|Year : 2021 | Volume
| Issue : 1 | Page : 1-5
Telemedicine and multichronic comorbidities in the days of COVID.19: Preliminary results from Calabria Project
Maurizio Cipolla1, Maria Teresa Savo2, Ilaria Cipolla1, Lina Giuseppina Gentile1, Antonio Vittorino Gaddi1
1 Italian Society of Digital Health and Telemedicine, Florence, Italy
2 Italian Society of Digital Health and Telemedicine; University of Florence, Florence, Italy
|Date of Submission||09-Nov-2020|
|Date of Decision||17-Dec-2020|
|Date of Acceptance||19-Dec-2020|
|Date of Web Publication||11-Feb-2021|
Dr. Maria Teresa Savo
University of Florence, Florence
Source of Support: None, Conflict of Interest: None
CONTEXT: The COVID-19 pandemic is probably the most challenging health crisis of the modern era as international health systems were not prepared to fight a virus whose capacity of spread is still being debated. The following are the two main challenges: the management of patients with acute infection of SARS-CoV-2, which needs more attention to have results in brief time, and the prevention of resultant neglect of patients who are not infected but need constant care for their chronic diseases.
AIMS: To prevent the deaths from the “indirect effect” of the virus, the main aim was, with the help of telemedicine, to follow-up patients with high risk of poor outcome and to develop a protective system to reduce emergency department and hospitalizations access. The secondary aim was to develop an efficient telehealth model to be applied also after the COVID-19 pandemic.
SETTINGS AND DESIGN: The study was voluntary and observational on patients enrolled between March and May 2020, during the first wave of the Italian pandemic. The project involved primary care and specialist physicians, nurses, informatics, and administrative services in the complex unity of primary care in Catanzaro Lido, Calabria Region.
MATERIALS AND METHODS: Data such as blood pressure, heart rate, blood oxygenation, and glycemia were recorded using sphygmomanometer, oximeter, and glucometer and were communicated with a smartphone or a Bluetooth directly to a control room. The alerts were stratified according to the common emergency code: green for low risk, yellow for intermediate risk, red for high risk, and critic red for very high risk.
RESULTS: Regarding patients with glycemic alerts, totally, 2135 were alert, 25% of them were at high risk, but only in 1 single case (0.04%), the intervention of 118 was necessary. The rest was resolved by telemedicine system with the help, when necessary, of first-level medical intervention. In 6.1% of cases, a specialist advice was required. Moreover, cardiovascular alerts were all resolved by the telemedicine system.
CONCLUSIONS: The results obtained are preliminary but satisfying, a clear sign of how telemedicine could improve the management of disease chronicity but also of infectious disease.
Keywords: Chronic disease, control room, COVID-19, telehealth
|How to cite this article:|
Cipolla M, Savo MT, Cipolla I, Gentile LG, Gaddi AV. Telemedicine and multichronic comorbidities in the days of COVID.19: Preliminary results from Calabria Project. Vasc Invest Ther 2021;4:1-5
|How to cite this URL:|
Cipolla M, Savo MT, Cipolla I, Gentile LG, Gaddi AV. Telemedicine and multichronic comorbidities in the days of COVID.19: Preliminary results from Calabria Project. Vasc Invest Ther [serial online] 2021 [cited 2021 Apr 11];4:1-5. Available from: https://www.vitonline.org/text.asp?2021/4/1/1/311338
| Introduction|| |
The COVID-19 pandemic is probably the most challenging health crisis of the modern era as international health systems were – and are not – prepared to fight a virus whose capacity of spreading is still being debated. The following two are the main challenges: the management of patients with acute infection of SARS-CoV-2, which needs more attention to have results in brief time, and the prevention of resultant neglect of patients who are not infected but need constant care for their chronic diseases., To prevent the deaths from the “indirect effect” of virus, in Regione Calabria, the preexisting network of telemedicine services guaranteed the follow-up of a consistent number of alerts from chronic patients usually examined in day hospital or emergency room. The World Health Organization indeed defined telemedicine as The delivery of health-care services, where distance is a critical factor, by all health-care professionals, using information and communications technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and the continuing education of health-care workers, with the aim of advancing the health of individuals and communities. The first aim of the study was, with the help of telemedicine, to track patients with high risk of poor outcome and to develop a protective system to reduce the access to emergency department and hospitalizations. The secondary aim was to develop an efficient telehealth model to be applied also after the COVID-19 pandemic.
