Virtual Care During the COVID-19 Pandemic: Difference in Differences Analysis of Program Financial and Clinical Impact.

BACKGROUND: Virtual care (VC) and remote patient monitoring programs were deployed widely during the COVID-19 pandemic. Deployments were heterogenous and evolved as the pandemic progressed, complicating subsequent attempts to quantify their impact. The unique arrangement of the Military Health System (MHS) enabled direct comparison between facilities that did, and did not, implement a standardized VC program. The VC program enrolled patients symptomatic for COVID-19, or at risk for severe disease. Patients' vital signs were continuously monitored at home with a wearable device (Current Health). A central team monitored vital signs and conducted daily or twice-daily reviews (nurse-to-patient ratio = 1:30).

OBJECTIVE: Describe the operational model of a VC program for COVID-19, evaluate its financial impact and detail its clinical outcomes.

METHODS: Retrospective difference-in-differences (DiD) evaluation that compared eight Military Treatment Facilities (MTFs) with, and 39 MTFs without, the VC program. Tricare Prime beneficiaries diagnosed with COVID-19 (MS-DRG 177, U07.1/07.2), eligible for care within the MHS, aged 21 and over, between December 2020-2021 were included. Primary outcomes were length of stay and associated cost savings; secondary outcomes were escalation to physical care from home, 30-day readmissions post VC discharge, adherence to wearable and alarms per patient-day.

RESULTS: 1,838 patients with COVID-19 were admitted to an MTF with the VC program, of 3,988 admitted in the MHS in total. Two hundred-and-thirty-seven of the 1,838 patients (13%) were enrolled in the VC program. The DiD analysis indicated that centers with the program had a 12% lower length of stay averaged across all COVID-19 patients, saving $2,047 per patient. The total cost of equipping, establishing and staffing the VC program was estimated at $3,816 per day. Total net savings were estimated at 2.3 million dollars in the first year of the program across the MHS. Two hundred and thirty-one (97.5%) patients activated their wearable and were monitored through the CH platform for a total of 3,474 days (median 7.9 (3.2-16.5) days). Wearable adherence was 85 (IQR 63-94)%. Patients triggered a median of 1.6 (IQR 0.7-5.2) vital sign alarms per patient per day. Two-hundred-and-three (85.7%) were monitored at home and then directly discharged from VC. Twenty-seven (11.4%) were escalated to a physical hospital bed as part of their initial admission, and there were no increases in 30-day readmissions or Emergency Department visits.

CONCLUSIONS: Monitored patients were adherent to the wearable device and triggered a manageable number of alarms/day for the monitoring team to patient ratio. Despite only enrolling 13% of COVID-19 patients at centers where it was available, the program offered substantial savings averaged across all patients in those centers without adversely affecting clinical outcomes.