Comparison of Mortality and Hospital Readmissions Among Patients Receiving Virtual Ward Transitional Care vs Usual Postdischarge Care: A Systematic Review and Meta-analysis

Application of Integrated Medical Care "Cloud-Based Virtual Ward" Management Model on Postoperative Analgesia: Based on Zigbee Technology

PURPOSE

This study aimed to compare acute care postoperative patients monitored by standard care to those monitored through virtual ward technology by pain team to evaluate status in real-time.

DESIGN

Retrospective cohort study.

METHODS

We included 72,240 and 68,424 postoperative patients who underwent the acute pain service model between January 2021 and April 2022 and the "cloud-based virtual ward" management model between May 2022 and September 2023, respectively. Patients were administered patient-controlled intravenous analgesia after surgery, and we collected perioperative data regarding the general condition, operation type, postoperative moderate-to-severe pain, nausea and vomiting, dizziness, hoarseness, and drowsiness of the patients.

RESULTS

The incidences of moderate-to-severe postoperative pain, postoperative nausea and vomiting, dizziness, drowsiness, hoarseness, resting pain, and activity pain were significantly reduced in the "cloud-based virtual ward" management model when compared with the acute pain service model.

CONCLUSIONS

Compared to the acute pain service model, the "cloud-based virtual ward" management model can enhance pain management satisfaction and lower the frequency of moderate-to-severe postoperative pain and adverse effects.

CLINICAL IMPLICATIONS

The "cloud-based virtual ward" management model proposed in this study may improve the care of patients with acute postoperative pain. By reviewing the two pain management models for postoperative patients, we were able to compare the incidence of postoperative adverse reactions and use the standard process of the integrated medical care "cloud-based virtual ward" management model to optimize the management of postoperative patients and promote their health outcomes.

Tele-medicine controlled hospital at home is associated with better outcomes than hospital stay

BACKGROUND

Hospital-at-home (HAH) is increasingly becoming an alternative for in-hospital stay in selected clinical scenarios. Nevertheless, there is still a question whether HAH could be a viable option for acutely ill patients, otherwise hospitalized in departments of general-internal medicine.

METHODS

This was a retrospective matched study, conducted at a telemedicine controlled HAH department, being part of a tertiary medical center. The objective was to compare clinical outcomes of acutely ill patients (both COVID-19 and non-COVID) admitted to either in-hospital or HAH. Non-COVID patients had one of three acute infectious diseases: urinary tract infections (UTI, either lower or upper), pneumonia, or cellulitis.

RESULTS

The analysis involved 159 HAH patients (64 COVID-19 and 95 non-COVID) who were compared to a matched sample of in-hospital patients (192 COVID-19 and 285 non-COVID). The median length-of-hospital stay (LOS) was 2 days shorter in the HAH for both COVID-19 patients (95% CI: 1-3; p = 0.008) and non-COVID patients (95% CI; 1-3; p < 0.001). The readmission rates within 30 days were not significantly different for both COVID-19 patients (Odds Ratio (OR) = 1; 95% CI: 0.49-2.04; p = 1) and non-COVID patients (OR = 0.7; 95% CI; 0.39-1.28; p = 0.25). The differences remained insignificant within one year. The risk of death within 30 days was significantly lower in the HAH group for COVID-19 patients (OR = 0.34; 95% CI: 0.11-0.86; p = 0.018) and non-COVID patients (OR = 0.38; 95% CI: 0.14-0.9; p = 0.019). For one year survival period, the differences were significant for COVID-19 patients (OR = 0.5; 95% CI: 0.31-0.9; p = 0.044) and insignificant for non-COVID patients (OR = 0.63; 95% CI: 0.4-1; p = 0.052).

CONCLUSIONS

Care for acutely ill patients in the setting of telemedicine-based hospital at home has the potential to reduce hospitalization length without increasing readmission risk and to reduce both 30 days and one-year mortality rates.

Remote Vital Sign Monitoring in Admission Avoidance Hospital at Home: A Systematic Review

OBJECTIVES

To examine randomized controlled trials (RCTs) of "hospital at home" (HAH) for admission avoidance in adults presenting with acute physical illness to identify the use of vital sign monitoring approaches and evidence for their effectiveness.

