The Next Frontier of Remote Patient Monitoring: Hospital at Home.

Remote patient monitoring (RPM) has shown promise in aiding safe and efficient remote care for chronic conditions; however, its use remains more limited within the hospital at home (HaH) model of care despite a significant opportunity to increase patient eligibility, improve safety, and decrease costs. HaH could achieve these goals by further adopting the 3 primary modalities of RPM (ie, vital sign, continuous single-lead electrocardiogram, and fall monitoring). With only 2 in-person vital sign checks required per day, HaH patient eligibility is currently often limited to lower-acuity cases. The use of vital sign RPM within HaH could better match the standard clinical practice of vital sign checks every 4-8 hours and enable safe care for appropriate moderate-acuity medical and surgical floor-level patients not traditionally enrolled in HaH. Robust, efficient collection of more frequent vital signs via RPM could expand patient eligibility for HaH and create a digital health safety net that enables high quality care. Similarly, our experience at Massachusetts General Hospital has demonstrated that appropriate use of continuous single-lead electrocardiogram RPM can also expand HaH enrollment, particularly for patients with acute decompensated heart failure. Through increasing enrollment of patients in HaH, RPM stands to enable more patients to reap the potential safety benefits of home hospitalization, including decreased rates of delirium and hospital-acquired infections, and better avoid aspects of posthospital syndrome. Furthermore, instituting fall detection RPM allows care teams to further HaH patient safety during their episode of acute care and develop enhanced mitigation strategies to avoid falls post home hospitalization. RPM also has the potential to assist HaH in achieving greater economies of scale and decreasing direct variable costs. By expanding HaH eligibility, RPM could enable HaH programs, which have traditionally operated under capacity, to care for a larger census and decrease allocated fixed costs per hospitalization. Additionally, RPM for HaH could further optimize hybrid in-home and remote nurse or physician evaluations, decreasing costs on a per-episode basis by up to an estimated 3.5%. Overall, RPM holds great promise to increase patient eligibility and patient safety while decreasing costs. However, it is in its infancy in achieving its potential to advance the HaH model of care; further research and experience that inform operational and technical as well as policy considerations are needed.

Mobile app helps trainees manage emergencies at the bedside.

BACKGROUND: Although emergency departments (ED) have standardized guidelines for low-frequency, high-acuity diagnoses, they are not immediately accessible at the bedside, and this can cause anxiety in trainees and delay patient care. This problem is exacerbated during events like COVID-19 that require the rapid creation, iteration, and dissemination of new guidelines. METHODS: Physician innovators used design thinking principles to develop EM Protocols (EMP), a mobile application that clinicians can use to immediately view guidelines, contact consultants (e.g., cath lab activation), and access code-running tools. The project became an institutional high priority, because it helps EM trainees and off-service rotators manage low-frequency, high-acuity emergencies at the point of care, and its COVID-19 guidelines can be rapidly updated and disseminated in real time. RESULTS: This intervention was deployed across two academic medical centers during the COVID-19 surge. Nearly 300 ED clinicians have downloaded EMP, and they have interacted with the app over 5,400 times. It continues to be used regularly, over 12 months after the initial surge. Since the app was received positively, there are efforts to build in additional adult and pediatric guidelines. DISCUSSION: Digital health tools like EMP can serve as invaluable adjuncts for managing acute, life-threatening emergencies at the point of care. They can benefit trainees during normal day-to-day operations as well as scenarios that cause large-scale operational disruptions, such as natural disasters, mass casualty events, and future pandemics.

STAT: Mobile app helps clinicians manage inpatient emergencies.

In response to the unprecedented surge of patients with COVID-19, Massachusetts General Hospital created both repurposed and de-novo COVID-19 inpatient general medicine and intensive care units. The clinicians staffing these new services included those who typically worked in these care settings (e.g., medicine residents, hospitalists, intensivists), as well as others who typically practice in other care environments (e.g., re-deployed outpatient internists, medical subspecialists, and other physician specialties). These surge clinicians did not have extensive experience managing low frequency, high acuity emergencies, such as those that might result from COVID-19. Physician-innovators, in collaboration with key hospital stakeholders, developed a comprehensive strategy to design, develop, and distribute a digital health solution to address this problem. MGH STAT is an intuitive mobile application that empowers clinicians to respond to medical emergencies by providing immediate access to up-to-date clinical guidelines, consultants, and code-running tools at the point-of-care. 100% of surveyed physicians found STAT to be easy to use and would recommend it to others. Approximately 1100 clinicians have downloaded the app, and it continues to enjoy consistent use over a year after the initial COVID-19 surge. These results suggest that STAT has helped clinicians manage life threatening emergencies during and after the pandemic, although formal studies are necessary to evaluate its direct impact on patient care.