| Materials and Methods|| |
The present study aimed to follow-up patients who are at a high risk of poor outcome, by developing a protective system in order to reduce the access to emergency department and hospitalizations during the SARS-CoV-2 pandemic. The secondary aim was to develop an efficient model to be applied also after the pandemic. The study was voluntary and observational on patients enrolled between March and May 2020; the data were collected using an excel sheet. The volunteers were capable of self or caregiver management of telemedicine devices. The project involved primary care and specialist physicians, nurses, informatics, and administrative services in the complex unit of primary care (UCCP) in Catanzaro Lido, Calabria Region.
Objective parameters included blood pressure, heart rate, blood oxygenation, and glycemia. The data were recorded using sphygmomanometer, oximeter, and glucometer, and were communicated with a smartphone or Bluetooth directly or indirectly to a control room [Figure 1].
|Figure 1: Control room. The figure reassumes the role of a control room where data are collected and alarms are resolved. The alarms were recorded through sphygmomanometer, oximeter, and glucometer by the patients and then transmitted to the control room through Skype, mobile phone, or platform. Doctors and nurses resolve the alarms without increasing the risk of exposure for patients according to the emergency code|
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The control room was managed by two information technology operators, two doctors, a nurse, and two operators, who collected data on the health status of patients through phone call.
In the beginning, only data from diabetic patients were collected, which were managed by the control room, which was extended for cardiovascular alerts, reports, communication and information technology support, and sanitary assistance.
The protocol used was noticed as Effect on glucose control and quality of life for people with type 2 diabetes of using a device to measure glucose levels at home and send them to the clinic, rather than attending an outpatient clinic for blood tests – EudraCT number 2018-002223-41, 2018.
- Voluntary recruitment
- Age: Above 65 years
- Sex: Male or female
- Medical history: Hypertensive heart disease, diabetes, chronic obstructive pulmonary disease, and ischemic heart disease
- Capable of self or caregiver management of telemedicine devices
- Agreement: Subjects who provided written informed consent to comply with the conditions of the trial.
| Results|| |
On March 1, 2020, 161 patients were enrolled on a voluntary basis. After 45 days, 34 patients dropped out of the study.
In the beginning, only data from diabetic patients were collected, which were managed by the control room, which was extended for cardiovascular alerts. The alerts were divided according to an emergency code in the order of gravity, from a minor degree to a higher one, as follows:
- Green: Minor risk
- Yellow: Moderate risk
- Red: Dangerous risk
- Critic red: Very dangerous risk.
[Table 1] reports the management of glycemic and cardiovascular alerts according to the emergency code fixed.
|Table 1: Management of glycemic and cardiovascular alerts according to the different emergency codes|
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Once the alerts were received by the control room, they were assigned a color code in order to define the time of intervention. The total number of alerts resolved was 2135. Green glycemic alerts were resolved within 24 h, thanks to the control room. No hospitalization or access to emergency department was necessary.
Emergency department access was not required for the yellow glycemic alerts, but for 62 yellow alerts, a specialistic telematic consultation was necessary. Sixty red alerts required specialist consultation also. Only 1 critic red glycemic alert of 10 required access to emergency department or hospitalization.
Green cardiovascular alerts were resolved within 24 h by the control room.
Yellow and red ones were resolved within 6 h. For cardiovascular alerts, the control room guaranteed telemedical resolution.
In [Table 2], the alerts are reported according to the setting management: the recourse of general practitioners (GPs) guarantees a reduction of access to the emergency department for patients with a medical history of hypertensive heart disease, chronic obstructive pulmonary disease, diabetes, and ischemic heart disease.
|Table 2: Management of glycemic and cardiovascular alerts according to the medical history|
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| Discussion|| |
In 2015, a previous study, Progetto Diabete Calabria, demonstrated that a health program based on remote consultation was at least as effective as standard outpatient in order to control patients with diabetes mellitus. Progetto Diabete Calabria was a new organizational model for the management of patients with diabetes mellitus, based on GPs' empowerment and the use of a web-based electronic health record, shared in remote consultations among GPs and hospital consultants. With a high prevalence of diabetes, it is important to monitor patient's blood glucose at home as most parts of the world are witnessing restrictions on mobility in order to contain the pandemic.
