Effect of post-discharge virtual wards on improving outcomes in heart failure and non-heart failure populations: A systematic review and meta-analysis

Virtual wards for people with frailty: what works, for whom, how and why-a rapid realist review

BACKGROUND

Virtual wards (VWs) deliver multidisciplinary care at home to people with frailty who are at high risk of a crisis or in crisis, aiming to mitigate the risk of acute hospital admission. Different VW models exist, and evidence of effectiveness is inconsistent.

AIM

We conducted a rapid realist review to identify different VW models and to develop explanations for how and why VWs could deliver effective frailty management.

METHODS

We searched published and grey literature to identify evidence on multidisciplinary VWs. Information on how and why VWs might 'work' was extracted and synthesised into context-mechanism-outcome configurations with input from clinicians and patient/public contributors.

RESULTS

We included 17 peer-reviewed and 11 grey literature documents. VWs could be short-term and acute (1-21 days), or longer-term and preventative (typically 3-7 months). Effective VW operation requires common standards agreements, information sharing processes, an appropriate multidisciplinary team that plans patient care remotely, and good co-ordination. VWs may enable delivery of frailty interventions through appropriate selection of patients, comprehensive assessment including medication review, integrated case management and proactive care. Important components for patients and caregivers are good communication with the VW, their experience of care at home, and feeling involved, safe and empowered to manage their condition.

CONCLUSIONS

Insights gained from this review could inform implementation or evaluation of VWs for frailty. A combination of acute and longer-term VWs may be needed within a whole system approach. Proactive care is recommended to avoid frailty-related crises.

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.

Effectiveness of hospital-to-home transitional care interventions and consultation for implementation in Sudan: a scoping review of systematic reviews

Background

Hospital discharge is often associated with a lack of continuity resulting in fragmented care, particularly in low-income countries. As there is limited information about interventions in these countries and no study evaluating the effectiveness of hospital discharge interventions, we conducted a scoping review to identify effective hospital-to-home transitional care interventions and explore their applicability in a low-income country (Sudan).

Methods

Our scoping review of systematic reviews and meta-analyses classed interventions as effective, ineffective, undesirable, or uncertain, based on the quality of their evidence and their estimated effects on the following outcomes: readmission rates, mortality, costs, quality of life, and adverse outcomes) and certainty of evidence. Our authors from Sudan used the SUPPORT summary tool to determine if three effective interventions could be implemented in Sudan.

Results

Out of 3,276 articles that were identified, and 72 articles were reviewed, 10 articles has been included in the review. Seven interventions were classified as effective, one as ineffective, and none with undesirable effects. Eight interventions were classified as having an uncertain effect. The effective interventions were composed of home visits, information and communication technology (ICT), case manager models, multidisciplinary teams, and self-management support.

Conclusions

The finding of this study suggested that a combining two to four interventions can improve enhance hospital-to-home transitional care. Effective interventions are composed of home visits, ICT, case manager models, multidisciplinary teams, and self-management support. The implementation of these interventions in Sudan was found to be undermined by contextual factors such as inadequate human resources, telecommunication instability, and inequality in accessibility. These interventions could be tailored based on an in-depth understanding of the contextual factors in low-income countries that influence implementation.

Systematic Review Registration

https://osf.io/9eqvr/, doi: 10.17605/OSF.IO/9EQVR.

Use of Wearable and Wireless Technology in Real-World Clinical Settings to Improve Patient Outcomes in Chronic Kidney Disease: A Mixed Methods Pilot Prospective Trial

Background

During the 30-day period prior to initiating dialysis, there is a 10-fold rise in emergency department visits and hospitalizations related to kidney failure.

Objective

The Virtual Ward Incorporating Electronic Wearables (VIEWER) trial implemented a home telemonitoring system to track changes in patients' vitals and assess their adherence and the acceptability of telemonitoring in a chronic kidney disease (CKD) population.

Design

A pilot prospective clinical trial using a mixed methods approach was performed.

Setting

The research was conducted in Winnipeg, Manitoba.