The Establishment and Management of an Observation Unit.

The current health care landscape and evidence support the establishment of observation units (OUs) for safe and efficient care for observation patients. Careful attention is required in the design of OU process, location, and layout to enable optimal care and finances. Developing and maintaining protocols to guide patient selection and clinical care are critical. OU management requires a strong, collaborative leadership model, appropriate staffing, and a robust monitoring system for quality, safety, and finances. With a better understanding of these principles of OU establishment and management, hospital leaders can generate and sustain service excellence.

Alternative Strategies to Inpatient Hospitalization for Acute Medical Conditions: A Systematic Review.

Importance: Determining innovative approaches that better align health needs to the appropriate setting of care remains a key priority for the transformation of US health care; however, to our knowledge, no comprehensive assessment exists of alternative management strategies to hospital admission for acute medical conditions. Objective: To examine the effectiveness, safety, and cost of managing acute medical conditions in settings outside of a hospital inpatient unit. Evidence Review: MEDLINE, Scopus, CINAHL, and the Cochrane Database of Systematic Reviews (January 1995 to February 2016) were searched for English-language systematic reviews that evaluated alternative management strategies to hospital admission. Two investigators extracted data independently on trial design, eligibility criteria, clinical outcomes, patient experience, and health care costs. The quality of each review was assessed using the revised AMSTAR tool (R-AMSTAR) and the strength of evidence from primary studies was graded according to the Oxford Centre for Evidence-Based Medicine. Findings: Twenty-five systematic reviews (representing 123 primary studies) met inclusion criteria. For outpatient management strategies, several acute medical conditions had no significant difference in mortality, disease-specific outcomes, or patient satisfaction compared with inpatient admission. For quick diagnostic units, the evidence was more limited but did demonstrate low mortality rates and high patient satisfaction. For hospital-at-home, a variety of acute medical conditions had mortality rates, disease-specific outcomes, and patient and caregiver satisfaction that were either improved or no different compared with inpatient admission. For observation units, several acute medical conditions were found to have no difference in mortality, a decreased length of stay, and improved patient satisfaction compared to inpatient admission; results for some conditions were more limited. Across all alternative management strategies, cost data were heterogeneous but showed near-universal savings when assessed. Conclusions and Relevance: For low-risk patients with a range of acute medical conditions, evidence suggests that alternative management strategies to inpatient care can achieve comparable clinical outcomes and patient satisfaction at lower costs. Further study and application of such opportunities for health system redesign is warranted.

Cost-saving innovations for acute ischemic stroke and transient ischemic attack.

Health care costs continue to rise toward unsustainable levels that will affect our nation's ability to support other key funding priorities for education, military, and infrastructure. Changing the way we deliver health care is critical to mitigating this financial crisis. This review highlights opportunities for redesigning care of acute ischemic stroke and TIA to maintain quality while substantially lowering costs. The recent innovations described are (1) adopting teleneurology networks to improve access to thrombolysis for acute ischemic stroke; (2) improving efficiency of emergency care for acute ischemic stroke; and (3) providing alternatives to inpatient care for TIA. Applying such process innovations will enable us to achieve the goal of patients and the nation-high-quality care at an affordable cost.

Does low-intensity pulsed ultrasound reduce time to fracture healing? A meta-analysis.

We conducted a meta-analysis of randomized controlled trials to obtain a more precise estimate of the effect of low-intensity pulsed ultrasound (LIPU) versus placebo on the acceleration of fracture healing in skeletally mature persons and to determine if any serious adverse events are associated with LIPU when used to accelerate fracture healing.

Recent clinical history and cognitive dysfunction for attention and executive function among human immunodeficiency virus-infected patients.

