Practices That Adopted Remote Physiologic Monitoring Increased Medicare Revenue And Outpatient Visits.

Remote Automated Peritoneal Dialysis Management in Colombia

Blood pressure and heart periods fluctuate at respiratory frequencies in healthy humans. Some researchers ([8][1], [23][2]) explain this as a cause-and-effect relation: blood pressure changes trigger baroreflex-mediated R-R interval changes. Here I make the case that respiratory sinus arrhythmia is

A Systems Approach to Morbidity and Mortality Conference

Internet of Things (IoT) technology enables physiological measurements to be recorded at home from people living with dementia and monitored remotely. However, measurements from people with dementia in this context have not been previously studied. We report on the distribution of physiological measurements from 82 people with dementia over approximately 2 years. Our objective was to characterize the physiology of people with dementia when measured in the context of their own homes. We also wanted to explore the possible use of an alerts-based system for detecting health deterioration and discuss the potential applications and limitations of this kind of system. We performed a longitudinal community-based cohort study of people with dementia using "Minder," our IoT remote monitoring platform. All people with dementia received a blood pressure machine for systolic and diastolic blood pressure, a pulse oximeter measuring oxygen saturation and heart rate, body weight scales, and a thermometer, and were asked to use each device once a day at any time. Timings, distributions, and abnormalities in measurements were examined, including the rate of significant abnormalities ("alerts") defined by various standardized criteria. We used our own study criteria for alerts and compared them with the National Early Warning Score 2 criteria. A total of 82 people with dementia, with a mean age of 80.4 (SD 7.8) years, recorded 147,203 measurements over 958,000 participant-hours. The median percentage of days when any participant took any measurements (ie, any device) was 56.2% (IQR 33.2%-83.7%, range 2.3%-100%). Reassuringly, engagement of people with dementia with the system did not wane with time, reflected in there being no change in the weekly number of measurements with respect to time (1-sample t-test on slopes of linear fit, P=.45). A total of 45% of people with dementia met criteria for hypertension. People with dementia with α-synuclein-related dementia had lower systolic blood pressure; 30% had clinically significant weight loss. Depending on the criteria used, 3.03%-9.46% of measurements generated alerts, at 0.066-0.233 per day per person with dementia. We also report 4 case studies, highlighting the potential benefits and challenges of remote physiological monitoring in people with dementia. These include case studies of people with dementia developing acute infections and one of a person with dementia developing symptomatic bradycardia while taking donepezil. We present findings from a study of the physiology of people with dementia recorded remotely on a large scale. People with dementia and their carers showed acceptable compliance throughout, supporting the feasibility of the system. Our findings inform the development of technologies, care pathways, and policies for IoT-based remote monitoring. We show how IoT-based monitoring could improve the management of acute and chronic comorbidities in this clinically vulnerable group. Future randomized trials are required to establish if a system like this has measurable long-term benefits on health and quality of life outcomes.

Economic Assessment of the General Thoracic Surgery Outpatient Service

Current International State of Remote Monitoring Ventricular Assist Device Patients

BackgroundManagement of noncommunicable diseases (NCDs) is an increasing challenge for health care systems. Although remote patient monitoring presents a promising solution by utilizing technology to monitor patients outside clinical settings, there is a lack of knowledge about the effect on resource utilization.ObjectiveThis systematic review aimed to review the effects of remote patient monitoring on health care resource utilization by patients with NCDs.MethodsEligible randomized controlled trials (RCTs) involved digital transmission of health data from patients to health care personnel. Outcomes included hospitalizations, length of stay, outpatient visits, and emergency visits. A systematic literature search was performed in Medline, Embase, and Cochrane Central Register of Controlled Trials in June 2024. Titles, abstracts, and full texts were screened individually by 2 authors. Risk of bias was assessed, and data were extracted, analyzed, and pooled in meta-analysis when possible. Confidence in the estimates was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.ResultsWe included 40 RCTs published between 2017 and 2024. The largest group of NCDs was cardiovascular disease (16 studies). Remote patient monitoring may slightly decrease the proportion of hospitalizations compared with usual care (risk ratio [RR] 0.86, 95% CI 0.77 to 0.95; low certainty). Compared with usual care, remote patient monitoring had fewer or an equal number of hospitalizations (mean difference –0.13, 95% CI –0.29 to 0.03; low certainty). Hospital length of stay may be slightly reduced with remote patient monitoring compared with usual care (mean difference –0.84, 95% CI –1.61 to –0.06 days; low certainty). The proportion of outpatient visits showed probably little to no difference between remote patient monitoring and usual care (RR 0.94, 95% CI 0.87 to 1.02; moderate certainty). Compared with usual care, remote patient monitoring had slightly more outpatient visits, but the CI was wide (mean difference 0.41, 95% CI –0.22 to 1.03; low certainty). The results indicate a small or no difference between remote patient monitoring and usual care regarding proportion of emergency visits (RR 0.91, 95% CI 0.79 to 1.05; low certainty). We are uncertain whether remote patient monitoring increases or decreases the number of emergency visits, as the evidence was of very low certainty.ConclusionsThis systematic review showed that remote patient monitoring possibly led to lower proportions of patients being hospitalized, fewer hospitalizations, and shorter hospital length of stay compared with usual care. Patients undergoing remote monitoring had possibly more outpatient visits compared with usual care. The proportions of patients with outpatient visits or emergency visits were probably similar. Finally, we had very low certainty in the number of emergency visits. The results should be considered with caution as the certainty of evidence was moderate to very low. We did not find results regarding institutional stay.