Participants

There were 2 phases: Phase 1 was a 2-week-long pilot trial consisting of 10 participants. Phase 2 was a 3-month-long trial with a total of 26 participants. Patients with an estimated glomerular filtration rate <15 and a >40% risk of beginning dialysis in the next 2 years according to the kidney failure risk equation were eligible to participate in the study.

Methods

The primary quantitative outcome was adherence, defined as the proportion of daily self-assessments completed using VIEWER over the follow-up period. The usability and acceptability of VIEWER was assessed qualitatively at the end of the trial through structured questionnaires and focus groups.

Results

Phase 1 participants (n = 10) had a median adherence of 77.17% for the 2-week observation period. Phase 2 participants (n = 26) showed a lower median adherence of 36% for the 3-month period. Focus group participants (n = 11) identified many positive aspects of VIEWER, including increased awareness and empowerment over health, simplicity of the data platform, and the ability to show clinical staff their health trends. Some challenges identified with VIEWER were connectivity issues with the Bluetooth, perceived inconvenience, and negative thoughts toward their health.

Limitations

Limitations of the study include a small sample size, which limited our ability to measure quantitative outcomes. In addition, patients agreeing to participate in any trial are generally more highly motivated and engaged in their care than those declining participation. Therefore, our results may not be generalizable to individuals who are not interested in self-management of their health.

Conclusion

Our results suggest that home telemonitoring in patients with advanced CKD is feasible using a CKD-specific platform like VIEWER. We anticipate that improved functionality with incorporation of feedback from this study will result in greater long-term adherence. A future randomized clinical trial is planned.

A rapid mixed-methods evaluation of remote home monitoring models during the COVID-19 pandemic in England

Background

Remote home monitoring services were developed and implemented for patients with COVID-19 during the pandemic. Patients monitored blood oxygen saturation and other readings (e.g. temperature) at home and were escalated as necessary.

Objective

To evaluate effectiveness, costs, implementation, and staff and patient experiences (including disparities and mode) of COVID-19 remote home monitoring services in England during the COVID-19 pandemic (waves 1 and 2).

Methods

A rapid mixed-methods evaluation, conducted in two phases. Phase 1 (July-August 2020) comprised a rapid systematic review, implementation and economic analysis study (in eight sites). Phase 2 (January-June 2021) comprised a large-scale, multisite, mixed-methods study of effectiveness, costs, implementation and patient/staff experience, using national data sets, surveys (28 sites) and interviews (17 sites).

Results

Phase 1 Findings from the review and empirical study indicated that these services have been implemented worldwide and vary substantially. Empirical findings highlighted that communication, appropriate information and multiple modes of monitoring facilitated implementation; barriers included unclear referral processes, workforce availability and lack of administrative support. Phase 2 We received surveys from 292 staff (39% response rate) and 1069 patients/carers (18% response rate). We conducted interviews with 58 staff, 62 patients/carers and 5 national leads. Despite national roll-out, enrolment to services was lower than expected (average enrolment across 37 clinical commissioning groups judged to have completed data was 8.7%). There was large variability in implementation of services, influenced by patient (e.g. local population needs), workforce (e.g. workload), organisational (e.g. collaboration) and resource (e.g. software) factors. We found that for every 10% increase in enrolment to the programme, mortality was reduced by 2% (95% confidence interval: 4% reduction to 1% increase), admissions increased by 3% (-1% to 7%), in-hospital mortality fell by 3% (-8% to 3%) and lengths of stay increased by 1.8% (-1.2% to 4.9%). None of these results are statistically significant. We found slightly longer hospital lengths of stay associated with virtual ward services (adjusted incidence rate ratio 1.05, 95% confidence interval 1.01 to 1.09), and no statistically significant impact on subsequent COVID-19 readmissions (adjusted odds ratio 0.95, 95% confidence interval 0.89 to 1.02). Low patient enrolment rates and incomplete data may have affected chances of detecting possible impact. The mean running cost per patient varied for different types of service and mode; and was driven by the number and grade of staff. Staff, patients and carers generally reported positive experiences of services. Services were easy to deliver but staff needed additional training. Staff knowledge/confidence, NHS resources/workload, dynamics between multidisciplinary team members and patients' engagement with the service (e.g. using the oximeter to record and submit readings) influenced delivery. Patients and carers felt services and human contact received reassured them and were easy to engage with. Engagement was conditional on patient, support, resource and service factors. Many sites designed services to suit the needs of their local population. Despite adaptations, disparities were reported across some patient groups. For example, older adults and patients from ethnic minorities reported more difficulties engaging with the service. Tech-enabled models helped to manage large patient groups but did not completely replace phone calls.