Moreover, it is interesting to understand the special aspects of COVID-19 infection in people with diabetes. Data in literature about the association of blood glucose levels and COVID-19 are limited at the moment, but a critical association has been established between other infections such as SARS and influenza H1N1 and poor glycemic control with higher risk of complications and death., In diabetic patients, it is known that impaired neutrophil chemotaxis and phagocytosis predispose to infections; in addition, increased angiotensin-converting enzyme 2 (ACE-2), furin, interleukin-6 expression, and impaired T-cell functions seem to be implied in more severe infections with SARS-CoV-2. Evolving studies also suggest that diabetes can be considered a risk factor for severe or critical COVID-19 disease in a percentage variable from 14% to 32%,, For this, and more reasons, the possibility offered by telemedicine to track and visit diabetic patients, respecting social distancing and quarantines, is an incredible weapon for GPs.
Several studies, emphasize the high percentage of hypertension among COVID-19 patients. It is unclear whether uncontrolled blood pressure is a risk factor for COVID-19 infection, considering the higher prevalence of hypertension between the elderly who often develop a severe disease from infection. The chaos arises also from the evidence that SARS-CoV-2 binds to ACE-2 in the lung to enter cells., No evident conclusions are deduced about the use of ACE inhibitors or angiotensin receptor blockers, which might increase the risk of COVID-19 penetrance in lug cell, although the risk of uncontrolled blood pressure overcomes the risk of viral infection.
Regardless diabetes and hypertension and all the cardiovascular diseases are not established risk factors for COVID 19 infection, chronic and elderly patients should be not leave to their loneliness, independently if they have or not SARS CoV 2 infections as it is frequently happening to leave place to Covid patients. Between March and May 2020 in the UCCP of Calabria Region, 161 patients have been followed up through a control room and the help of telemedicine. The alerts from the devices were resolved and in only one circumstance, for a red critic alarm, hospitalization was necessary. This project had results in advance in benefit/cost, reducing the access to the emergency department and the pressure on hospitalization and moreover, increasing patient's compliance. The patients followed up on a voluntary basis were not infected by SARS-CoV-2, but the study (probably the first one in timing in this field with a specific protocol) was realized during the first wave of infection in Italy.
The crucial advantages of telemedicine include crossing social distancing and quarantine, continuing follow up, avoiding avoidable access to emergency department, and, more importantly, not neglecting chronic patients.
Telemedicine indeed can play an important role in this pandemic age,, in order to provide on-demand medical resources efficiently, to the correct location at the correct time. Surprisingly, Pierce and Stevermen underline the absence of disparities in the use of telehealth in elderly people, suggesting that the COVID-19 pandemic might have modified the patterns of telehealth uptake. The great barrier seems to be overcame by the pandemic fear, considering the general patients reluctance reported until September 2019, just before the pandemic break although with exceptions.
Nevertheless, the present study design has some limitations. Participation in the study was on a voluntary basis for patients. This might have selected particularly motivated participants. The results obtained depend also on the growing up experience of reference center. Imparting appropriate training, following good medical practice principles, and, last but not the least, observing information governance guidelines are necessary to avoid pitfalls associated with remote consultations.
| Conclusions|| |
The data obtained are certainly preliminary, nevertheless satisfying. They symbolize the important role that telemedicine can play not only for the management for disease chronicity but also as a weapon against infectious diseases.
Financial support and sponsorship
This study was financially supported by Alpha Farm Service and DigitCal Srl.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Extance A. COVID-19 and long term conditions: What if you have cancer, diabetes, or chronic kidney disease? BMJ 2020;368:m1174.
Guan WJ, Liang WH, Zhao Y, Liang HR, Chen ZS, Li YM, et al., Comorbidity and its impact on 1590 patients with COVID-19 in China: a nationwide analysis. Eur Respir J 2020;55:2000547. doi: 10.1183/13993003.00547-2020.