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

This review compared strategies for vital sign monitoring in admission avoidance HAH for adults presenting with acute physical illness. Vital sign monitoring can support HAH acute multidisciplinary care by contributing to safety, determining requirement of further assessment, and guiding clinical decisions. There are a wide range of systems currently available, including reliable and automated continuous remote monitoring using wearable devices.

METHODS

Eligible studies were identified through updated database and trial registries searches (March 2, 2016, to February 15, 2023), and existing systematic reviews. Risk of bias was assessed using the Cochrane risk of bias 2 tool. Random effects meta-analyses were performed, and narrative summaries provided stratified by vital sign monitoring approach.

RESULTS

Twenty-one eligible RCTs (3459 participants) were identified. Two approaches to vital sign monitoring were characterized: manual and automated. Reporting was insufficient in the majority of studies for classification. For HAH compared to hospital care, 6-monthly mortality risk ratio (RR) was 0.94 (95% CI 0.78-1.12), 3-monthly readmission to hospital RR 1.02 (0.77-1.35), and length of stay mean difference 1.91 days (0.71-3.12). Readmission to hospital was reduced in the automated monitoring subgroup (RR 0.30 95% CI 0.11-0.86).

CONCLUSIONS AND IMPLICATIONS

This review highlights gaps in the reporting and evidence base informing remote vital sign monitoring in alternatives to admission for acute illness, despite expanding implementation in clinical practice. Although continuous vital sign monitoring using wearable devices may offer added benefit, its use in existing RCTs is limited. Recommendations for the implementation and evaluation of remote monitoring in future clinical trials are proposed.

Two-year prospective cohort of intensive care survivors enrolled on a digitally enabled recovery pathway focussed on individualised recovery goal attainment

BACKGROUND

Despite substantial evidence documenting physical, psychological, and cognitive problems experienced by intensive care unit (ICU) survivors, few studies explore interventions supporting recovery after hospital discharge. Individualised recovery goal setting, the standard of care across many rehabilitation areas, is rarely used for ICU survivors. Digital health technologies may help to address current service fragmentation and gaps. We developed and implemented a digital ICU recovery pathway using the aTouchaway e-health platform.

OBJECTIVES

The objective of this study was to explore recovery barriers and challenges; recovery goals set and achieved; self-reported patient outcomes; and healthcare costs of patients enrolled on a 12-week digital ICU recovery pathway after hospital discharge.

METHODS

We conducted a prospective observational single-centre cohort study (June 2021 to May 2023) at a 90-bed tertiary critical care service in London, UK. We enrolled adults ventilated for ≥3 days who were able to participate in recovery activities. We ascertained baseline recovery challenges and identified recovery goals and achievement over 12 weeks. We collected patient-reported outcomes at 2-4, 12-14, 26-28 weeks and healthcare utilisation monthly for 28 weeks.

RESULTS

We enrolled 105 participants (35% of eligible patients). Common rehabilitation challenges were standing balance (60%), walking indoors (56%), and washing (64%) and dressing (47%) abilities. Of 522 home recovery goals, 63% weekly, 48% monthly, and 38% aspirational goals were achieved. Most goals related to self-care: ability to move outside (91 goals, 55% achieved) and inside (45 goals, 47% achieved) the home and community access (65 goals, 48% achieved). Nottingham Extended Activities of Daily Living Scale scores improved from timepoints 1 to 2 (median [interquartile range]: 15 [7, 19] versus 19 [15, 21], P = 0.01). Total healthcare costs were £240,017 (median [interquartile range] cost per patient: £784 [£125, £4419]).

CONCLUSIONS

This study found multiple ongoing functional deficits, challenges achieving recovery goals, and limited improvements in self-reported outcomes, with moderate healthcare costs after hospital discharge indicate substantial ongoing rehabilitative needs.

Three-year mortality, readmission, and medical expenses in critical care survivors: A population-based cohort study

BACKGROUND

Due to the increasing number of critical care survivors, population-based studies on the long-term outcomes after discharge are necessary to inform local decision-making.

OBJECTIVES

This study aimed to investigate mortality and its risk factors, readmissions, and medical expenses of intensive care unit survivors for 3 years after hospital discharge.