This study examined the association between recent trends in CD4 and viral loads and cognitive test performance with the expectation that recent history could predict cognitive performance. Eighty-three human immunodeficiency virus (HIV)-infected patients with a mean CD4 count of 428 copies/ml were examined in this study (62% with undetectable plasma viral load [PVL]). We investigated the relationships between nadir CD4 cell count, 1-year trends in immunologic function/PVLs, and cognitive performance across several domains using linear regression models. Nadir CD4 cell count was predictive of current executive function (p = .004). One year clinical history for CD4 cell counts and/or PVLs were predictive of executive function, attention/working memory, and learning/memory measures (p < .05). Models that combined recent clinical history trends and nadir CD4 cell counts suggested that recent clinical trends were more important in predicting current cognitive performance for all domains except executive function. This research suggests that recent CD4 and viral load history is an important predictor of current cognitive function across several cognitive domains. If validated, clinical variables and cognitive dysfunction models may improve our understanding of the dynamic relationships between disease evolution and progression and CNS involvement.

Regional areas and widths of the midsagittal corpus callosum among HIV-infected patients on stable antiretroviral therapies.

Recent reports suggest that a growing number of human immunodeficiency virus (HIV)-infected persons show signs of persistent cognitive impairment even in the context of combination antiretroviral therapies (cART). The basis for this finding remains poorly understood as there are only a limited number of studies examining the relationship between CNS injury, measures of disease severity, and cognitive function in the setting of stable disease. This study examined the effects of HIV infection on cerebral white matter using quantitative morphometry of the midsagittal corpus callosum (CC) in 216 chronically infected participants from the multisite HIV Neuroimaging Consortium study currently receiving cART and 139 controls. All participants underwent MRI assessment, and HIV-infected subjects also underwent measures of cognitive function and disease severity. The midsagittal slice of the CC was quantified using two semi-automated procedures. Group comparisons were accomplished using ANOVA, and the relationship between CC morphometry and clinical covariates (current CD4, nadir CD4, plasma and CSF HIV RNA, duration of HIV infection, age, and ADC stage) was assessed using linear regression models. HIV-infected patients showed significant reductions in both the area and linear widths for several regions of the CC. Significant relationships were found with ADC stage and nadir CD4 cell count, but no other clinical variables. Despite effective treatment, significant and possibly irreversible structural loss of the white matter persists in the setting of chronic HIV disease. A history of advanced immune suppression is a strong predictor of this complication and suggests that antiretroviral intervention at earlier stages of infection may be warranted.

Quantitative diffusion tensor imaging tractography metrics are associated with cognitive performance among HIV-infected patients.

There have been many studies examining HIV-infection-related alterations of magnetic resonance imaging (MRI) diffusion metrics. However, examining scalar diffusion metrics ignores the orientation aspect of diffusion imaging, which can be captured with tractography. We examined five different tractography metrics obtained from global tractography maps (global tractography FA, average tube length, normalized number of streamtubes, normalized weighted streamtube length, and normalized total number of tubes generated) for differences between HIV positive and negative patients and the association between the metrics and clinical variables of disease severity. We also examined the relationship between these metrics and cognitive performance across a wide range of cognitive domains for the HIV positive and negative patient groups separately. The results demonstrated a significant difference between the groups for global tractography FA (t = 2.13, p = 0.04), but not for any of the other tractography metrics examined (p-value range = 0.39 to 0.95). There were also several significant associations between the tractography metrics and cognitive performance (i.e., tapping rates, switching 1 and 2, verbal interference, mazes; r > or = 0.42) for HIV infected patients. In particular, associations were noted between tractography metrics, speed of processing, fine motor control/speed, and executive function for the HIV-infected patients. These findings suggest that tractography metrics capture clinically relevant information regarding cognitive performance among HIV infected patients and suggests the importance of subtle white matter changes in examining cognitive performance.

Novel combination regimens: biologics and acitretin for the treatment of psoriasis-- a case series.

Combination therapy has long been a mainstay of psoriasis treatment, particularly for those that suffer from moderate-to-severe disease. The biologics represent a new and exciting approach to psoriasis treatment though their use in combination regimens has not been adequately examined. This brief series reports on the combination of biologics with acitretin in the treatment of psoriasis.