Limitations

Limitations included data completeness, inability to link data on service use to outcomes at a patient level, low survey response rates and under-representation of some patient groups.

Future work

Further research should consider the long-term impact and cost-effectiveness of these services and the appropriateness of different models for different groups of patients.

Conclusions

We were not able to find quantitative evidence that COVID-19 remote home monitoring services have been effective. However, low enrolment rates, incomplete data and varied implementation reduced our chances of detecting any impact that may have existed. While services were viewed positively by staff and patients, barriers to implementation, delivery and engagement should be considered.

Study registration

This study is registered with the ISRCTN (14962466).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (RSET: 16/138/17; BRACE: 16/138/31) and NHSEI and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 13. See the NIHR Journals Library website for further project information. The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health and Care Research or the Department of Health and Social Care.

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.

Virtual wards: a rapid evidence synthesis and implications for the care of older people

BACKGROUND

Virtual wards are being rapidly developed within the National Health Service in the UK, and frailty is one of the first clinical pathways. Virtual wards for older people and existing hospital at home services are closely related.

METHODS

In March 2022, we searched Medline, CINAHL, the Cochrane Database of Systematic Reviews and medRxiv for evidence syntheses which addressed clinical-effectiveness, cost-effectiveness, barriers and facilitators, or staff, patient or carer experience for virtual wards, hospital at home or remote monitoring alternatives to inpatient care.

RESULTS

We included 28 evidence syntheses mostly relating to hospital at home. There is low to moderate certainty evidence that clinical outcomes including mortality (example pooled RR 0.77, 95% CI 0.60-0.99) were probably equivalent or better for hospital at home. Subsequent residential care admissions are probably reduced (example pooled RR 0.35, 95% CI 0.22-0.57). Cost-effectiveness evidence demonstrated methodological issues which mean the results are uncertain. Evidence is lacking on cost implications for patients and carers. Barriers and facilitators operate at multiple levels (organisational, clinical and patient). Patient satisfaction may be improved by hospital at home relative to inpatient care. Evidence for carer experience is limited.

CONCLUSIONS

There is substantial evidence for the clinical effectiveness of hospital at home but less evidence for virtual wards. Guidance for virtual wards is lacking on key aspects including team characteristics, outcome selection and data protection. We recommend that research and evaluation is integrated into development of virtual ward models. The issue of carer strain is particularly relevant.

Meeting today’s healthcare needs: Medicine at the interface

The demographic of Singapore has undergone dramatic change. Historically, younger patients with communicable diseases predominated, whereas patients are now older with chronic multimorbidity and functional impairment. This shift challenges existing health and social care systems in Singapore, which must pivot to meet the changing need. The consequences of mismatched health and social care to patient needs are the fragmentation of care, dysfunctional acute care utilisation and increasing care costs. In Singapore and internationally, there is an inexorable rise in acute care utilisation, with patients facing the greatest point of vulnerability at transitions between acute and chronic care. Recently, innovative care models have developed to work across the boundaries of traditional care interfaces. These “Interface Medicine” models aim to provide a comprehensive and integrated approach to meet the healthcare needs of today and optimise value with our finite resources. These models include Acute Medical Units, Ambulatory Emergency Care, Extensivist-Comprehensivist Care, Virtual Wards, Hospital-at-Home and Acute Frailty Units. We describe these models of care across the acute care chain and explore how they may apply to the Singapore setting. We discuss how these models have evolved, appraise the evidence for clinical effectiveness, point out gaps in knowledge for further study and make recommendations for future progress. Keywords: Frailty, health services research, integrated care, interface medicine, public health

Optimal effectiveness of heart failure management - an umbrella review of meta-analyses examining the effectiveness of interventions to reduce (re)hospitalizations in heart failure

