Apurv Soni

Background: Home Test-to-Treat (HTTT) programs deliver timely antiviral treatment for acute respiratory infections, including COVID-19 and influenza, through at-home testing and telehealth. Because access is often measured by visit occurrence, variation in how and when care is delivered may be overlooked. We hypothesized that telehealth access follows distinct process-based patterns. Methods: We analyzed de-identified encounters from the national HTTT program (September 2023–July 2024); 6,213 of 8,160 eligible individuals remained after exclusions for missing data. Phenotypes were derived by k-means clustering of standardized variables capturing encounter timing, modality preference, process duration, and sociodemographic and digital access attributes. Ten-day surveys assessed symptom duration and healthcare utilization. Results: Three phenotypes emerged: Delayed/Disrupted Access (n = 1,537; 24.7%), Digitally Engaged but Socioeconomically Vulnerable (n = 1,460; 23.5%), and Mainstream Access and Efficient Utilization (n = 3,216; 51.8%). Mean process duration differed (15.93 [SD 3.84] vs 3.69 [3.31] vs 2.87 [2.41] hours; p < 0.001). Synchronous preference was lowest in the Digitally Engaged group (22.9%); antiviral prescribing was high (88.6%–91.9%). Among 10-day respondents (n = 1,023), symptom duration did not differ. Emergency department visits were most frequent in the Digitally Engaged group (2.3% vs 0.0% and 0.5%; p = 0.02) and urgent care in the Delayed/Disrupted group (5.8% vs 4.1% vs 2.0%; p = 0.02). Conclusions: Telehealth use in a national HTTT program formed distinct phenotypes defined by timing, modality, and care-process efficiency. Evaluating equity requires attention to how and when care is delivered, not simply whether it occurred.

Background: Limited evidence exists on the clinical and cost impact of diabetes coaching programs integrated into care teams. The Diabetes Care Coach (DCC) program is a pharmacist-driven telehealth coaching program for patients with poorly controlled diabetes. Coaches provide frequent telehealth support to improve glycemic control through medication management, nutrition and lifestyle counseling, leveraging diabetes technologies, initiating mental health referrals, and addressing health-related social needs. The objective of this study was to evaluate the effectiveness of the UMass Memorial Health (UMMH) DCC program. Methods and findings: A retrospective matched cohort study was conducted with data collected from the UMMH electronic health record and the UMass Memorial Medicare Accountable Care Organization (ACO) claims database from January 2020 to December 2023. The DCC program was implemented at the UMMH diabetes clinic, a specialty care clinic in Worcester, MA, supported by the UMass Specialty Pharmacy program, which is managed by Shields Health Solutions. Participants included patients with persistent severe hyperglycemia (hemoglobin A1c [A1c] ≥ 9) receiving care at the diabetes clinic. Intervention participants (n = 239) enrolled in the DCC program were matched with comparison participants (n = 815) not enrolled in the program during the study period. Intervention and comparison participants who were also enrolled in ACO were considered for cost analyses. Between-group differences in glycemic control (A1c change), health care utilization (emergency department visits and days hospitalized), and cost (total medical expenditures, TME) were evaluated. Intervention participants experienced a greater mean A1c reduction of –0.4 percentage points (95% CI, –1.1 to 0.3) compared with comparison participants. Within the ACO subgroup, intervention participants also had a greater mean reduction in annual TME of $2,649 per patient (95% CI, –$14,425 to $9,127) and a reduction in hospital days per patient per year of –5.2 (95% CI, –9.8 to –0.6) relative to comparison participants. Conclusions: The DCC program was associated with directional improvements in clinical, health care utilization, and cost outcomes and was cost-neutral due to savings and associated revenue. With approximately one-third of participants having Medicaid insurance, the sustainability of such programs increases through leveraging the 340B program to enhance care for economically vulnerable patients.

