Virtual hospitals: why we need them, how they work and what might come next

A Virtual Hospital Model of Care for Low Back Pain, Back@Home: Protocol for a Hybrid Effectiveness-Implementation Type-I Study

BACKGROUND

Low back pain (LBP) was the fifth most common reason for an emergency department (ED) visit in 2020-2021 in Australia, with >145,000 presentations. A total of one-third of these patients were subsequently admitted to the hospital. The admitted patient care accounts for half of the total health care expenditure on LBP in Australia.

OBJECTIVE

The primary aim of the Back@Home study is to assess the effectiveness of a virtual hospital model of care to reduce the length of admission in people presenting to ED with musculoskeletal LBP. A secondary aim is to evaluate the acceptability and feasibility of the virtual hospital and our implementation strategy. We will also investigate rates of traditional hospital admission from the ED, representations and readmissions to the traditional hospital, demonstrate noninferiority of patient-reported outcomes, and assess cost-effectiveness of the new model.

METHODS

This is a hybrid effectiveness-implementation type-I study. To evaluate effectiveness, we plan to conduct an interrupted time-series study at 3 metropolitan hospitals in Sydney, New South Wales, Australia. Eligible patients will include those aged 16 years or older with a primary diagnosis of musculoskeletal LBP presenting to the ED. The implementation strategy includes clinician education using multimedia resources, staff champions, and an "audit and feedback" process. The implementation of "Back@Home" will be evaluated over 12 months and compared to a 48-month preimplementation period using monthly time-series trends in the average length of hospital stay as the primary outcome. We will construct a plot of the observed and expected lines of trend based on the preimplementation period. Linear segmented regression will identify changes in the level and slope of fitted lines, indicating immediate effects of the intervention, as well as effects over time. The data will be fully anonymized, with informed consent collected for patient-reported outcomes.

RESULTS

As of December 6, 2023, a total of 108 patients have been cared for through Back@Home. A total of 6 patients have completed semistructured interviews regarding their experience of virtual hospital care for nonserious back pain. All outcomes will be evaluated at 6 months (August 2023) and 12 months post implementation (February 2024).

CONCLUSIONS

This study will serve to inform ongoing care delivery and implementation strategies of a novel model of care. If found to be effective, it may be adopted by other health districts, adapting the model to their unique local contexts.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/50146.

Systematic review of predictors of hospitalisation for non-specific low back pain with or without referred leg pain

Significant costs and utilisation of healthcare resources are associated with hospitalisations for non-specific low back pain despite clinical guidelines recommending community-based care. The aim of this systematic review was to investigate the predictors of hospitalisation for low back pain. A protocol was registered with PROSPERO international prospective register of systematic reviews (#CRD42021281827) and conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement. Database search of Ovid Medline, Emcare, Embase, PsycINFO, Cochrane Library, PEDro and OTSeeker was conducted. Studies were included if they examined a predictor of hospitalisation for non-specific low back pain with or without referred leg pain. Data was extracted and descriptively synthesised. Risk of bias of included studies was assessed using the Critical Appraisal Skills Programme Checklists. There were 23 studies published over 29 articles which identified 52 predictor variables of hospitalisation for low back pain. The risk of hospitalisation was grouped into themes: personal, health and lifestyle, psychology, socioeconomic, occupational, clinical, and health systems and processes. There was moderate level evidence that arrival to an emergency department via ambulance with low back pain, and older age increase the risk of hospitalisations for low back pain. There was low level evidence that high pain intensity, past history of low back pain, opioid use, and occupation type increase the risk of hospitalisation for low back pain. Further research into psychological and social factors is warranted given the paucity of available studies. Hospital avoidance strategies, improved patient screening and resource utilisation in emergency departments are considerations for practice.

Management of patients with low back pain admitted to hospital: An observational study of usual care

BACKGROUND

Knowledge gaps exist around diagnostic and treatment approaches for patients admitted to hospital with low back pain.

METHODS

Medical record review of patients admitted to three Sydney teaching hospitals with a provisional emergency department diagnosis of non-serious low back pain, from 2016 to 2020. Data on demographic variables, hospital costs, length of stay (LOS), diagnostic imaging and analgesic administration were extracted. Logistic regression was used to identify predictors of longer hospital stay, advanced imaging, and concomitant use of sedating medicines.

RESULTS

Median inpatient LOS for non-specific low back pain was 4 days (interquartile range [IQR] 2-7), and for radicular low back pain was 4 days (IQR 3-10). Older patients with non-serious low back pain were more likely to stay longer, as were arrivals by ambulance. Plain lumbar radiography was used in 8.3% of admissions, whereas 37.6% of patients received advanced lumbar imaging (computed tomography or magnetic resonance imaging). Opioids were administered in ~80% of admissions; 49% of patients with radicular low back pain were given an antiepileptic in addition to an opioid. In all, 18.4% of admissions resulted in at least one hospital-acquired complication, such as an accidental fall (3.1%) or a medication-related adverse effect (13.3%). Physiotherapists saw 82.6% of low back pain admissions. Costs of inpatient care were estimated at a mean of AU$ 14 000 per admission.

CONCLUSIONS

We noted relatively high rates of concomitant use of sedating pain medicines and referrals for advanced lumbar imaging and laboratory tests. Strategies to address these issues in inpatient care of low back pain are needed.

Many people admitted to hospital with a provisional diagnosis of nonserious back pain are subsequently found to have serious pathology as the underlying cause

To determine the proportion of patients admitted to the hospital for back pain who have nonserious back pain, serious spinal, or serious other pathology as their final diagnosis. The proportion of nonserious back pain admissions will be used to plan for future 'virtual hospital' admissions. Electronic medical record data between January 2016 and September 2020 from three emergency departments (ED) in Sydney, Australia were used to identify inpatient admissions. SNOMED-CT-AU diagnostic codes were used to select ED patients aged 18 and older with an admitting diagnosis related to nonserious back pain. The inpatient discharge diagnosis was determined from the primary ICD-10-AM codes by two independent clinician-researchers. Inpatient admissions were then analysed by sociodemographic and hospital admission variables. A total of 38.1% of patients admitted with a provisional diagnosis of nonserious back pain were subsequently diagnosed with a specific pathology likely unsuitable for virtual care; 14.2% with a serious spinal pathology (e.g., fracture and infection) and 23.9% a serious pathology beyond the lumbar spine (e.g., pathological fracture and neoplasm). A total of 57% of admissions were identified as nonserious back pain, likely suitable for virtual care. A challenge for implementing virtual care in this setting is screening for patients with serious pathology. Protocols need to be developed to reduce the risk of patients being admitted to virtual hospitals with serious pathology as the cause of their back pain. Key Points • Among admitted patients provisionally diagnosed in ED with non-serious back pain, 38.1% were found to have 'serious spinal pathologies' or 'serious pathologies beyond the lumbar spine' at discharge. • Spinal fractures were the most common serious spinal pathology, accounting for 9% of all provisional 'non-serious back pain' admissions from ED. • 57% of back pain admissions were confirmed to be non-serious back pain and may be suitable to virtual hospital care; the challenge is discriminating these patients from those with serious pathology.