DOI: 10.3886/icpsr38951.v1
title: Comparing Ways to Monitor Patients with COVID-19 at Home (COVID Watch), New Jersey, Pennsylvania, Delaware, 2020-2021
title: Version 1

description: The University of Pennsylvania Health System (Penn Medicine) developed COVID Watch, an automated text message-based, remote monitoring program with 24/7 clinical support. Remote outpatient monitoring of patients with COVID-19 became needed because patients with SARS-CoV-2 infection can decline rapidly and unpredictably, and because of their own limited capacity to manage acute symptoms and concerns about staff safety, office-based outpatient practices often redirect patients with confirmed or suspected COVID-19 to hospitals. As a result, emergency departments (EDs) and hospitals became overwhelmed during surge periods of high community incidence rates and prevalence. Remote monitoring has the potential to facilitate ED- and hospital-level care for patients who require it while supporting access to care for patients who can safely remain at home.
This study compared outcomes for patients enrolled in COVID Watch with those of patients who were eligible to enroll but received usual care, with the hypothesis that enrollment in COVID Watch was associated with reduced mortality. The present research examined whether patients with COVID-19 who were enrolled in COVID Watch experienced better health outcomes compared with usual care (Aim 1) and whether augmenting COVID Watch with at-home monitoring of SpO2 (blood-oxygen saturation) improves patient outcomes (Aim 2).
description: The purpose of this study was to examine whether patients with COVID-19 who were enrolled in COVID Watch, a text-message based remote monitoring program experienced better health outcomes compared with usual care, and whether augmenting COVID Watch with at-home monitoring of SpO2 (blood-oxygen saturation) improved patient outcomes.
description: This is a retrospective cohort study that follows the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guideline for reporting observational studies.
Penn Medicine is an academic health system serving large portions of southeast Pennsylvania, New Jersey, and Delaware, with 6 hospitals and hundreds of outpatient practices. Community-dwelling adults (aged &gt;18 years) with presumed or confirmed COVID-19 could be enrolled in COVID Watch through an electronic health record order. The health care worker entering the electronic order did not have to be a physician and could include nurses, social workers, and care coordinators involved in the patient's care in the health system. Enrollment often occurred during or after a provider had a conversation with a patient. Patients were not required to have established care with a Penn Medicine provider, having only received COVID-19 testing at Penn Medicine, for example.
The first patient was enrolled on March 23rd, 2020. The enrollment order results in an instantaneous text message sent to the patient introducing them to the program. Once enrolled and the patient texts back confirming they want to engage with the program, they begin receiving twice-daily automated text message check-ins asking the following question: "How are you feeling compared to 12 hours ago: better, same, or worse?" Patients replying "worse" receive a follow-up question: "Is it harder than usual for you to breath: yes or no?" For patients who respond "yes," an alert is generated for a telemedicine clinician to contact the patient by telephone within 1 hour.
Outside of the twice-daily check-ins, patients were instructed to text "worse" to trigger a clinician call back. During the daytime, nurses were the primary responders, with support from nurse practitioners and physicians. At night, escalations were directly relayed to on-call nurse practitioners and physicians. The clinical team for COVID Watch received regular training and guidelines for managing patients with COVID-19. After an escalation, clinicians could provide reassurance, advise how best to manage symptoms at home, prescribe medications, or redirect patients to the emergency department (ED). The program continued for 14 days from enrollment, at which point patients were offered the option to remain enrolled for 7 more days. A Spanish-language version of COVID Watch was made available on May 18th, 2020.
description: This study includes variables regarding COVID-19 status and treatment, general health history and demographics, and descriptives of medical care.
description: Response Rates: Of the 3,488 patients enrolled in COVID Watch, 3,028 (86.8%) engaged by responding to at least one text (mean: 23 check-in responses).
description: This study included 2 Aims, which included different methods. Aim 1 was to examine whether patients with COVID-19 who were enrolled in COVID Watch, a text-message based remote monitoring program experience better health outcomes compared with usual care. Aim 2 was to examine whether augmenting COVID Watch with at-home monitoring of SpO2 (blood-oxygen saturation) improved patient outcomes.
<b>Aim 1:</b>
The overall sample included 7865 patients, 3488 of which who were in enrolled in the COVID Watch program and 4377 in usual care as a comparison group.
Patient Exclusion: Patients who tested positive for COVID-19 as outpatients at Penn Medicine between March 23 and November 30, 2020 after excluding those less than 18, those who were enrolled in home health or hospice or who resided in long-term care (N=8249). Then the research team excluded patients enrolled before COVID Watch was launched in their site (N=144), followed by patients enrolled greater than 7 days after or before anchor date (N=118); patients with prior evidence of long-term care even though no longer in long-term care (N=88); and patients who were DNR (do not resuscitate)/DNI (do not intubate) at or before time of COVID-19 test (N=14). The final sample included in propensity score weighted analysis was 7865.
<b>Aim 2:</b>
Randomized controlled trial of adult outpatients with suspected or confirmed COVID-19 in a mid-Atlantic academic health system between 11/30/20 and 2/5/21 and who were enrolled in COVID Watch, a home monitoring program for COVID-19. 1056 patients (611 COVID-19 positive) were assigned to receive automated remote monitoring of both peripheral oxygen saturation levels and self reported symptoms of dyspnea and 1041 (606 COVID-19 positive) to receive symptom monitoring alone.
Study Population: All home-dwelling patients 18 years or older who received COVID Watch during the study period were eligible and automatically enrolled in the trial to receive standard COVID Watch or COVID Watch + Pulse Oximetry. Patients who should have been excluded from COVID Watch receipt (e.g., already receiving home health services, skilled nursing, inpatient rehabilitation, or an alternative remote monitoring program for patients) were uninvited from COVID Watch within 48 hours based on standard operational procedures. These patients, as well as those with an invalid date of birth, were excluded from the trial's analytic cohorts.
description: Datasets: 
DS0: Study-Level Files
DS1: Aim 1 Analytical Data
DS2: Aim 1 Return Visit Data
DS3: Aim 1 Escalation Data
DS4: Aim 2 Analytical Data
DS5: Aim 2 Escalation Data
DS6: Aim 2 Return Visits Data
DS7: Aim 2 Survey Data
DS8: Do Not Resuscitate/Do Not Intubate Data
description: Adults who tested positive for SARS-CoV-2. Smallest Geographic Unit: State
description: record abstracts; remote sensing; web-based survey