Effect of Pay for Performance on Hypertension in the United Kingdom

Hypertension management has traditionally been based on office visits. Integrating remote monitoring into routine clinical practices and leveraging social support might improve blood pressure (BP) control. To evaluate the effectiveness of a bidirectional text monitoring program focused on BP control and medication adherence with and without social support in adults with hypertension. This randomized clinical trial included adults aged 18 to 75 treated at an academic family medicine practice in Philadelphia in 2018 and 2019. Patients had been seen at least twice in the prior 24 months and had at least 2 elevated BP measurements (>150/90 mm Hg or >140/90 mm Hg for patients aged 18-59 years or with diabetes or chronic kidney disease) during visits. All participants had a cell phone with text messaging, offered at least 1 support partner, and were taking maintenance medications to treat hypertension. Patients were randomized 2:2:1 to remote monitoring of BP and medication adherence (RM), remote monitoring of BP and medication adherence with feedback provided to a social support partner (SS), or usual care (UC). Data were analyzed on an intention-to-treat basis between October 14, 2019, and May 30, 2020, and were revisited from May 23 through June 2, 2023. The RM and SS groups received an automatic home BP monitor, 3 weekly texts requesting BP measurements, 1 weekly text inquiring about medication adherence, and a weekly text with feedback. In the SS arm, support partners received a weekly progress report. The UC group received UC through their primary care practice. Clinicians caring for the patients in the intervention groups received nudges via electronic health records to adjust medications when 3 of 10 reported BP measurements were elevated. Patients were followed up for 4 months. The primary outcome was systolic BP at 4 months measured during the final follow-up visit. Secondary outcomes included achievement of normotension and diastolic BP. In all, 246 patients (mean [SD] age, 50.9 [11.4] years; 175 females [71.1%]; 223 Black individuals [90.7%] and 13 White individuals [5.3%]) were included in the intention-to-treat analysis: 100 patients in the RM arm, 97 in the SS arm, and 49 in the UC arm. Compared with the UC arm, there was no significant difference in systolic or diastolic BP at the 4-month follow-up visit in the RM arm (systolic BP adjusted mean difference, -5.25 [95% CI, -10.65 to 0.15] mm Hg; diastolic BP adjusted mean difference, -1.94 [95% CI, -5.14 to 1.27] mm Hg) or the SS arm (systolic BP adjusted mean difference, -0.91 [95% CI, -6.37 to 4.55] mm Hg; diastolic BP adjusted mean difference, -0.63 [95% CI, -3.77 to 2.51] mm Hg). Of the 206 patients with a final BP measurement at 4 months, BP was controlled in 49% (41 of 84) of patients in the RM arm, 31% (27 of 87) of patients in the SS arm, and 40% (14 of 35) of patients in the UC arm; these rates did not differ significantly between the intervention arms and the UC group. In this randomized clinical trial, neither remote BP monitoring nor remote BP monitoring with social support improved BP control compared with UC in adults with hypertension. Additional efforts are needed to examine whether interventions directed at helping patients remember to take their BP medications can lead to improved BP control. ClinicalTrials.gov Identifier: NCT03416283.