METHODS

This retrospective study analysed data from the National Health Insurance Service-National Sample Cohort in Korea. Of the 195,702 patients who survived and were discharged from hospital in 2012, 2693 intensive care unit patients were assigned to the case group for the study, and the remaining 193,009 were assigned to the comparison group. The primary outcome was all-cause mortality for 3 years after discharge. Secondary outcomes were all-cause hospital readmission and medical expenses in 3 years. We analysed risk factors for mortality using the Cox proportional hazard regression. The differences in hospital readmission and medical expenses between the case and comparison groups were analysed by multivariate logistic regression and independent t-tests.

RESULTS

The 1-year, 2-year, and 3-year cumulative mortality rates in the case group were 15.9%, 20.5%, and 24.4%, respectively, and older age, disability, medical admission, and longer hospital stay increased mortality. Almost 40% of intensive care unit survivors were readmitted to hospital within 6 months of discharge, and their odds of being readmitted were significantly higher than those of the comparison group. Medical expenses were also significantly higher in the case group, with the highest paid within 6 months.

CONCLUSIONS

Mortality, hospital readmission, and medical expenses for intensive care unit survivors were the worst within 6 months of discharge. In light of the long-term recovery trajectory of critical illness, it is necessary to investigate what factors may have contributed to the negative outcome during this period. Further research is needed to determine which services primarily contributed to the increase in medical expenses.

Insights from a single centre implementation of a digitally-enabled atrial fibrillation virtual ward

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia and poses a significant public health burden. Virtual wards are a novel approach utilising digital solutions to provide hospital-level care remotely; their rollout has become a key priority for the UK National Health Service to expand acute care capacity. We devised and implemented a digitally-enabled AF virtual ward to monitor patients being established onto medical therapy following an AF diagnosis or an AF-related hospitalisation. Patients were onboarded either as outpatients to avoid admission or on discharge after an acute AF hospitalisation. Remote monitoring was undertaken using a clinically validated photoplethysmography-based smartphone app. Over a 1-2 week period, patients performed twice daily measurements of heart rate and rhythm and provided corresponding symptoms. A traffic light system guided frequency of telephone assessments by specialist practitioners. Red flag symptoms or abnormal heart rate parameters prompted an urgent care escalation. We report our experience of the first 73 patients onboarded to the AF virtual ward from October 2022 to June 2023 (mean age 65 years, median 68 years, IQR range 27-101 years; 33 females). Thirty-nine (53%) patients had red flag features requiring care escalation, of whom 9 (23%) were advised to attend ED (emergency department) for urgent assessment, 10 (26%) attended for expedited review and 14 (36%) required medication changes. By 3 months post-monitoring, only 3 patients (4%) had re-attended ED with an arrhythmia-related presentation. Virtual ward patients had an average 3-day shorter inpatient stay (mean duration 4 days) compared with AF patients hospitalised prior to virtual ward implementation (mean duration 7 days). Overall, 22 arrhythmia-related readmissions were prevented via the virtual ward model. In this study, we present a novel implementation of a digitally-enabled virtual ward for the acute management of patients with newly diagnosed or poorly controlled AF. Our pilot data indicate that this model is feasible and is potentially cost-effective. Further longitudinal study is needed to definitively evaluate long-term clinical utility and safety.

Length of stay and economic sustainability of virtual ward care in a medium-sized hospital of the UK: a retrospective longitudinal study

OBJECTIVE

To evaluate the length of stay difference and its economic implications between hospital patients and virtual ward patients.

DESIGN

Retrospective longitudinal study.

SETTING

Wrightington, Wigan and Leigh (WWL) Teaching Hospitals, National Health Service (NHS) Foundation Trust, a medium-sized NHS trust in the north-west of England.

PARTICIPANTS

Virtual ward patients (n=318) were matched 1:1 to 1:4, depending on matching characteristics, to all hospital patients (n=350). All patients were admitted to the hospital during the calendar year 2022.

OUTCOME MEASURES

The primary outcome is the length of stay as defined from the date of hospital admission to the date of discharge or death (hospital patients) and from the date of hospital admission to the date of admission in a virtual ward (virtual ward patients). The secondary outcome is the cost of a hospital bed day and the equivalent value of virtual ward savings in hospital bed days. Additional measures were 6-month readmission rates and survival rates at the follow-up date of 30 April 2023.

