COD19 and COD20: An Italian Experience of Active Home Surveillance in COVID-19 Patients

Round 1

Reviewer 1 Report

Zuccotti et al. describe active home surveillance in COVID-19 patients.

Monitoring patients with COVID-19 is essential, and I recommend the authors provide more detail about results including negative information about this isolation and monitoring.

First, the authors should present how many candidates with COVID-19 for this system were included. Were all candidates included?

Second, the authors should describe how this system was effective for managing patients with COVID-19. Of 1097 patients, 52 patients were admitted to the hospital and it is not a small number. How about the mortality of these admitted patients? Household transmissions during home surveillance is an important issue in home isolation. Also, counting the respiratory rate is difficult for laypersons. How did the authors evaluate accuracy?

Third, the authors described this service was well accepted by the 177 patients. Since 1097 patients were included in this study, the satisfaction questionnaire must not be representative because of the small number of respondents.

 

 

Author Response

1. First, the authors should present how many candidates with COVID-19 for this system were included. Were all candidates included?

• All candidates were included. The following subjects were considered candidates:

• Covid-19-positive patients discharged from the inpatient hospital wards of the ASST hospitals COVID+

• Covid-19-positive or suspected positive patients (symptomatic but with negative swab) discharged from the Emergency Departments of the ASST hospitals

• healthcare Covid-19-positive workers or suspected positive ordered to home quarantine by the Occupational Medicine specialist. We have clarified this point at line 104-105.

2. Second, the authors should describe how this system was effective for managing patients with COVID-19.

1. Of 1097 patients, 52 patients were admitted to the hospital and it is not a small number. How about the mortality of these admitted patients?

• As our service monitored patients during home isolation, we don’t have data during their hospital stay, but none of the patients that were readmitted to the hospital died to this day. We have clarified this point at line 235-236.

1. Household transmissions during home surveillance is an important issue in home isolation.

• Health status of other family members was investigated in a less structured manner if they were not patients themselves. The policy for asymptomatic family members was of fiduciary home isolation, and a diagnostic swab was performed only at the appearance of one or more symptoms related to COVID-19. Of our patients, 76 families or shared habitations were recorded, for a total of 163 patients. Most (72%) of these patients were referred to our service on the same day, while 28% were referred on different days, indicating a lagged manifestation of symptoms in some family members. While some of these could have been infected before the beginning of home isolation of the first patient, 4% were referred after 14 days from the first referral, probably indicating household transmission. We thank you for the interesting point of discussion, we have added these findings at lines 233-242.

1. Also, counting the respiratory rate is difficult for laypersons. How did the authors evaluate accuracy?

• Patients were instructed by healthcare professionals at discharge on how to collect the various parameters. Respiratory rate was indeed the most challenging parameter to collect accurately, but accuracy was improved by the resident physicians performing the monitoring, as they were well aware of the risk of at-home collection of respiratory rate. During the first days of monitoring, parameters were often retested with assistance of the operator, that ensured that proper timing and counting were used. After few days of monitoring, the intra-patient longitudinal trend was also useful to highlight improvements or worsening of respiratory rate, even when systematic bias was introduced by the patient. We have clarified these points at line 135-138.

3. Third, the authors described this service was well accepted by the 177 patients. Since 1097 patients were included in this study, the satisfaction questionnaire must not be representative because of the small number of respondents.

• Data was updated with new responses, including 306 patients in total. Relative results were similar to the original analysis.

Reviewer 2 Report

The authors have done a great job describing the active home surveillance model in Milan for COVID-19 patients. This was a well written paper with some minor typographical and grammatical errors that can be edited. Thank you for this important contribution.

Major Comments

1. Consider adding a comment in the Conclusion section about the applicability and scalability of this home surveillance model to other parts of Italy, Europe, or to the world?

 

2. Consider discussing the barriers (i.e. financial, policy, logistical challenges) to implementing this model to help readers who are looking to implement something similar in their respective regions. What were the lessons learned from the implementation?

 

3. Would be curious to compare the results of this model to Italian cities that did not implement such a model (i.e. a control group) to compare and contrast the findings?

 

4. Consider adding to the Conclusion as what the authors plan on doing as a result of the findings in this manuscript? What are the next steps?

 

5. Line 210-211: Was there a rationale for the negative rating given by the patients? Would be interesting to learn from the quality improvement standpoint.

