Community health worker knowledge, attitudes and practices towards COVID-19: learnings from an online cross-sectional survey using a digital health platform, UpSCALE, in Mozambique

Healthcare workers (HCWs) are at the frontline of the Coronavirus Disease 2019 (COVID-19) pandemic response, yet there is a paucity of literature on their knowledge, attitudes and practices (KAP) in relation to the pandemic. Community Health Workers (CHWs) in Mozambique are known locally as agentes polivalentes elementares (APEs). While technical guidance surrounding COVID-19 is available to support APEs, communicating this information has been challenging due to restrictions on travel, face-to-face group meetings and training, imposed from May to August 2020. A digital health platform, upSCALE, that already supports 1,213 APEs and 299 supervisors across three provinces, is being used to support APEs on effective COVID-19 management by delivering COVID-19 sensitive SMS messages, training modules and a COVID-19 KAP survey. The KAP survey, conducted from June 2020 to August 2020, consisted of 10 questions. Of 1,065 active upSCALE APEs, 28% completed the survey. Results indicate that only a small proportion of APEs listed the correct COVID-19 symptoms, transmission routes and appropriate prevention measures (n = (25%), n = (16%) and n = (39%), respectively) specifically included in national health education materials. Misconceptions were mainly related to transmission routes, high risk individuals and asymptomatic patients. 84% said they followed all government prevention guidelines. The results from the KAP survey were used to support the rapid development and deployment of targeted COVID-19 awareness and education materials for the APEs. A follow-up KAP survey is planned for November 2020. Adapting the existing upSCALE platform enabled a better understanding, in real time, of the KAP of APEs around COVID-19 management. Subsequently, supporting delivery of tailored messages and education, vital for ensuring a successful COVID-19 response.

Impact of remote continuous positive airway pressure set-up on treatment usage and effectiveness

Introduction: Initiating treatment with continuous positive airway pressure (CPAP) traditionally relies on in-person visits with trained therapists to provide hands-on instruction regarding CPAP usage and mask fit. To overcome geographic barriers and reduce COVID-19 transmission, health systems increasingly rely on remote set-ups of mailed equipment. Despite a strong rationale for the mailed approach, relative effectiveness is unclear. Methods: Our VA medical center shifted from in-person to mailed CPAP dispensation during the COVID-19 pandemic in March 2020. Using VA administrative and wireless CPAP usage data, we assembled a cohort of patients with newly diagnosed obstructive sleep apnea (OSA) who initiated CPAP for the first time from July 2019 to August 2020. Our primary outcome was mean nightly usage over the first 90 days. We compared patients with in-person vs. mailed CPAP dispensation using generalized linear models adjusted for age, gender, race, and Charlson Comorbidity Index. Among patients with >1 hour of overall usage, we compared secondary outcomes of leak, apnea hypopnea index (AHI), and obstructive/central apnea indices. Results: We identified 693 patients with newly diagnosed OSA whose CPAP was provided in-person and 296 who had CPAP mailed. Nightly usage in the first 90 days was modest in both groups (in-person: 149.7, mailed: 152.9 min/night), and we did not detect a difference in adjusted models (+7.6 min/night, 95%CI -13.6-28.8). We also did not detect a difference in 95th percentile leak (-1.2 liter/minute, 95%CI -3.3-0.9). Device-detected AHI was relatively low overall (in-person: 3.2, mailed: 4.1 events/hour), but was greater in the mailout group (+1.0/hour, 95%CI 0.2-1.7). AHI differences appeared to be driven by obstructive (+0.5/hour, 95%CI 0.2-0.8) but not central events (-0.1, 95% CI -0.2-0.4). Risk of AHI>5 was comparable between groups (in-person: 17.3%, mailed: 19.0%, OR 1.2, 95%CI 0.8-1.7). Conclusion: We were able to switch from an in-person to a mailbased system of CPAP initiation without a change in CPAP adherence or mask leak. While AHI was slightly greater in the mailed group, the clinical significance of this finding is unclear. Future work will need to evaluate the impact of remote CPAP dispensation on patient-centered outcomes.