Iyengar K, Jain VK, Vaishya R. Pitfalls in telemedicine consultations in the era of COVID-19 and how to avoid them. Diabetes Metab Syndr 2020;14:797-9.
Carallo C, Scavelli FB, Cipolla M, Merante V, Medaglia V, Irace C, et al
. Management of Type 2 Diabetes Mellitus through Telemedicine. PLoS One 2015;10:e0126858.
Yang JK, Feng Y, Yuan MY, Yuan SY, Fu HJ, Wu BY, et al
. Plasma glucose levels and diabetes are independent predictors for mortality and morbidity in patients with SARS. Diabet Med 2006;23:623-8.
Badawi A, Ryoo SG. Prevalence of diabetes in the 2009 influenza A (H1N1) and the Middle East respiratory syndrome coronavirus: A systematic review and meta-analysis. J Public Health Res 2016;5:733.
Singh AK, Gupta R, Ghosh A, Misra A. Diabetes in COVID-19: Prevalence, pathophysiology, prognosis and practical considerations. Diabetes Metab Syndr 2020;14:303-10.
Yu C, Lei Q, Li W, Wang X, Liu W, Fan X, et al
. Clinical characteristics, associated factors, and predicting COVID-19 mortality risk: A retrospective study in Wuhan, China. Am J Prev Med 2020;59:168-75.
Fumagalli C, Rozzini R, Vannini M, Coccia F, Cesaroni G, Mazzeo F, et al
. Clinical risk score to predict in-hospital mortality in COVID-19 patients: A retrospective cohort study. BMJ Open 2020;10:e040729.
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al
. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet 2020;395:1054-62.
Wu C, Chen X, Cai Y, Xia J, Zhou X, Xu S, et al
. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med 2020;180:934-43.
Schiffrin EL, Flack JM, Ito S, Muntner P, Webb RC. Hypertension and COVID-19. Am J Hypertens 2020;33:373-374. doi: 10.1093/ajh/hpaa057.
Wan Y, Shang J, Graham R, Baric RS, Li F. Receptor recognition by the novel coronavirus from Wuhan: An analysis based on decade-long structural studies of SARS coronavirus. J Virol 2020;94:e00127-20. doi: 10.1128/JVI.00127-20.
Hoffmann M, Kleine-Weber H, Schroeder S, Krüger N, Herrler T, Erichsen S, et al. SARS-CoV-2 Cell Entry Depends on ACE2 and TMPRSS2 and Is Blocked by a Clinically Proven Protease Inhibitor. Cell 2020;181:271-280.e8. doi: 10.1016/j.cell.2020.02.052. Epub 2020 Mar 5.
Hollander JE, Carr BG. Virtually perfect? Telemedicine for COVID-19. N Engl J Med 2020;382:1679-81.
Mann DM, Chen J, Chunara R, Testa PA, Nov O. COVID-19 transforms health care through telemedicine: Evidence from the field. J Am Med Inform Assoc 2020;27:1132-5.
Ohannessian R, Duong TA, Odone A. Global telemedicine implementation and integration within health systems to fight the COVID-19 pandemic: A call to action. JMIR Public Health Surveill 2020;6:e18810.
Scott BK, Miller GT, Fonda SJ, Yeaw RE, Gaudaen JC, Pavliscsak HH, et al
. Advanced digital health technologies for COVID-19 and future emergencies. Telemed J E Health 2020;26:1226-33.
Pierce RP, Stevermer JJ. Disparities in use of telehealth at the onset of the COVID-19 public health emergency. J Telemed Telecare. 2020 Oct 21:1357633X20963893. doi: 10.1177/1357633X20963893. Epub ahead of print.
Lee JY, Chan CK, Chua SS, Paraidathathu T, Lee KK, Tan CS, et al
. Using telemedicine to support care for people with type 2 diabetes mellitus: A qualitative analysis of patients' perspectives. BMJ Open 2019;9:e026575.
Rodríguez-Fortúnez P, Franch-Nadal J, Fornos-Pérez JA, Martínez-Martínez F, de Paz HD, Orera-Peña ML. Cross-sectional study about the use of telemedicine for type 2 diabetes mellitus management in Spain: Patient's perspective. The EnREDa2 Study. BMJ Open 2019;9:e028467.
[Table 1], [Table 2]