 in England: A mixed-method evaluation

Objective: To evaluate patient and staff experiences of using technology-enabled (‘tech-enabled’) and analogue remote home monitoring models for COVID-19, implemented in England during the pandemic. // Methods: Twenty-eight sites were selected for diversity in a range of criteria (e.g. pre-hospital or early discharge service, mode of patient data submission). Between February and May 2021, we conducted quantitative surveys with patients, carers and staff delivering the service, and interviewed patients, carers, and staff from 17 of the 28 services. Quantitative data were analysed using descriptive statistics and both univariate and multivariate analyses. Qualitative data were interpreted using thematic analysis. // Results: Twenty-one sites adopted mixed models whereby patients could submit their symptoms using either tech-enabled (app, weblink, or automated phone calls) or analogue (phone calls with a health professional) options; seven sites offered analogue-only data submission (phone calls or face-to-face visits with a health professional). Sixty-two patients and carers were interviewed, and 1069 survey responses were received (18 % response rate). Fifty-eight staff were interviewed, and 292 survey responses were received (39 % response rate). Patients who used tech-enabled modes tended to be younger (p = 0.005), have a higher level of education (p = 0.011), and more likely to identify as White British (p = 0.043). Most patients found relaying symptoms easy, regardless of modality, though many received assistance from family or friends. Staff considered the adoption of mixed delivery models beneficial, enabling them to manage large patient numbers and contact patients for further assessment as needed; however, they suggested improvements to the functionality of systems to better fit clinical and operational needs. Human contact was important in all remote home monitoring options. // Conclusions: Organisations implementing tech-enabled remote home monitoring at scale should consider adopting mixed models which can accommodate patients with different needs; focus on the usability and interoperability of tech-enabled platforms; and encourage digital inclusivity for patients

Self management of patients with mild COPD in primary care: randomised controlled trial

Objective: To evaluate the effectiveness of nurse-led telephone health coaching to encourage self-management in a primary care population with mild symptoms of COPD. Design: Pragmatic, multi-centre randomised controlled trial. Setting: 71 general practices in four areas of England. Participants: 577 people, with MRC dyspnoea grade 1 or 2, recruited from primary care COPD registers with spirometry confirmed diagnosis, were randomised to the intervention (n=289) or usual care (n=288). Interventions: Nurse-delivered telephone health coaching intervention, underpinned by Social Cognitive Theory, promoting: accessing smoking cessation services, increasing physical activity, medication management and action planning (4 sessions over 11 weeks; postal information at weeks 16 and 24). Nurses received two days of training. The usual care group received a leaflet about COPD. Main outcome measures: The primary outcome was health related quality of life at 12 months using the short version of the St Georges Respiratory Questionnaire (SGRQ-C). Results: The intervention was delivered with good fidelity: 86% of scheduled calls were delivered; 75% of participants received all four calls. 92% participants were followed-up at six months and 89% at 12 months. There was no difference in SGRQ-C total score at 12 months (mean difference -1.3, 95%CI -3.6 to 0.9; p=0.2). Compared to usual care participants, at six months follow-up, the intervention group reported significantly greater physical activity, more had received a care plan (44% v 30%), rescue packs of antibiotics (37% v 29%) and inhaler technique check (68% v 55%). There were no differences in other secondary outcomes (dyspnoea, smoking cessation, anxiety, depression, self-efficacy, objectively measured physical activity). Conclusions A novel telephone health coaching intervention to promote behaviour change in primary care patients with mild symptoms of dyspnoea did lead to changes in self-management activities, but did not improve health related quality of life. Trial registration Current controlled trials ISRCTN 0671039

Self management of patients with mild COPD in primary care : randomised controlled trial

Objective: To evaluate the effectiveness of nurse-led telephone health coaching to encourage self-management in a primary care population with mild symptoms of COPD. Design: Pragmatic, multi-centre randomised controlled trial. Setting: 71 general practices in four areas of England. Participants: 577 people, with MRC dyspnoea grade 1 or 2, recruited from primary care COPD registers with spirometry confirmed diagnosis, were randomised to the intervention (n=289) or usual care (n=288). Interventions: Nurse-delivered telephone health coaching intervention, underpinned by Social Cognitive Theory, promoting: accessing smoking cessation services, increasing physical activity, medication management and action planning (4 sessions over 11 weeks; postal information at weeks 16 and 24). Nurses received two days of training. The usual care group received a leaflet about COPD. Main outcome measures: The primary outcome was health related quality of life at 12 months using the short version of the St Georges Respiratory Questionnaire (SGRQ-C). Results: The intervention was delivered with good fidelity: 86% of scheduled calls were delivered; 75% of participants received all four calls. 92% participants were followed-up at six months and 89% at 12 months. There was no difference in SGRQ-C total score at 12 months (mean difference -1.3, 95%CI -3.6 to 0.9; p=0.2). Compared to usual care participants, at six months follow-up, the intervention group reported significantly greater physical activity, more had received a care plan (44% v 30%), rescue packs of antibiotics (37% v 29%) and inhaler technique check (68% v 55%). There were no differences in other secondary outcomes (dyspnoea, smoking cessation, anxiety, depression, self-efficacy, objectively measured physical activity). Conclusions A novel telephone health coaching intervention to promote behaviour change in primary care patients with mild symptoms of dyspnoea did lead to changes in self-management activities, but did not improve health related quality of life