Optimizing telehealth technology in sleep medicine at a VA medical center during the COVID19 pandemic

Introduction: The COVID19 pandemic poses an unprecedented challenge for healthcare delivery. Optimization of resources and safety of patients and healthcare workers is crucial. The aim of this study is to analyze impact on resource utilization at VA Maryland Healthcare System (VAMHCS). At the pandemic onset, we deployed a mail-in store-and-forward technology (SFT) for carrying out home sleep apnea testing (HSAT), using WatchpatDirect® Peripheral Arterial Tonometry-based testing. This led to a substantial decrease in reliance on care in the community (CITC) or out-of-VA care, resulting in fiscal savings. Interpretation of studies is done by VA physicians using a cloud-based network, resulting in improved workforce optimization and continuity of care. Methods: We compared CITC expenditures for sleep studies in financial year (FY) 2019 (October 2018 to September 2019) with that of FY2020 in the VA Support Service Center Capital Assets (VSSC) database. Results: In FY2019, VAMHCS conducted 402 polysomnograms, 805 HSATs and referred 64 patients to CITC, including 5 HSATs, with CITC costs of $102,388. CITC referral initiated by primary care providers often resulted in clinic visit and polysomnography (PSG). In FY2020, VAMHCS conducted 436 PSGs, 986 HSATs and referred 10 patients to CITC, including 3 HSATs, costing $6,780;a decrease of $95,608 compared to FY2019. The ratio of VA to CITC studies was 18:1 in FY2019, compared to 142:1 in FY2020. VAMHCS conducted 166 HSATs between 3-15-2020 and 6-30-2020, while the sleep lab was closed due to COVID surge, at a cost of $160 per study. According to VSSC data, an average of $1,005 is spent per patient (including a thirdparty administrator fee of $200) when utilizing CITC. Approximately 80% of CITC referrals underwent PSG. If all studies were done using CITC, it would have cost an additional $ 140,270. The cost would have been $546, 855 if all studies done between 3-15-2020 and 9-30-2020 were done through CITC. Conclusion: The use of SFT during the pandemic resulted in VAMHCS relying less on CITC, leading to a decrease in expenditure, administrative burden and turnaround time. SFT minimizes the risk of infection transmission because PAT probes are disposable and obviates patient visits to the hospital.

Video telehealth increased during COVID-19 pandemic among va pulmonary clinics, but barriers remain to reaching similar levels of use as primary care and among high risk groups

RationaleThe COVID-19 pandemic has shifted care away from face to face encounters towards telephone and video telehealth. To accommodate this, the VA prioritized use of VA Video Connect (VVC) a software platform that connects providers with patients on their personal devices. As there may be factors particular to pulmonary or other specialty care clinics that are barriers or facilitators of VVC use, we wished to describe uptake of VVC in pulmonary clinics relative to a comparable specialty (cardiology) and primary care. We also sought to evaluate whether appropriate high-risk patient groups were being prioritized for VVC (e.g rural Veterans with limited access to VA services and older Veterans) to inform program development to facilitate wider expansion of this technology. MethodsWe collected data from the Veteran Health Administration Support Service Center (VSSC). We identified all encounters associated with a Pulmonary/Chest clinic location, Cardiology clinic, and Primary Care clinic. Among those encounters we identified all scheduled as VVC and sliced data by standard VA definitions of rurality. We compared use of VVC, as a proportion of total encounters, in September 2019 and September 2020 at the end of each fiscal year. As this study was hypothesis generating, we did not perform statistical testing though anticipate all differences would have been significant. Results We found that 0.02% of cardiology, 0.2% of pulmonary and 0.3% of primary care visits were conducted using VVC in 2019 and had increased to 6%, 6% and 14% respectively in 2020 (Table 1). During the pandemic, Veterans living in rural areas and highly rural were approximately half and one-quarter as likely to have a VVC encounter with a specialty clinic (cardiology or pulmonary) as Veterans in urban areas, respectively. Use of VVC was higher in primary care than specialty care clinics across rurality groups. Although use increased substantially across all age groups between 2019-20, it decreased with increasing age group across all three clinic types - with Veterans 85+y approximately half as likely to use VVC as Veterans 45-64y in both primary and specialty care. ConclusionsPrimary care use of video telehealth was higher than in specialty care clinics, potentially due to concerns about ability to examine and appropriately triage patients. Groups with limited access to hospital beds and at higher risk of severe complications of COVID infection were less likely to use VVC, suggesting targeted efforts are necessary to improve VVC use among high risk groups. .