Importance: Timely initiation of antivirals for SARS CoV 2 and influenza depends on rapid diagnosis and access to prescribing. A national home based test to treat service was implemented to address these barriers. Objective: To evaluate reach, use, and timeliness of prescribing in the Home Test to Treat program. Design: Observational cohort analysis of program data from August 15, 2023 through April 17, 2024. Multivariable models assessed factors associated with test kit receipt, telehealth use and timing from symptom onset, antiviral prescribing and timing, and modality of medication fulfillment. Setting: Nationwide, remote program providing free at home tests, on demand telehealth, and oral antivirals with pharmacy pickup or home delivery. Participants: 66,169 adults who enrolled in the program and were eligible for analysis. Participation pathways included 1) proactive testing before symptoms, 2) on demand testing after symptom onset without a diagnosis, and 3) treatment only after a positive test. Exposures: Program pathway and participant characteristics, including insurance status and prior difficulties accessing care. Main Outcomes and Measures: Receipt of test kits, telehealth use and timing from symptom onset, and prescription of guideline directed oral antivirals within 1 day and within 5 days of symptom onset; choice of home delivery versus local pharmacy pickup. Results: Enrollees represented all 50 states and 891 of 896 three-digit ZIP Code areas. Proactive testers comprised 52.6%; 15.0% of the analytical sample reported a positive result. Among positives, 80.7% used the treatment only pathway; 83.2 percent chose telehealth and 76.3% of consults occurred outside local business hours. Antivirals were prescribed to 6,821 enrollees; 59.8% received oral antivirals within 1 day and 92.8% within 5 days of symptom onset. Prescribing within 1 day did not differ notably by age, insurance, race or ethnicity, or prior difficulty accessing care. Of those prescribed, 1,092 enrollees, 16.0%, selected home delivery rather than pharmacy pickup. Home delivery was more common among enrollees reporting more reasons for delaying care, difficulty accessing care, lacking insurance, or enrolled in Medicaid (P < .05). Conclusions and Relevance: Home Test to Treat delivered timely prescribing, including for adults with prior access barriers, by combining home based testing, on demand telehealth, and options for medication delivery across the country. Key Points: Question: Does a national home test-to-treat program deliver timely antiviral treatment for COVID-19 and influenza across diverse adults? Findings: Among 66,169 enrollees in all 50 states, 83% of positives used telehealth; 82% received antivirals; 60% were treated within 1 day and 93% within 5 days of symptoms; most visits occurred outside business hours; timeliness did not differ meaningfully by age, insurance, or race/ethnicity once enrolled. Meaning: An integrated home testing and on-demand telehealth pathway achieved rapid, equitable treatment at national scale and provides a practical model to strengthen access and preparedness.

Background Digital health technologies can expand healthcare access, improve care coordination, and reduce costs. However, integrating these tools into routine care faces complex barriers. Understanding health system leaders’ perspectives is essential for developing scalable, sustainable digital solutions. Objective To explore the attitudes, experiences, and priorities of health system stakeholders regarding the implementation of digital health technologies in clinical practice. Methods The study team conducted semi-structured interviews with 12 stakeholders from diverse U.S. health systems, including clinical, operational, and executive leadership. Interviewees were selected using purposeful and snowball sampling. Interviews were transcribed, de-identified, and analyzed thematically using the Consolidated Framework for Implementation Research (CFIR). A constant comparative coding process was used to identify and organize key themes. Results Participants saw digital tools as a way to enhance healthcare access and efficiency and improve public health operations, especially in rural or underserved settings. However, several major adoption challenges emerged: (1) integrating digital tools into existing workflows and electronic health record is operationally burdensome; (2) digital care can introduce risks to quality, continuity, and equity; and (3) external factors (reimbursement policy, regulatory constraints, infrastructure investment) are critical to long-term adoption. Conclusions Digital health is seen as essential to the future of healthcare delivery, but meaningful integration requires alignment across clinical, operational, and policy domains. Coordinated investment, regulatory reform, and robust data infrastructure are needed to ensure digital solutions are scalable and sustainable.

Background Worldwide, there are differences in hypertension control by sex. The use of home blood pressure monitoring (HBPM) is associated with lower average blood pressures and higher medication adherence. However, little is known about adherence trajectories and sex differences in HBPM. This study characterizes adherence to HBPM among those with and without hypertension. Methods Electronic Framingham Heart Study participants were instructed to perform HBPM weekly for 1 year. Adherence was defined as having ≥1 measurement per week averaged over 4-week segments. Primary exposures of hypertension status and sex were self-reported. Group-based trajectory modeling was used to identify adherence trajectories. Logistic regression was applied to investigate factors associated with membership in each trajectory group in the sex-stratified and whole cohorts. Results Among 990 participants (58% women, age 53±9 years, 26% hypertension), three groups with distinct HBPM adherence patterns were identified: “early discontinuation”, “gradual decrease”, and “high adherence”. Participants with hypertension were more likely to maintain “high adherence” compared to those without (OR 1.55; 95% CI 1.08-2.23), with similar findings seen among women with hypertension (OR 2.24; 95% CI 1.35-3.72) but not men. In women, these findings remained significant when adjusting for anxiety, depression, and blood pressure, but were attenuated by adjusting for age and income. Conclusions This study highlights HBPM adherence trajectories and shows that women with hypertension were more likely to be in the high adherence group, though these associations were attenuated after adjusting for demographic factors and co-morbidities. Future studies should explore strategies to enhance adherence in populations at risk of early discontinuation.