Minor Comments

1. Please review and fix typographical and grammatical errors carefully for the next submission:
   • Consistency in abbreviations (COD20 vs. COD-20), COVID vs. Covid (line 235)
   • Define all abbreviations as readers are unfamiliar with the Italian health system (i.e. AWS, ASST hospitals, ATS, ADI, API, etc.)
   • Line 96: add “oxygen” to saturation meter
   • Figure A2: unfamiliar with BPCO – did authors mean COPD (chronic obstructive pulmonary disease?)
   • Figure A3: spelling issue – “Hosptial” accesses – “Hospital access”
   • Line 131: write out numbers less than 10 (4 should be four)
   • Consider having a native English editor review manuscript
     • Line 23-25: sentence structure issue
     • Capitalization of random words (i.e. Regions (lines 36-37), Intensive Care Units (line 42), Dossier (line 171), Continuity (line 185), Developers (line 187), Regional Health System (line 237)
     • Line 181: an Hospital – a hospital?
     • Line 182: it’ – it’s?
     • Line 222: and suddenly and found

Author Response

1. Consider adding a comment in the Conclusion section about the applicability and scalability of this home surveillance model to other parts of Italy, Europe, or to the world?

• We have added the following statement at line 308-312: “The flexibility to use low level but widely available technology such as phone calls to more advanced implementation permits high applicability in other part of Italy or the rest of the world. The high patient acceptance of active monitoring also contrast with low adoption of app-based passive monitoring recorded during this pandemic.”

2. Consider discussing the barriers (i.e. financial, policy, logistical challenges) to implementing this model to help readers who are looking to implement something similar in their respective regions. What were the lessons learned from the implementation?

• We encountered very low barriers to this model during the pandemic crisis and it was well accepted by the regional health system. Moreover, due to its relative low costs and patient acceptance it is now being evaluated for future normal clinical practice. We have clarified these points at lines 304-305.

3. Would be curious to compare the results of this model to Italian cities that did not implement such a model (i.e. a control group) to compare and contrast the findings?

• While other local project similar to our exist exist, to the best of our knowledge our was the most structured in term of data collection, so no data are available yet from other project and ours are the first to be disseminated. Our model was born to answer a clinical need first, while collecting data to provide insights on at-home isolated COVID-19 patients. It would have not been ethic to propose this surveillance only to part of the patients and so a control group does not exist.

4. Consider adding to the Conclusion as what the authors plan on doing as a result of the findings in this manuscript? What are the next steps?

• The service is still active and will be extended in the next future on the basis of the experience collected in these months. New partners are working on existing data and improved version of the data collection process to generate predictive and prescriptive models to manage even better future COVID-19 patients. We have added these considerations at lines 319-321.

5. Line 210-211: Was there a rationale for the negative rating given by the patients? Would be interesting to learn from the quality improvement standpoint.

• Negative ratings were mostly related to asymptomatic patients. To adjust to those feedbacks, we updated the protocol for asymptomatic patients that were contacted only once-a-day after the initial 4 days of monitoring twice-a-day. We added this consideration at lines 253-256.

6. Please review and fix typographical and grammatical errors carefully for the next submission:

1. Consistency in abbreviations (COD20 vs. COD-20), COVID vs. Covid (line 235) Done

2. Define all abbreviations as readers are unfamiliar with the Italian health system (i.e. AWS, ASST hospitals, ATS, ADI, API, etc.) Done

3. Line 96: add “oxygen” to saturation meter Done

4. Figure A2: unfamiliar with BPCO – did authors mean COPD (chronic obstructive pulmonary disease?) >non ho gli originali per modificare la figura, credo l’abbia modificata il servizio di traduzione, potremmo chiedere a loro

5. Figure A3: spelling issue – “Hosptial” accesses – “Hospital access” >come sopra

6. Line 131: write out numbers less than 10 (4 should be four) Done

7. Consider having a native English editor review manuscript Done

8. Line 23-25: sentence structure issue Done

9. Capitalization of random words (i.e. Regions (lines 36-37), Intensive Care Units (line 42), Dossier (line 171), Continuity (line 185), Developers (line 187), Regional Health System (line 237) Done

10. Line 181: an Hospital – a hospital? Done

11. Line 182: it’ – it’s? its, done

12. Line 222: and suddenly and found “The SARS-Cov2 pandemic hit Italy hard and suddenly, and found the country…” Done

Round 2

Reviewer 1 Report

The revised manuscript improved.

Author Response

Thank you