Heart failure (HF) is a major health concern, which accounts for 1-2% of all hospital admissions. Nevertheless, there remains a knowledge gap concerning which interventions contribute to effective prevention of HF (re)hospitalization. Therefore, this umbrella review aims to systematically review meta-analyses that examined the effectiveness of interventions in reducing HF-related (re)hospitalization in HFrEF patients. An electronic literature search was performed in PubMed, Web of Science, PsycInfo, Cochrane Reviews, CINAHL, and Medline to identify eligible studies published in the English language in the past 10 years. Primarily, to synthesize the meta-analyzed data, a best-evidence synthesis was used in which meta-analyses were classified based on level of validity. Secondarily, all unique RCTS were extracted from the meta-analyses and examined. A total of 44 meta-analyses were included which encompassed 186 unique RCTs. Strong or moderate evidence suggested that catheter ablation, cardiac resynchronization therapy, cardiac rehabilitation, telemonitoring, and RAAS inhibitors could reduce (re)hospitalization. Additionally, limited evidence suggested that multidisciplinary clinic or self-management promotion programs, beta-blockers, statins, and mitral valve therapy could reduce HF hospitalization. No, or conflicting evidence was found for the effects of cell therapy or anticoagulation. This umbrella review highlights different levels of evidence regarding the effectiveness of several interventions in reducing HF-related (re)hospitalization in HFrEF patients. It could guide future guideline development in optimizing care pathways for heart failure patients.

Remote care and triage of obstetric patients with COVID-19 in the community: operational considerations

Background

During the SARS-CoV-2 (COVID-19) pandemic, routine antenatal care was disrupted, and pregnant women positive for COVID-19 were at increased risk of caesarean section, intensive care admission or neonatal unit admission for their baby. Virtual care and telehealth can reduce barriers to care and improve maternity outcomes, and adoption has been encouraged by health authorities in the United Kingdom.

Methods

Norfolk and Norwich University Hospitals Trust deployed a flexible maternity virtual ward (MVW) service using the Current Health platform to care for pregnant women during the pandemic. Patients were monitored either intermittently with finger pulse oximetry or continuously with a wearable device. We outline the MVW technology, intervention and staffing model, triage criteria and patient feedback, as an example of an operational model for other institutions.

Results

Between October 2021 and February 2022, 429 patients were referred, of which 228 were admitted to the MVW. Total bed-days was 1,182, mean length of stay was 6 days (SD 2.3, range 1–14 days). Fifteen (6.6%) required hospital admission and one (0.4%) critical care. There were no deaths. Feedback alluded to feelings of increased safety, comfort, and ease with the technology.

Conclusions

The MVW offered a safety net to pregnant women positive for COVID-19. It provided reassurance for staff, while relieving pressures on infrastructure. When setting up similar services in future, attention should be given to identifying clinical champions, triage criteria, technology and alarm selection, and establishing flexible escalation pathways that can adapt to changing patterns of disease.

The impact of post-hospital remote monitoring of COVID-19 patients using pulse oximetry: A national observational study using hospital activity data

BACKGROUND

There was a national roll out of 'COVID Virtual Wards' (CVW) during England's second COVID-19 wave (Autumn 2020 - Spring 2021). These services used remote pulse oximetry monitoring for COVID-19 patients following discharge from hospital. A key aim was to enable rapid detection of patient deterioration. It was anticipated that the services would support early discharge, reducing pressure on beds. This study is an evaluation of the impact of the CVW services on hospital activity.

METHODS

Using retrospective patient-level hospital admissions data, we built multivariate models to analyze the relationship between the implementation of CVW services and hospital activity outcomes: length of COVID-19 related stays and subsequent COVID-19 readmissions within 28 days. We used data from more than 98% of recorded COVID-19 hospital stays in England, where the patient was discharged alive between mid-August 2020 and late February 2021.

FINDINGS

We found a longer length of stay for COVID-19 patients discharged from hospitals where a CVW was available, when compared to patients discharged from hospitals where there was no CVW (adjusted IRR 1·05, 95% CI 1·01 to 1·09). We found no evidence of a relationship between the availability of CVW and subsequent rates of readmission for COVID-19 (adjusted OR 0.97, 95% CI 0.91 to 1·03).

