Dear Editor,
Our unit of Internal Medicine routinely runs outpatient clinics for a range of chronic medical conditions, from mild to severe, with a specific focus on infectious disease, liver diseases, and hemostasis and thrombosis.
During the coronavirus disease 19 (COVID-19) pandemic, scientific societies encouraged physicians to avoid clinical contacts with any patient, outside of medical emergencies or when otherwise absolutely necessary, to contribute to the control of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spread.1-3 Following guidelines and position paper indications, remote care by the use of information and communication technology became an important option for health care professionals to keep contacts with their outpatients.
In Italy, lockdown started on March 9, 2020. Our hospital trust shut down all outpatient services, excluding oncology, starting March 6. In addition, most patients asked to skip follow-up visits, fearing acquiring SARS-CoV-2 infection in the hospital environment.
Accordingly, we started a remote care service for chronically ill outpatients, implementing it in a structured fashion by use of phone, e-mail, and WhatsApp, according to patient preference and feasibility. Our program was based on a strategy of active patient support, contacting each patient with a scheduled visit with us in the period between March 6 and May 31, 2020. Our aims were (i) to ascertain patient clinical conditions and possible SARS-CoV-2 infection; (ii) to ensure continuation of remote care for their chronic diseases during the pandemic, offering the possibility to contact us for any advice or send us laboratory tests and diagnostic images; (iii) to quickly direct to the hospital those patients with worsening condition before complications; (iv) to plan a subsequent contact with a precise schedule; and (v) to prevent patient discouragement, as they faced alone their chronic disease as well as the risk of acquiring SARS-CoV-2 infection, and encourage containment procedures.
During the lockdown period, there were 204 outpatients with at least one scheduled visit; only one patient was unreachable. The primary reason for clinical follow-up was chronic liver disease in 149 patients (73%); atrial fibrillation or deep venous thrombosis on anticoagulation therapy with direct oral anticoagulants in 50 patients (20.4%); and miscellaneous conditions in 4 patients (6.6%). The most common comorbidities were arterial hypertension, coronary artery disease, diabetes mellitus, dyslipidemia, and chronic obstructive pulmonary disease. Median age of patients was 66 years (range, 19-91 years), and 50% were males. The preferred contact was by mobile/phone for 125 (61.6%) and e-mail for 78 (38.4%) patients. During the observation time, no patient acquired SARS-CoV-2 infection. One patient needed inpatient care due to ileus and secondary hepatic encephalopathy, 3 patients (1.5%) were directed to another hospital for emergency procedures, and 12 (6%) needed changes in treatment schedule; 7 of them (3.4%) for significant modification of laboratory examinations, and 5 (2.4%) for modification of clinical conditions. There were no deaths.
Between June 1 and June 5, using the same device adopted during the lockdown, we administered a predefined satisfaction questionnaire to each patient, asking about the remote care system. One hundred ninety-six (96.6%) patients answered they were satisfied with the care model adopted and felt they were followed up for any problems or possible emergencies. Seven patients, mostly elderly subjects with limited functional capacity in the instrumental activities of daily living, answered they preferred traditional care with a personal clinic encounter.
Our experience shows that remote assistance during COVID-19 pandemic was widely valued by outpatients and confirms the potential of information and communication technology in medicine to ensure continuation of care for chronically ill patients,4 facing difficulties related to abrupt and unexpected situations, such as the ongoing SARS-CoV-2 pandemic. Indeed, this approach might be more successful for patients with mild disease and may be insufficient for those with decompensated disease.5
Although a standard approach with clinical visit remains the gold standard of internal medicine outpatient care, in the short term, remote assistance has proven to be a valid alternative in the management of chronic illness patients, accepted and valued by patients themselves. Our plan for the future consists of continuing remote visits only for stable chronic illness patients, alternating a remote visit with an ambulatory one, assessing in-person effectiveness, quality, and benefits, and reducing unnecessary use of the hospital.
-Rosa Zampino, MD
Internal Medicine
University of Campania 'L. Vanvitelli'
Naples, Italy
[email protected]
Units of Infectious and Transplant Medicine
AORN Ospedali dei Colli-Monaldi Hospital
Naples, Italy
-Martina Vitrone, MD
-Serenella Spiezia, MD
Internal Medicine
University of Campania 'L. Vanvitelli'
Naples, Italy
-Rosina Albisinni, MD
Infectious and Transplant Medicine
AORN Ospedali dei Colli-Monaldi Hospital
Naples, Italy
-Emanuele Durante-Mangoni, MD
Internal Medicine
University of Campania 'L. Vanvitelli'
Naples, Italy
Units of Infectious and Transplant Medicine
AORN Ospedali dei Colli-Monaldi Hospital
Naples, Italy
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