Patient experiences with telehealth in sleep medicine: A qualitative evaluation

Rationale: The field of sleep medicine has been an avid adopter of telehealth, particularly during the COVID-19 pandemic. While numerous randomized trials support the efficacy of telehealth to treat conditions such as obstructive sleep apnea (OSA) and insomnia, relatively little is known about patients' experiences and perceptions of telehealth in typical practice. Methods: We recruited a purposive sample of patients who had sleep provider encounters via one of three telehealth modalities: in-clinic video, home-based video, and telephone. We conducted semi-structured interviews to assess general telehealth experiences, elicit perceptions around most and least helpful aspects, and contrast their experiences with in-person care. Two analysts coded transcripts using content analysis. After review of coding and categorization, the analysts identified emergent themes that cut across participants and categories. Results: We conducted interviews with 35 patients (in-clinic video n=12, home-based video n=11, telephone n=12) at two VA medical centers from June 2019 to May 2020. Five themes emerged including access to care, security and privacy, personalization of care, patient empowerment, and unmet needs. 1) Access to care: Patients perceived that telehealth provided access to sleep care in a timely and convenient manner, especially during the COVID-19 pandemic. Patients also saw telehealth as a way to improve continuity of care with their preferred providers. 2) Security and Privacy: Patients described how home-based telehealth afforded them greater feelings of safety and security within appointments due to avoidance of anxiety provoking triggers (e.g. crowds). However, patients also noted a potential loss of privacy when telehealth was delivered at home. 3) Personalization of care: Patients outlined ways in which telehealth both improved and hindered their ability to communicate their individual needs to providers. In turn, this communication translated into the delivery of personalized care and positive health impacts. 4) Patient Empowerment: Patients described how telehealth empowered them to engage in self-management for their sleep disorders. 5) Unmet Needs: Patients recognized that there were specific areas where telehealth was not meeting their needs, including lack of follow-through with PAP therapy. Patients also expressed concerns around the lack of a physical examination. Conclusion: Patients described both positive and negative experiences with telehealth, highlighting areas where care can be further adapted to better suit their needs. As we continue to refine telehealth practices, we encourage providers and hospital systems to consider these aspects of the patient experience.

Interpret with caution: An evaluation of the commercial AusDiagnostics versus in-house developed assays for the detection of SARS-CoV-2 virus.

INTRODUCTION: There is limited data on the analytical performance of commercial nucleic acid tests (NATs) for laboratory confirmation of COVID-19 infection. METHODS: Nasopharyngeal, combined nose and throat swabs, nasopharyngeal aspirates and sputum was collected from persons with suspected SARS-CoV-2 infection, serial dilutions of SARS-CoV-2 viral cultures and synthetic positive controls (gBlocks, Integrated DNA Technologies) were tested using i) AusDiagnostics assay (AusDiagnostics Pty Ltd); ii) in-house developed assays targeting the E and RdRp genes; iii) multiplex PCR assay targeting endemic respiratory viruses. Discrepant SARS-CoV-2 results were resolved by testing the N, ORF1b, ORF1ab and M genes. RESULTS: Of 52 clinical samples collected from 50 persons tested, respiratory viruses were detected in 22 samples (42 %), including SARS CoV-2 (n = 5), rhinovirus (n = 7), enterovirus (n = 5), influenza B (n = 4), hMPV (n = 5), influenza A (n = 2), PIV-2 (n = 1), RSV (n = 2), CoV-NL63 (n = 1) and CoV-229E (n = 1). SARS-CoV-2 was detected in four additional samples by the AusDiagnostics assay. Using the in-house assays as the "gold standard", the sensitivity, specificity, positive and negative predictive values of the AusDiagnostics assay was 100 %, 92.16 %, 55.56 % and 100 % respectively. The Ct values of the real-time in-house-developed PCR assay targeting the E gene was significantly lower than the corresponding RdRp gene assay when applied to clinical samples, viral culture and positive controls (mean 21.75 vs 28.1, p = 0.0031). CONCLUSIONS: The AusDiagnostics assay is not specific for the detection SARS-CoV-2. Any positive results should be confirmed using another NAT or sequencing. The case definition used to investigate persons with suspected COVID-19 infection is not specific.