Remote blood pressure (BP) monitoring for hypertension has been limited by low participation and engagement. To evaluate if an opt-out behavioral economic approach to remote BP monitoring improves enrollment and BP outcomes compared with an opt-in approach. This pragmatic, 3-arm randomized clinical trial included patients aged 18 to 75 years with hypertension who were followed up by an academic family medicine practice in Philadelphia. Eligible patients used text messaging, had at least 2 elevated BP measurements during the prior 24 months, and were prescribed hypertension medication. Patients were randomized beginning February 25, 2021, and the last patient completed the program March 22, 2022. Data were analyzed from December 2023 to January 2024. Prior to consent, patients were randomized 2:2:1 to opt-in or opt-out recruitment for remote monitoring of BP or to usual-care control. The opt-in group received outreach to consent and enroll in remote monitoring, and those who consented received a home BP monitor; the opt-out group received a home BP monitor and similar recruitment and follow-up. For 6 months, participants in the opt-in and opt-out groups received weekly text messages requesting BP readings and received support from a social partner or clinician as needed. The primary outcome was the proportion of all participants in the intervention arms consenting to enroll in remote BP monitoring. Secondary outcomes for the intervention groups included number of BP measurements submitted and proportion of patients actively engaged. Secondary outcomes for all participants were BP measurements and the proportion with controlled BP. Among 424 randomized patients (171 opt-in, 168 opt-out, and 85 control), the mean (SD) age was 52.1 (11.5) years, and 264 (62.3%) were female. A total of 58 patients (33.9%) in the opt-in and 63 (37.5%) in the opt-out arm consented to enroll in monitoring, yielding no significant difference in enrollment rate (3.6 percentage points [pp]; 90% CI, -5.0 to 12.1 pp; P = .49). There was no difference in the mean number of BP measurements submitted (unadjusted difference, -0.03 [95% CI, -0.09 to 0.03] measurements; P = .30) or proportion of actively engaged patients (absolute difference, -0.7 pp [90% CI, -15.6 to 14.3 pp]; P = .94) between intervention arms. Using BP measurements from clinic visits, 55 patients (32.2%) in the opt-in arm and 64 (38.1%) in the opt-out arm had controlled BP, compared with 18 (21.2%) in the control arm (opt-in difference vs control, 11.7 pp [95% CI, -0.2 to 23.5 pp]; P = .05; opt-out difference vs control, 18.0 pp [95% CI, 6.1-30.0 pp]; P = .003). In this randomized clinical trial, the behavioral economic approach of opt-out framing vs opt-in framing did not improve enrollment and retention of patients in a remote BP monitoring program. The findings suggest additional approaches are needed to boost participation. ClinicalTrials.gov Identifier: NCT04714398.

Aim. To study the effectiveness and benefits of blood pressure (BP) remote monitoring in outpatients with hypertension.Material and methods. The study included 100 patients with a verified diagnosis of hypertension, who didn’t achieve target BP pressure levels. The patients measured their BP twice a day over 6 months with facilities with automatic data transmission over GSM-channel to a remote monitoring center. BP parameters were being transmitted online to the remote monitoring center, where they were being processed and transferred to the personal account planner (created by the Web interface based on the software and hardware complex) of the attending physician and operator of the remote monitoring center. It is important that doctor received information only on clinically significant measurement results, based on which he determined the urgency of contact with the patient and the further tactics of his management.Results. No malfunctions in the work of communication facilities, technical failures in the software and hardware complex were registered over the entire period of the study. After 6 months of the monitoring it was possible to achieve target BP levels less than 135/85 mm Hg in 70% of patients. The proportion of patients with a high level of normal BP increased from 10% to 19%, while the proportion of patients with grade 1 and 2 of hypertension decreased significantly (from 33% to 7% and from 54% to 3%, respectively). At the beginning of telemedicine monitoring 3% of patients had stage 3 of hypertension, at the end of the study – 1%.Conclusion. The technology of telemedicine monitoring has shown itself as a simple, affordable and reliable way of management of outpatients with hypertension in conditions of real clinical practice. It was possible to achieve BP levels less than 135/85 mm Hg in 70% of patients by the method of remote outpatient monitoring. BP remote monitoring changed fundamentally the decision-making strategy of the patients management: it was not the patient who independently determined the need for consultation with a medical professional, but the attending physician made a decision on the method and urgency of contact with the patient on the basis of the data of objective monitoring indicators.

To evaluate the impact of hospitals' participation in the Medicare Shared Savings Program (MSSP) on their financial performance. Centers for Medicare & Medicaid Services Hospital Cost Reports and MSSP Accountable Care Organizations (ACO) Provider-Level Research Identifiable File from 2011 to 2018. We used an event-study design to estimate the temporal effects of MSSP participation on hospital financial outcomes and compared within-hospital changes over time between MSSP and non-MSSP hospitals while controlling for hospital and year fixed effects and organizational and service-area characteristics. The following financial outcomes were evaluated: outpatient revenue, inpatient revenue, net patient revenue, Medicare revenue, operating margin, inpatient revenue share, Medicare revenue share, and allowance and discount rate. Secondary data linked at the hospital level. Controlling for trends in non-MSSP hospitals, MSSP participation was associated with differential increases in net patient revenue by $3.28 million (p < 0.001), $3.20 million (p < 0.01), and $4.20 million (p < 0.01) in the second, third, and fourth year and beyond after joining MSSP, respectively. Medicare revenue differentially increased by $1.50 million (p < 0.05), $2.24 million (p < 0.05), and $4.47 million (p < 0.05) in the first, second, and fourth year and beyond. Inpatient revenue share differentially increased by 0.29% (p < 0.05) in the second year and 0.44% (p < 0.05) in the fourth year and beyond. Medicare revenue share differentially increased by 0.17% (p < 0.01), 0.25% (p < 0.01), 0.32% (p < 0.01), and 0.41% (p < 0.01) in consecutive years following MSSP participation. MSSP participation was associated with 0.33% (p < 0.05) and 0.39% (p < 0.05) differential reduction in allowance and discount rate in the second and third years. MSSP participation was associated with differential increases in net patient revenue, Medicare revenue, inpatient revenue share, and Medicare revenue share, and a differential reduction in allowance and discount rate.

Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Russian Ministry of Health Background. Low adherence to statins remains a challenge in the treatment of patients with cardiovascular diseases. Some patients who underwent coronary stenting (CS) are unavailable for regular follow-up with outpatient visits. The ability to remotely monitor patients after CS may facilitate adherence to treatment, achieve target low density lipoprotein (LDL) cholesterol levels and early detection of adverse events. We aimed to evaluate the adherence to statin therapy in patients after CS receiving remote monitoring or care with outpatient visits. Methods. We enrolled 279 consecutive stable CAD/silent myocardial ischemia patients (61.5 ± 9.5 years) who underwent CS. The patients were randomized into groups of regular outpatient visits (group 1, n = 96), remote monitoring (group 2, n = 95) and control group (group 3, n = 88). The visits (cardio exam and blood testing) and remote monitoring (videoconference, telephone care and blood tests interpretation) were performed at 1, 3, 6 and 12 months after CS for groups 1 and 2. Patients in the control group were cared by a physician at the residence place, the contact with the study coordinator was performed at baseline and 12 months after CS. Adherence to the prescribed medical therapy based on the four-item Morisky Green Levine Medication Adherence Scale was assessed at each contact with the study coordinator. Results. Patient adherence to statin therapy 12 months after CS was 53.6% for group 1, 55.8% for group 2 and 24.4% for group 3 (p &amp;lt; 0.05 for group 3 versus groups 1 and 2). In group 1 26.9/36.5/31.7/37.4*/41.3*% of patients achieved target LDL level at baseline/1mo/3mo/6mo/12mo, respectively (р&amp;lt;0.05 vs. baseline). In group 2 - 35.8/36.8/40.0/51.6*/57.9*% of patients (р&amp;lt;0.05 vs. baseline). In group 3 25.5/28.2% of patients achieved target LDL level at baseline/12mo, respectively. The significant decrease in LDL cholesterol levels between baseline and 12mo values was observed in groups 1 and 2 (p &amp;lt; 0.05). No differences were observed in group 3. Conclusion. The groups of patients receiving remote monitoring or care with outpatient visits demonstrate the same increase in the proportion of patients that achieved target LDL cholesterol levels within 12 months after CS. The remote monitoring is a safe strategy for improving and maintaining the adherence to statins in patients after CS.

Impact of the COVID-19 Pandemic on Urological Care Delivery in the United States.

The Finnish public healthcare system aims to ensure equal access to health services for all but faces challenges in meeting the demand for specialized care, such as neurosurgery, due to resource constraints. This study investigates interventions to increase resources at a neurosurgery outpatient clinic to improve patient care without compromising waiting times for diagnoses and treatments, leveraging Finland's unique healthcare landscape. The study was conducted at Kuopio University Hospital's Department of Neurosurgery, the sole provider of neurosurgical care in Eastern Finland. Two interventions were designed to optimize clinic operations: one focusing on dynamic resource allocation through continuous monitoring and the other on establishing a fixed additional neurosurgeon slot. Process capability and regression analysis were employed to evaluate the effects of these interventions on the number of outpatient visits and the variability in daily patient numbers. The preliminary analysis showed an average of 9.3 outpatient visits per day (SD 5.2). The introduction of an additional neurosurgeon led to an increase of 5.014 visits per day, according to the regression analysis performed before the interventions. Following the interventions, the clinic observed an increase in the average number of daily outpatient visits to 9.8 after the first intervention and 11.6 after the second, with corresponding improvements in the number of neurosurgeons present. The second intervention, which established a predictable additional resource, resulted in a more significant improvement in process efficiency and stability. After the interventions, the number of new neurosurgical first patient visits increased by 7% (97 patients). This study demonstrates the importance of structured and predictable resource allocation in enhancing the efficiency of specialized healthcare services, particularly in neurosurgery. It also underscores the potential of planned interventions to manage and improve patient care in a publicly funded healthcare system, despite the challenges posed by limited resources and the need for prioritization. Moreover, the findings highlight the necessity of ongoing measurement and analysis of development projects to ensure sustained improvement and avoid regression in process quality.