Contribution of Continuous Virtual Monitoring to Hospital Safety, Quality, and Value of Care for COVID-19 Patients.

Introduction: The rapid onset of the COVID-19 pandemic increased hospital admissions and shortages for personal protective equipment (PPE) used to slow the spread of infections. In addition, nurses treating COVID-19 patients have time-consuming guidelines to properly don and doff PPE to prevent the spread. Methods: To address these issues, the Medical University of South Carolina repurposed continuous virtual monitoring (CVM) systems to reduce the need for staff to enter patient rooms. The objective of this study was to identify the economic implications associated with using the CVM program for COVID-19 patients. We employed a time-driven activity-based costing approach to determine time and costs saved by implementing CVM. Results: Over the first 52 days of the pandemic, the use of the CVM system helped providers attend to patients needs virtually while averting 19,086 unnecessary in-person interactions. The estimated cost savings for the CVM program for COVID-19 patients in 2020 were $419,319, not including potential savings from avoided COVID-19 transmissions to health care workers. A total of 19,086 PPE changes were avoided, with savings of $186,661. After accounting for cost of the CVM system, the net savings provided an outstanding return on investment of 20.6 for the CVM program for COVID-19 patient care. Conclusion: The successful and cost saving repurposing of CVM systems could be expanded to other infectious disease applications, and be applied to high-risk groups, such as bone marrow and organ transplant patients.

A Modification of Time-Driven Activity-Based Costing for Comparing Cost of Telehealth and In-Person Visits.

Introduction: Cost studies of telehealth (TH) and virtual visits are few and report mixed results of the economic impact of virtual care and TH. Largely missing from the literature are studies that identify the cost of delivering TH versus in-person care. The objective was to demonstrate a modified time-driven activity-based costing (TDABC) approach to compare weighted labor cost of an in-person pediatric clinic sick visit before COVID-19 to the same virtual and in-person sick-visit during COVID-19. Methods: We examined visits before and during COVID-19 using: (1) recorded structured interviews with providers; (2) iterative workflow mapping; (3) electronic health records time stamps for validation; (4) standard cost weights for wages; and (5) clinic CPT billing code mix for complexity weighs. We examined the variability in estimated time using a decision tree model and Monte Carlo simulations. Results: Workflow charts were created for the clinic before COVID-19 and during COVID-19. Using TDABC and simulations for varying time, the weighted cost of clinic labor for sick visit before COVID-19 was $54.47 versus $51.55 during COVID-19. Discussion: The estimated mean labor cost for care during the pandemic has not changed from the pre-COVID period; however, this lack of a difference is largely because of the increased use of TH. Conclusions: Our TDABC approach is feasible to use under virtual working conditions; requires minimal provider time for execution; and generates detailed cost estimates that have "face validity" with providers and are relevant for economic evaluation.

Impact of the COVID-19 Pandemic on the Care Continuum of Youth Living with HIV: Qualitative Study of the Scale It Up Program Clinical Sites.

The study objective was to explore the impact of COVID-19 pandemic restrictions on the clinics' ability to provide continuous healthcare services to youth (15-24 years) living with HIV (YLWH). One focused semi-structured interview was conducted with each HIV clinic site-resulting in ten interviews. Data were analyzed using thematic analysis techniques assisted by NVIVO coding software and themes indicating barriers and facilitators to providing uninterrupted healthcare were elicited. Six themes were identified that affected the care continuum of YLWH: Timeframe of clinic preparation to address COVID-19 restrictions; impact on treatment cascade monitoring data; impact on patient care; impact on staff and services offered; software use and virtual visits; community impact. With careful planning and preparation, clinics were able to successfully implement a process of care that adapted to COVID-19 restrictions. Guidance is provided on how healthcare facilities can effectively incorporate strategies to provide continued services during pandemics and natural disasters.

The Impact of Timing on Clinical and Economic Outcomes During Inter-ICU Transfer of Acute Respiratory Failure Patients: Time and Tide Wait for No One

IMPORTANCE AND OBJECTIVE: Approximately one in 30 patients with acute respiratory failure (ARF) undergoes an inter-ICU transfer. Our objectives are to describe inter-ICU transfer patterns and evaluate the impact of timing of transfer on patient-centered outcomes. DESIGN: Retrospective, quasi-experimental study. SETTING: We used the Healthcare Cost and Utilization Project State Inpatient Databases in five states (Florida, Maryland, Mississippi, New York, and Washington) during 2015–2017. PARTICIPANTS: We selected patients with International Classification of Diseases, 9th and 10th Revision codes of respiratory failure and mechanical ventilation who underwent an inter-ICU transfer (n = 6,718), grouping as early (≤ 2 d) and later transfers (3+ d). To control for potential selection bias, we propensity score matched patients (1:1) to model propensity for early transfer using a priori defined patient demographic, clinical, and hospital variables. MAIN OUTCOMES: Inhospital mortality, hospital length of stay (HLOS), and cumulative charges related to inter-ICU transfer. RESULTS: Six-thousand seven-hundred eighteen patients with ARF underwent inter-ICU transfer, 68% of whom (n = 4,552) were transferred early (≤ 2 d). Propensity score matching yielded 3,774 well-matched patients for this study. Unadjusted outcomes were all superior in the early versus later transfer cohort: inhospital mortality (24.4% vs 36.1%;p < 0.0001), length of stay (8 vs 22 d;p < 0.0001), and cumulative charges ($118,686 vs $308,977;p < 0.0001). Through doubly robust multivariable modeling with random effects at the state level, we found patients who were transferred early had a 55.8% reduction in risk of inhospital mortality than those whose transfer was later (relative risk, 0.442;95% CI, 0.403–0.497). Additionally, the early transfer cohort had lower HLOS (20.7 fewer days [13.0 vs 33.7;p < 0.0001]), and lower cumulative charges ($66,201 less [$192,182 vs $258,383;p < 0.0001]). CONCLUSIONS AND RELEVANCE: Our study is the first to use a large, multistate sample to evaluate the practice of inter-ICU transfers in ARF and also define early and later transfers. Our findings of favorable outcomes with early transfer are vital in designing future prospective studies evaluating evidence-based transfer procedures and policies.

