A Pilot Study of the Efficacy and Economical Sustainability of Acute Coronavirus Disease 2019 Patient Management in an Outpatient Setting

Rebecca De Lorenzo; Marco Montagna; Eleonora Bossi; Giordano Vitali; Alba Taino; Marta Cilla; Giulia Pata; Ludmilla Lazorova; Riccardo Pesenti; Chiara Pomaranzi; Cecilia Bussolari; Sabina Martinenghi; Nicoletta Bordonaro; Davide Di Napoli; Giuliano Rizzardini; Chiara Cogliati; Nuccia Morici; Patrizia Rovere-Querini

doi:10.3389/fmed.2022.892962

A Pilot Study of the Efficacy and Economical Sustainability of Acute Coronavirus Disease 2019 Patient Management in an Outpatient Setting

Front Med (Lausanne). 2022 Apr 27:9:892962. doi: 10.3389/fmed.2022.892962. eCollection 2022.

Authors

Rebecca De Lorenzo^{1

2}, Marco Montagna^{1

2}, Eleonora Bossi³, Giordano Vitali², Alba Taino⁴, Marta Cilla², Giulia Pata^{1

2}, Ludmilla Lazorova², Riccardo Pesenti¹, Chiara Pomaranzi^{1

2}, Cecilia Bussolari^{1

2}, Sabina Martinenghi², Nicoletta Bordonaro², Davide Di Napoli³, Giuliano Rizzardini⁵, Chiara Cogliati⁴, Nuccia Morici⁶, Patrizia Rovere-Querini^{1

2}

Affiliations

¹ School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
² Unit of Hospital-Primary Care Embedding, San Raffaele Hospital, Milan, Italy.
³ Clinical Governance Division, San Raffaele Hospital, Milan, Italy.
⁴ Unit of Internal Medicine, Luigi Sacco Hospital, Azienda Socio Sanitaria Territoriale - Fatebenefratelli (ASST-FBF)-Sacco, Milan, Italy.
⁵ Unit of Infectious Diseases, Luigi Sacco Hospital, Azienda Socio Sanitaria Territoriale - Fatebenefratelli (ASST-FBF)-Sacco, Milan, Italy.
⁶ Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) S. Maria Nascente - Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy.

Abstract

Objective: To report a preliminary experience of outpatient management of patients with Coronavirus disease 2019 (COVID-19) through an innovative approach of healthcare delivery.

Patients and methods: Patients evaluated at the Mild-to-Moderate COVID-19 Outpatient clinics (MMCOs) of San Raffaele University Hospital and Luigi Sacco University Hospital in Milan, Italy, from 1 October 2020 to 31 October 2021 were included. Patients were referred by general practitioners (GPs), Emergency Department (ED) physicians or hospital specialists (HS) in case of moderate COVID-19. A classification and regression tree (CART) model predicting ED referral by MMCO physicians was developed to aid GPs identify those deserving immediate ED admission. Cost-effectiveness analysis was also performed.

Results: A total of 660 patients were included. The majority (70%) was referred by GPs, 21% by the ED and 9% by HS. Patients referred by GPs had more severe disease as assessed by peripheral oxygen saturation (SpO₂), ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO₂/FiO₂), C-reactive protein (CRP) levels and interstitial involvement at lung ultrasound. Among them, 18% were addressed to the ED following MMCO assessment. CART analysis identified three independent predictors, namely home-measured SpO₂, age and body mass index (BMI), that robustly divide patients into risk groups of COVID-19 severity. Home-measured SpO₂ < 95% and BMI ≥ 33 Kg/m² defined the high-risk group. The model yielded an accuracy (95% CI) of 83 (77-88)%. Outpatient management of COVID-19 patients allowed the national healthcare system to spare 1,490,422.05 € when compared with inpatient care.

Conclusion: Mild-to-moderate COVID-19 outpatient clinics were effective and sustainable in managing COVID-19 patients and allowed to alleviate pressure on EDs and hospital wards, favoring effort redirection toward non-COVID-19 patients.

Keywords: COVID-19; care pathway; cost-effectiveness; healthcare; outpatient clinic; prediction model.