Background: Chronic obstructive pulmonary disease (COPD) is a common and impactful disease that is the target of a large portfolio of clinical research. However, there is limited understanding of how individuals with COPD perceive trial designs, outcomes, and intervention acceptability. The objective of this project was to explore the perspectives and priorities of patients and their caregivers toward COPD-focused clinical research. Methods: Semi-structured interviews were conducted with participants living with COPD and their caregivers using the Theoretical Framework of Acceptability (TFA) to guide data collection and analysis. Interviews were transcribed and coded using qualitative analysis software and analyzed using an inductive thematic approach. Results: Fifteen interviews were performed. Key themes included participant preference for outcome measures that directly impact daily living, such as mental wellness and physical function. Participants highlighted the need for research data to be actionable, advocating for health insights to be shared with participants and their healthcare providers. Study engagement was influenced by the perceived burden and complexity of interventions as well as their direct relevance to patients. Patients favored research designs that minimize physical and logistical challenges. Lastly, participants desired greater involvement in the research design process. Conclusions: Aligning COPD research with patient priorities requires incorporating meaningful outcome measures, reducing participation burdens, and fostering ongoing engagement. Integrating patient-centered approaches in study design can enhance recruitment, adherence, and the real-world impact of COPD interventions.

Background: Screening for cognitive impairment in primary care is important, yet primary care physicians (PCPs) report conducting routine cognitive assessments for less than half of patients older than 60 years of age. Linus Health’s Core Cognitive Evaluation (CCE), a tablet-based digital cognitive assessment, has been used for the detection of cognitive impairment, but its application in primary care is not yet studied. Objective: This study aimed to explore the integration of CCE implementation in a primary care setting. Methods: A cohort of participants was recruited from the upcoming schedules of participating PCPs at UMass Memorial Medical Center. Eligibility criteria included individuals aged ≥65 years; ability to read, write, and speak in English or Spanish; no previous diagnosis of cognitive impairment; and no known untreated hearing or vision impairment. Research coordinators collected consent from participants and facilitated the screening process. PCPs reviewed reports in real time, immediately before the scheduled visits, and shared results at their discretion. A report was uploaded to each participant’s REDCap (Research Electronic Data Capture; Vanderbilt University) record and linked to the encounter in the electronic health record. Feedback from patients and their caregivers (if applicable) was collected by a tablet-based survey in the clinic before and after screening. Participating PCPs were interviewed following the completion of the study. Results: The screened cohort included 150 patients with a mean age of 74 (SD 7) years, of whom 65% (97/150) were female. The CCE identified 40 patients as borderline and 7 as positive for cognitive impairment. A total of 84 orders were placed for select laboratory tests or referrals to neurology and neuropsychology within 20 days of CCE administration. Before the assessment, 95% (143/150) of patients and all 15 caregivers expressed a desire to know if their or their loved one’s brain health was declining. All except one patient also completed the postassessment survey. Among them, 96% (143/149) of patients reported finding the CCE easy to complete, and 70% (105/149) felt that the experience was beneficial. In addition, 87% (130/149) of patients agreed or strongly agreed that they wanted to know their CCE results. Among the 7 participating PCPs, 6 stated that the CCE results influenced their patient care management, and all 7 indicated they would continue using the CCE if it were made available after the study. Conclusions: We explored the integration of the CCE into primary care visits, which showed minimal disruption to the practice workflow. Future studies will be warranted to further validate the implementation of digital cognitive impairment screening tools within primary care settings in the real world.