Can we achieve better trial recruitment by presenting patient information through multimedia? : Meta-analysis of 'studies within a trial' (SWATs)

Acknowledgements We would like to acknowledge all those in the trial teams who supported this programme of SWATs, as well as our public contributors (Ailsa Donnelly and Judith Hogg). We also thank Paul Wallace (original MRC START applicant) and Reason Digital for multimedia development. We thank the patients who participated in the GHT2000, PSM COPD, HI-Light, seAFOod and STOP-ACEi trials, the members of the Birmingham and Nottingham Clinical Trials Units, the Research and Development Team at Hull University Teaching Hospitals NHS Trust, and the staff members at all the participating trial centres. Funding The authors wish to acknowledge the MRC Methodology Research Programme which funds this research (MRC grant reference: G1002325). The MRC has no role in study design; collection, management, analysis and interpretation of data; writing of the report; or the decision to submit the report for publication.Peer reviewedPublisher PD

The impact of post-hospital remote monitoring of COVID-19 patients using pulse oximetry: A national observational study using hospital activity data.

BACKGROUND: There was a national roll out of 'COVID Virtual Wards' (CVW) during England's 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, reducing pressure on beds. This study is an evaluation of the impact of the CVW services on hospital activity. METHODS: Using retrospective patient-level hospital admissions data, we built multivariate models to analyze 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. FINDINGS: We 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 1·05, 95% CI 1·01 to 1·09). We found no evidence of a relationship between the availability of CVW and subsequent rates of readmission for COVID-19 (adjusted OR 0.97, 95% CI 0.91 to 1·03). INTERPRETATION: We found no evidence of early discharges or changes in 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 and on potentially important confounders) may have meant that true impacts, especially at a local level, were not ultimately discernible. It is important that future research is able to make use of better quality - preferably linked - data, from multiple sites. FUNDING: This is independent research funded by the National Institute for Health Research, Health Services & Delivery Research program (RSET Project no. 16/138/17; BRACE Project no. 16/138/31) and NHSE&I. NJF is an NIHR Senior Investigator

The impact of remote home monitoring of people with COVID-19 using pulse oximetry: A national population and observational study.

BACKGROUND: Remote 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). METHODS: The setting was all Clinical Commissioning Group (CCG) areas in England where there were complete data on the number of people enrolled onto the programme between 2nd November 2020 and 21st February 2021. We 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. FINDINGS: For every 10% increase in coverage of the programme, mortality was reduced by 2% (95% confidence interval:4% reduction to 1% increase), admissions increased by 3% (-1% to 7%), in-hospital mortality fell by 3% (-8% to 3%) and lengths of stay increased by 1·8% (-1·2% to 4·9%). None of these results are statistically significant, although the confidence interval indicates that any adverse effect on mortality would be small, but a mortality reduction of up to 4% may have resulted from the programme. INTERPRETATION: There are several possible explanations for our findings. One is that 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. FUNDING: This 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

Undertaking rapid evaluations during the COVID-19 pandemic: Lessons from evaluating COVID-19 remote home monitoring services in England.

INTRODUCTION: Rapid evaluations can offer evidence on innovations in health and social care that can be used to inform fast-moving policy and practise, and support their scale-up according to previous research. However, there are few comprehensive accounts of how to plan and conduct large-scale rapid evaluations, ensure scientific rigour, and achieve stakeholder engagement within compressed timeframes. METHODS: Using a case study of a national mixed-methods rapid evaluation of COVID-19 remote home monitoring services in England, conducted during the COVID-19 pandemic, this manuscript examines the process of conducting a large-scale rapid evaluation from design to dissemination and impact, and reflects on the key lessons for conducting future large-scale rapid evaluations. In this manuscript, we describe each stage of the rapid evaluation: convening the team (study team and external collaborators), design and planning (scoping, designing protocols, study set up), data collection and analysis, and dissemination. RESULTS: We reflect on why certain decisions were made and highlight facilitators and challenges. The manuscript concludes with 12 key lessons for conducting large-scale mixed-methods rapid evaluations of healthcare services. We propose that rapid study teams need to: (1) find ways of quickly building trust with external stakeholders, including evidence-users; (2) consider the needs of the rapid evaluation and resources needed; (3) use scoping to ensure the study is highly focused; (4) carefully consider what cannot be completed within a designated timeframe; (5) use structured processes to ensure consistency and rigour; (6) be flexible and responsive to changing needs and circumstances; (7) consider the risks associated with new data collection approaches of quantitative data (and their usability); (8) consider whether it is possible to use aggregated quantitative data, and what that would mean when presenting results, (9) consider using structured processes & layered analysis approaches to rapidly synthesise qualitative findings, (10) consider the balance between speed and the size and skills of the team, (11) ensure all team members know roles and responsibilities and can communicate quickly and clearly; and (12) consider how best to share findings, in discussion with evidence-users, for rapid understanding and use. CONCLUSION: These 12 lessons can be used to inform the development and conduct of future rapid evaluations in a range of contexts and settings