RISK FACTORS

Age, sex, comorbidities and the clinical frailty score (CFS) were used to evaluate the importance and effect of these factors on the main and secondary outcomes.

METHODS

Statistical analyses included logistic and binomial mixed models for the length of stay in the hospital and readmission rate outcomes, as well as a Cox proportional hazard model for the survival of the patients.

RESULTS

The virtual ward patients had a shorter stay in the hospital before being admitted to the virtual ward (2.89 days, 95% CI 2.1 to 3.9 days). Chronic kidney disease (CKD) and frailty were associated with a longer length of stay in the hospital (58%, 95% CI 22% to 100%) compared with patients without CKD, and 14% (95% CI 8% to 21%) compared with patients with one unit lower CFS. The frailty score was also associated with a higher rate of readmission within 6 months and lower survival. Being admitted to the virtual ward slightly improved survival, although when readmitted, survival deteriorated rapidly. The cost of a 24-hour period in a general hospital bed is £536. The cost of a day hospital saved by a virtual ward was £935.

CONCLUSION

The use of a 40-bed virtual ward was clinically effective in terms of survival for patients not needing readmission and allowed for the freeing of three hospital beds per day. However, the cost for each day freed from hospital stay was three-quarters larger than the one for a single-day hospital bed. This raises concerns about the deployment of large-scale virtual wards without the existence of policies and plans for their cost-effective management.

Impact of a hospital service for adults with chronic childhood-onset disease: A propensity weighted analysis

BACKGROUND

Young adults with chronic childhood-onset diseases (CCOD) transitioning care from pediatrics to adult care are at high risk for readmission after hospital discharge. At our institution, we have implemented an inpatient service, the Med-Peds (MP) line, to improve transitions to adult care and reduce hospital utilization by young adults with CCOD.

OBJECTIVE

This study aimed to assess the effect of the MP line on length of stay (LOS) and 30-day readmission rates compared to other inpatient services.

METHODS

This was an observational, retrospective cohort analysis of patients admitted to the MP line compared to other hospital service lines over a 2-year period. To avoid potential confounding by indication for admission to the MP line, propensity score weighting methods were used.

RESULTS

The MP line cared for 302 patients with CCOD from June 2019 to July 2021. Compared to other service lines, there was a 33% reduction in relative risk of 30-day readmission (26.9% compared to 40.3%, risk ratio = 0.67, 95% confidence interval [CI] 0.55-0.81). LOS was 10% longer for the MP line (event time ratio (ETR): 1.10 95% CI 1.0-1.21) with median LOS 4.8 versus 4.5 days. Patients with sickle cell disease had less of a reduction in 30-day readmissions and longer LOS.

CONCLUSION

Hospitalization for young adults with CCOD on a MP service line was associated with lower 30-day readmission rates and longer LOS than hospitalization on other services. Further research is needed to assess which components of the line most contribute to decreased utilization.

Telehealth-based transitional care management programme to improve access to care

BACKGROUND

The transition from hospital to home is a vulnerable time for patients and families that can be improved through care coordination and structured discharge planning.

LOCAL PROBLEM

Our organisation aimed to develop and expand a programme that could improve 30-day readmission rates on overall and disease-specific populations by assessing the impact of a telehealth outreach by a registered nurse (RN) after discharge from an acute care setting on 30-day hospital readmission.

METHODS

This is a prospective observational design conducted from May 2021 to December 2022 with an urban, non-academic, acute care hospital in Westchester County, New York. Outcomes for patients discharged home following inpatient hospitalisation were analysed within this study. We analysed overall and disease-specific populations (congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and pneumonia (PNA)) as compared with a 40-month prestudy cohort.

INTERVENTIONS

Patients were identified in a non-random fashion meeting criterion of being discharged home after an inpatient admission. Participants received a telephonic outreach by an RN within 72 hours of discharge. Contacted patients were asked questions addressing discharge instructions, medication access, follow-up appointments and social needs. Patients were offered services and resources based on their individual needs in response to the survey.