Background: Despite the known benefits of physical activity, cancer survivors remain insufficiently active. Prior trials have adopted digital health methods, although several have been pedometer-based and enrolled mainly female, non-Hispanic White, and more highly educated survivors of breast cancer. Objective: The objective of this study was to test a previously developed mobile health system consisting of a Fitbit activity tracker and the MyDataHelps smartphone app for feasibility in a diverse group of cancer survivors, with the goal of refining the program and setting the stage for a larger future trial. Methods: Participants were identified from one academic medical center’s electronic health records, referred by a clinician, or self-referred to participate in the study. Participants were screened for eligibility, enrolled, provided a Fitbit activity tracker, and instructed to download the Fitbit: Health & Wellness and MyDataHelps apps. They completed usability surveys at 1 and 3 months. Interviews were conducted at the end of the 3-month intervention with participants and cancer care clinicians to assess the acceptability of the intervention and the implementation of the intervention into clinical practice, respectively. Descriptive statistics were calculated for demographics, usability surveys, and Fitbit adherence and step counts. Rapid qualitative analysis was used to identify key findings from interview transcriptions. Results: Of the 100 patients screened for eligibility, 31 were enrolled in the trial (mean age 64.8, SD 11.1 years; female patients=17/31, 55%; Hispanic or Latino=7/31, 23%; non-White=11/31, 35%; less than a bachelor’s degree=14/31, 45%; and household income <US $75,000=11/31, 35%). The mean (SD) years since diagnosis was 7.1 (8.2), and the two most frequent cancer diagnoses were prostate (9/31, 29%) and breast (4/31, 13%) cancer. Participants provided positive feedback on the MyDataHelps app usability; the overall app quality received a mean score of 3.79 (SD 0.82) on a 5-point Likert scale (1=worst, 5=best). Interviews with 10 patients yielded four themes: (1) Fitbit and app setup was easy but the research team provided assistance, when needed, which was helpful, (2) motivational messages within the app were not memorable, (3) step counts and Fitbit notifications were motivating, and (4) medical professionals viewing their data were acceptable. Interviews with 5 cancer care clinicians yielded four themes: (1) some patients used wearables but rarely discussed data with clinicians; (2) activity trackers can be helpful to motivate patients and keep them accountable; (3) objective activity measures—similar to BMI, weight, and blood pressure— that they can track over time and refer to afterward were preferred; and (4) training and systematic processes to view these data as part of active workflow were desired. Conclusions: Implementing a remotely delivered, light-intensity physical activity program was feasible and acceptable in a sample of diverse cancer survivors. Future studies should consider registry-based methods and work with clinicians to engage hard-to-reach survivor populations who have low physical activity levels and disproportionately high adverse health outcomes.

Background Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and healthcare utilization, with frequent exacerbations contributing to emergency department visits and hospitalizations. This study evaluates a multimodal, community-based digital health intervention’s association with changes in acute care utilization among patients with COPD to develop preliminary estimates of intervention effects. Methods In this decentralized, nonrandomized pilot clinical trial, participants with moderate to severe COPD were offered biometric monitoring, symptom tracking, on-demand MIH services, and a digital pulmonary rehabilitation program. Outcomes were compared between intervention participants and a weighted synthetic control group using full optimal matching. Weighted odds ratios derived from regression models were used to estimate intervention effect size. The primary outcome was hospitalization during the study period. Secondary outcomes included 30 and 90-day readmission rates, emergency department visits, and hospital length of stay. Results In total, 88 participants from the intervention arm (mean age 67, 50% female) were compared to a weighted synthetic control of 14,492 participants (weighted mean age 66, 48.7% female). We observed that participants in the intervention arm had a trend toward decreased hospitalization with an OR of 0.69 (CI 0.44-1.03, p=0.066). The intervention was also associated with 61% decreased odds of 30-day readmission after an index admission compared to controls (OR: 0.39, 95% CI: 0.16–0.95, p = 0.04). Trends toward reductions in ED visits and hospital length of stay were also observed. Conclusions A combined digital and mobile health approach to COPD management was associated with reductions in acute care utilization. These findings support further investigation into hybrid care models to enhance COPD self-management and improve patient outcomes. Future research should evaluate scalability, cost-effectiveness, and long-term clinical impact.

Background: Digital mental health interventions, such as artificial intelligence (AI) conversational agents, hold promise for improving access to care by innovating therapy and supporting delivery. However, little research exists on patient perspectives regarding AI conversational agents, which is crucial for their successful implementation. This study aimed to fill the gap by exploring patients’ perceptions and acceptability of AI conversational agents in mental healthcare.Methods: Adults with self-reported mild to moderate anxiety were recruited from the UMass Memorial Health system. Participants engaged in semi-structured interviews to discuss their experiences, perceptions, and acceptability of AI conversational agents in mental healthcare. Anxiety levels were assessed using the Generalized Anxiety Disorder scale. Data were collected from December 2022 to February 2023, and three researchers conducted rapid qualitative analysis to identify and synthesize themes.Results: The sample included 29 adults (ages 19-66), predominantly under age 35, non-Hispanic, White, and female. Participants reported a range of positive and negative experiences with AI conversational agents. Most held positive attitudes towards AI conversational agents, appreciating their utility and potential to increase access to care, yet some also expressed cautious optimism. About half endorsed negative opinions, citing AI’s lack of empathy, technical limitations in addressing complex mental health situations, and data privacy concerns. Most participants desired some human involvement in AI-driven therapy and expressed concern about the risk of AI conversational agents being seen as replacements for therapy. A subgroup preferred AI conversational agents for administrative tasks rather than care provision.Conclusions: AI conversational agents were perceived as useful and beneficial for increasing access to care, but concerns about AI’s empathy, capabilities, safety, and human involvement in mental healthcare were prevalent. Future implementation and integration of AI conversational agents should consider patient perspectives to enhance their acceptability and effectiveness.