A rapid mixed-methods evaluation of remote home monitoring models during the COVID-19 pandemic in England

Fulop NJ, Walton H, Crellin N, Georghiou T, Herlitz L, Litchfield I, Massou E, Sherlaw-Johnson C, Sidhu M, Tomini SM, Vindrola-Padros C, Ellins J, Morris S, Ng PL
Record ID 32018005220
Authors' objectives: Remote home monitoring services were developed and implemented for patients with COVID-19 during the pandemic. Patients monitored blood oxygen saturation and other readings (e.g. temperature) at home and were escalated as necessary. To evaluate effectiveness, costs, implementation, and staff and patient experiences (including disparities and mode) of COVID-19 remote home monitoring services in England during the COVID-19 pandemic (waves 1 and 2). Delays in the presentation of patients with COVID-19 has led to patients arriving at hospital with very low oxygen saturations often without breathlessness (‘silent hypoxia’). This has resulted in patients being admitted to hospital with advanced COVID-19, thus requiring invasive treatment, potential admission to intensive care and poorer outcomes. Remote home monitoring models that systematically record and communicate patients’ physiological parameters to clinicians are currently being used globally for a variety of conditions. These models offer a potential solution for reducing the delays in providing appropriate treatment for patients with COVID-19 by identifying at-risk patients earlier. As a result, services providing remote home monitoring using pulse oximetry for patients with COVID-19 were developed ad hoc in some areas in England during the first wave of the pandemic (March to July 2020). Learning from these earlier services, NHS England and NHS Improvement (in November 2020) launched a national roll-out of a model of care called ‘COVID Oximetry @home (CO@h)’, followed by early discharge models, referred to as ‘virtual wards’ (in January 2021). We refer to these services as COVID-19 remote home monitoring services. All of these services provide patients with an oximeter and ask them to regularly record and relay their oxygen levels (alongside other generic COVID-19 symptoms) to a supporting team of administrators and clinicians via a smartphone application (app), e-mail or online portal, or over the telephone. Patients being monitored are escalated to receive additional care if necessary. Previous research has explored remote home monitoring for other conditions, but there is a lack of research on the effectiveness, cost, implementation and staff/patient experiences of remote home monitoring models for COVID-19. This study explored the impact and implications of these COVID-19 remote home monitoring services during the first and second waves of the pandemic.
Authors' results and conclusions: Phase 1 Findings from the review and empirical study indicated that these services have been implemented worldwide and vary substantially. Empirical findings highlighted that communication, appropriate information and multiple modes of monitoring facilitated implementation; barriers included unclear referral processes, workforce availability and lack of administrative support. Phase 2 We received surveys from 292 staff (39% response rate) and 1069 patients/carers (18% response rate). We conducted interviews with 58 staff, 62 patients/carers and 5 national leads. Despite national roll-out, enrolment to services was lower than expected (average enrolment across 37 clinical commissioning groups judged to have completed data was 8.7%). There was large variability in implementation of services, influenced by patient (e.g. local population needs), workforce (e.g. workload), organisational (e.g. collaboration) and resource (e.g. software) factors. We found that for every 10% increase in enrolment to 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. We found slightly longer hospital lengths of stay associated with virtual ward services (adjusted incidence rate ratio 1.05, 95% confidence interval 1.01 to 1.09), and no statistically significant impact on subsequent COVID-19 readmissions (adjusted odds ratio 0.95, 95% confidence interval 0.89 to 1.02). Low patient enrolment rates and incomplete data may have affected chances of detecting possible impact. The mean running cost per patient varied for different types of service and mode; and was driven by the number and grade of staff. Staff, patients and carers generally reported positive experiences of services. Services were easy to deliver but staff needed additional training. Staff knowledge/confidence, NHS resources/workload, dynamics between multidisciplinary team members and patients’ engagement with the service (e.g. using the oximeter to record and submit readings) influenced delivery. Patients and carers felt services and human contact received reassured them and were easy to engage with. Engagement was conditional on patient, support, resource and service factors. Many sites designed services to suit the needs of their local population. Despite adaptations, disparities were reported across some patient groups. For example, older adults and patients from ethnic minorities reported more difficulties engaging with the service. Tech-enabled models helped to manage large patient groups but did not completely replace phone calls. We were not able to find quantitative evidence that COVID-19 remote home monitoring services have been effective. However, low enrolment rates, incomplete data and varied implementation reduced our chances of detecting any impact that may have existed. While services were viewed positively by staff and patients, barriers to implementation, delivery and engagement should be considered. Better information is needed to know whether these services work. Staff and patients liked these services. However, improvements may make them easier to deliver and use (e.g. further staff training and giving additional support to patients who need it). A summary of findings is provided in Figure A. FIGURE ASummary of key findings. Our evaluation was unable to provide conclusive evidence regarding the effectiveness of COVID-19 remote home monitoring services on hospitalisations, lengths of hospital stay and mortality, due to low rates of enrolment and lack of data. Findings also outline large variability in the models implemented in relation to design and intensity of monitoring, workforce, enrolment levels and criteria. A number of factors influenced implementation including patient, staff, organisational and resource factors. Services were viewed positively by staff and patients alike, but some challenges to delivery and engagement have been identified, so services may not be appropriate for all groups without adaptations. Future remote home monitoring services for COVID-19 and other conditions should ensure that staff are well supported and have capacity to deliver these services, that patients have appropriate support, ability, and understanding to engage with these services. Findings from these studies highlighted the need for quality data to be collected as part of future service implementation in order to enable evaluations of effectiveness in future. Future research is needed in several areas. For example, longitudinal evidence on the effectiveness and cost-effectiveness of COVID-19 remote home monitoring services (requiring high-quality complete linked data sets) is needed. Additionally, research on the appropriateness of different models of remote home monitoring services for different groups of patients, and experiences of staff, patients and carers whose views may not have been captured within this evaluation are needed.
Authors' methods: A rapid mixed-methods evaluation, conducted in two phases. Phase 1 (July–August 2020) comprised a rapid systematic review, implementation and economic analysis study (in eight sites). Phase 2 (January–June 2021) comprised a large-scale, multisite, mixed-methods study of effectiveness, costs, implementation and patient/staff experience, using national data sets, surveys (28 sites) and interviews (17 sites). Limitations included data completeness, inability to link data on service use to outcomes at a patient level, low survey response rates and under-representation of some patient groups. This study used mixed methods consisting of two phases. One limitation of our evaluation was that data were commonly incomplete or absent and services were not used as extensively as expected; therefore, we were unable to conclusively determine the effectiveness of services. Additional limitations included the inability to link data on service use to outcomes at a patient level, low survey response rates and the under-representation of some patient groups.
Project Status: Completed
Year Published: 2023
URL for additional information: English
English language abstract: An English language summary is available
Publication Type: Full HTA
Country: England, United Kingdom
MeSH Terms
  • COVID-19
  • Coronavirus Infections
  • SARS-CoV-2
  • Home Care Services
  • Monitoring, Ambulatory
  • Monitoring, Physiologic
  • Pandemics
  • Delivery of Health Care
  • Telemedicine
Organisation Name: NIHR Health Services and Delivery Research programme
Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK
Contact Name: journals.library@nihr.ac.uk
Contact Email: journals.library@nihr.ac.uk
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