RESULTS

68.2% of the 24 808 patients were contacted to assess and offer services. Median readmission rates for these patients were 1.2% less than the prestudy cohort (11.0% to 9.8%). Decreases were also noted for disease-specific conditions (CHF (14.3% to 9.1%), COPD (20.0% to 13.4%) and PNA (14.9% to 14.0%)). Among those in the study period, those that were contacted between 24 and 48 hours after discharge were 1.2 times less likely to be readmitted than if unable to be contacted (254/3742 (6.8%) vs 647/7866 (8.2%); p=0.005).

CONCLUSIONS

Using a multifaceted telehealth approach to improve patient engagement and access reduced 30-day hospital readmission for patients discharged from the acute care setting.

Effect of Chronic Disease Home Telehealth Monitoring in the Veterans Health Administration on Healthcare Utilization and Mortality

BACKGROUND

The high prevalence of chronic diseases, including congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM), accounts for a large burden of cost and poor health outcomes in US hospitals, and home telehealth (HT) monitoring has been proposed to improve outcomes.

OBJECTIVE

To measure the association between HT initiation and 12-month inpatient hospitalizations, emergency department (ED) visits, and mortality in veterans with CHF, COPD, or DM.

DESIGN

Comparative effectiveness matched cohort study.

PATIENTS

Veterans aged 65 years and older treated for CHF, COPD, or DM.

MAIN MEASURES

We matched veterans initiating HT with veterans with similar demographics who did not use HT (1:3). Our outcome measures included a 12-month risk of inpatient hospitalization, ED visits, and all-cause mortality.

KEY RESULTS

A total of 139,790 veterans with CHF, 65,966 with COPD, and 192,633 with DM were included in this study. In the year after HT initiation, the risk of hospitalization was not different in those with CHF (adjusted odds ratio [aOR] 1.01, 95% confidence interval [95%CI] 0.98-1.05) or DM (aOR 1.00, 95%CI 0.97-1.03), but it was higher in those with COPD (aOR 1.15, 95%CI 1.09-1.21). The risk of ED visits was higher among HT users with CHF (aOR 1.09, 95%CI 1.05-1.13), COPD (1.24, 95%CI 1.18-1.31), and DM (aOR 1.03, 95%CI 1.00-1.06). All-cause 12-month mortality was lower in those initiating HT monitoring with CHF (aOR 0.70, 95%CI 0.67-0.73) and DM (aOR 0.79, 95%CI 0.75-0.83), but higher in COPD (aOR 1.08, 95%CI 1.00-1.16).

CONCLUSIONS

The initiation of HT was associated with increased ED visits, no change in hospitalizations, and lower all-cause mortality in patients with CHF or DM, while those with COPD had both higher healthcare utilization and all-cause mortality.

Digital Health Technologies for Post-Discharge Care after Heart Failure Hospitalisation to Relieve Symptoms and Improve Clinical Outcomes

The prevention of recurrent heart failure (HF) hospitalisations is of particular importance, as each such successive event may increase the risk of death. Effective care planning during the vulnerable phase after discharge is crucial for symptom control and improving patient prognosis. Many clinical trials have focused on telemedicine interventions in HF, with varying effects on the primary endpoints. However, the evidence of the effectiveness of telemedicine solutions in cardiology is growing. The scope of this review is to present complementary telemedicine modalities that can support outpatient care of patients recently hospitalised due to worsening HF. Remote disease management models, such as video (tele) consultations, structured telephone support, and remote monitoring of vital signs, were presented as core components of telecare. Invasive and non-invasive monitoring of volume status was described as an important step forward to prevent congestion-the main cause of clinical decompensation. The idea of virtual wards, combining these facilities with in-person visits, strengthens the opportunity for education and enhancement to promote more intensive self-care. Electronic platforms provide coordination of tasks within multidisciplinary teams and structured data that can be effectively used to develop predictive algorithms based on advanced digital science, such as artificial intelligence. The rapid progress in informatics, telematics, and device technologies provides a wide range of possibilities for further development in this area. However, there are still existing gaps regarding the use of telemedicine solutions in HF patients, and future randomised telemedicine trials and real-life registries are still definitely needed.