Leveraging health system telehealth and informatics infrastructure to create a continuum of services for COVID-19 screening, testing, and treatment.

OBJECTIVES: We describe our approach in using health information technology to provide a continuum of services during the coronavirus disease 2019 (COVID-19) pandemic. COVID-19 challenges and needs required health systems to rapidly redesign the delivery of care. MATERIALS AND METHODS: Our health system deployed 4 COVID-19 telehealth programs and 4 biomedical informatics innovations to screen and care for COVID-19 patients. Using programmatic and electronic health record data, we describe the implementation and initial utilization. RESULTS: Through collaboration across multidisciplinary teams and strategic planning, 4 telehealth program initiatives have been deployed in response to COVID-19: virtual urgent care screening, remote patient monitoring for COVID-19-positive patients, continuous virtual monitoring to reduce workforce risk and utilization of personal protective equipment, and the transition of outpatient care to telehealth. Biomedical informatics was integral to our institutional response in supporting clinical care through new and reconfigured technologies. Through linking the telehealth systems and the electronic health record, we have the ability to monitor and track patients through a continuum of COVID-19 services. DISCUSSION: COVID-19 has facilitated the rapid expansion and utilization of telehealth and health informatics services. We anticipate that patients and providers will view enhanced telehealth services as an essential aspect of the healthcare system. Continuation of telehealth payment models at the federal and private levels will be a key factor in whether this new uptake is sustained. CONCLUSIONS: There are substantial benefits in utilizing telehealth during the COVID-19, including the ability to rapidly scale the number of patients being screened and providing continuity of care.

Evaluating the impact of COVID-19: A cohort comparison study of drug use and risky sexual behavior among sexual minority men in the U.S.A.

BACKGROUND: Sexual minority men who use drugs have high sexual HIV transmission risk. Sexual interactions may also increase COVID-19 risk.This study compared marijuana use, other illegal drugs use (i.e. cocaine/crack, methamphetamine, MDMA/ecstasy, GHB, and ketamine) and sexual behavior with casual partners among sexual minority cismen active on social networking and dating applications before and during the COVID-19 epidemic. METHODS: This cohort-control study compared 455 adult respondents (surveyed May 6th to 17th, 2020) and a matched sample selected from 65,707 respondents surveyed pre-COVID. Participants were recruited on social networking and dating applications and completed surveys online. RESULTS: The proportion reporting marijuana use declined significantly in the COVID cohort (34.5 % versus 45.7 % pre-COVID,p < .001) as did their illegal drug use (11.0 % versus 22.9 % pre-COVID, p < .001). While the number of casual partners per month was stable, the proportion reporting condomless anal sex with casual partners declined significantly during COVID (26.4 % versus 71.6 % pre-COVID, p < .001). The effect of illegal drug use (excluding marijuana) on number of casual partners per month (aRR = 1.45 pre-COVID versus 2.84, p < .01) and odds of condomless anal sex (aOR = 2.00 pre-COVID versus 5.22, p = .04) were significantly greater in the COVID cohort. CONCLUSIONS: While the proportion of participants reporting drug use and condomless anal sex with casual partners declined in the COVID cohort, the association between drug use and sexual behavior was magnified. Sexual minority men who use drugs are significantly more likely to engage in sexual behaviors that place them at risk for HIV and COVID-19 transmission.

COVID-19 Pandemic and Beyond: Considerations and Costs of Telehealth Exercise Programs for Older Adults With Functional Impairments Living at Home-Lessons Learned From a Pilot Case Study.

OBJECTIVE: The purpose of this study was to describe the process and cost of delivering a physical therapist-guided synchronous telehealth exercise program appropriate for older adults with functional limitations. Such programs may help alleviate some of the detrimental impacts of social distancing and quarantine on older adults at-risk of decline. METHODS: Data were derived from the feasibility arm of a parent study, which piloted the telehealth program for 36 sessions with 1 participant. The steps involved in each phase (ie, development, delivery) were documented, along with participant and program provider considerations for each step. Time-driven activity-based costing was used to track all costs over the course of the study. Costs were categorized as program development or delivery and estimated per session and per participant. RESULTS: A list of the steps and the participant and provider considerations involved in developing and delivering a synchronous telehealth exercise program for older adults with functional impairments was developed. Resources used, fixed and variable costs, per-session cost estimates, and total cost per person were reported. Two potential measures of the "value proposition" of this type of intervention were also reported. Per-session cost of $158 appeared to be a feasible business case, especially if the physical therapist to trained assistant personnel mix could be improved. CONCLUSIONS: The findings provide insight into the process and costs of developing and delivering telehealth exercise programs for older adults with functional impairments. The information presented may provide a "blue print" for developing and implementing new telehealth programs or for transitioning in-person services to telehealth delivery during periods of social distancing and quarantine. IMPACT: As movement experts, physical therapists are uniquely positioned to play an important role in the current COVID-19 pandemic and to help individuals who are at risk of functional decline during periods of social distancing and quarantine. Lessons learned from this study's experience can provide guidance on the process and cost of developing and delivering a telehealth exercise program for older adults with functional impairments. The findings also can inform new telehealth programs, as well as assist in transitioning in-person care to a telehealth format in response to the COVID-19 pandemic.