INTERPRETATION

We found no evidence of early discharges or changes in readmissions associated with the roll out of COVID Virtual Wards across England. Our analysis made pragmatic use of national-scale hospital data, but it is possible that a lack of specific data (for example, on which patients were enrolled and on potentially important confounders) may have meant that true impacts, especially at a local level, were not ultimately discernible. It is important that future research is able to make use of better quality - preferably linked - data, from multiple sites.

FUNDING

This is independent research funded by the National Institute for Health Research, Health Services & Delivery Research program (RSET Project no. 16/138/17; BRACE Project no. 16/138/31) and NHSE&I. NJF is an NIHR Senior Investigator.

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

IMPORTANCE

Virtual wards (VWs) include patient assessment in their homes by health care personnel and offer ongoing assessment and case management via home, telephone, and/or clinic visits. The association between VWs and patient outcomes during the transition from the hospital to home are unclear; earlier reviews on this topic have often conflated telemonitoring programs with VW models.

OBJECTIVE

To evaluate the use of VW transition systems for community-dwelling individuals after medical discharge.

DATA SOURCES

English-language articles indexed in PubMed or Cochrane and published between January 1, 2000, and June 15, 2021.

STUDY SELECTION

Randomized clinical trials comparing VW care with usual postdischarge care. Studies were stratified by diagnosis.

DATA EXTRACTION AND SYNTHESIS

Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline, 2 reviewers independently identified studies and extracted data. DerSimonian-Laird inverse variance weighted random-effects models were used to compute relative risks (RRs) for dichotomous outcomes and mean differences for continuous outcomes.

MAIN OUTCOMES AND MEASURES

All-cause mortality, hospital readmissions, emergency department visits, health care costs, readmission length of stay, quality of life, and functional status.

RESULTS

Twenty-four randomized clinical trials (11 in patients with heart failure, 3 in patients with chronic obstructive pulmonary disease, 4 in patients at high-risk for readmission, and 6 in mixed patient populations) with 10 876 patients were included (20 more trials than earlier reviews). In patients with heart failure, VWs were associated with fewer deaths (RR, 0.86; 95% CI, 0.76-0.97) and fewer readmissions (RR, 0.84; 95% CI, 0.74-0.96). However, similar associations were not seen in randomized clinical trials enrolling patients with other diagnoses (RR, 0.93; 95% CI, 0.83-1.04 for mortality and RR, 0.96; 95% CI, 0.88-1.05 for readmissions). Across all studies, VWs were associated with fewer emergency department visits (RR, 0.83; 95% CI, 0.70-0.98) and shorter readmission lengths of stay (mean difference, -1.94 days; 95% CI, -3.28 to -0.60 days). Three of 7 studies that evaluated health care expenses reported statistically significant lower costs with VW transition systems.

CONCLUSIONS AND RELEVANCE

Although postdischarge VW interventions appear to be associated with fewer subsequent emergency department visits, shorter readmission lengths of stay, and lower health care costs, fewer deaths and readmissions were seen only in trials enrolling patients with heart failure.

Deliver Cardiac Virtual Care (CVC) - A Primer for Cardiovascular Professionals in Canada

The COVID-19 pandemic, with its need for distancing, has necessitated the use of virtual care in never-before-seen volumes. This review article aims to provide a primer on virtual care for cardiovascular professionals in Canada. The technology to facilitate remote patient interactions is already available, but barriers exist. Adequate and effective cardiac virtual care must be further developed given the need for rapid evaluation and close ongoing follow-up of patients, as seen in the areas of management of heart failure, cardiac rehabilitation, electrophysiology, and hypertension. Many Canadian organizations have published resources to assist health care providers and patients navigate the unfamiliar virtual care landscape. Although there are concerns surrounding issues such as patient privacy, access to technology, language discrepancies, and billing, these deficits provide opportunities for growth by health care organizations and technology companies. The integration of virtual care, home-based devices, and disruptive technologies emphasize the trend toward virtualization of health care, with the potential for greater personalization of health care interactions and continuity of care. Funding models were rapidly developed at the beginning of the COVID-19 pandemic, and although some provinces have deemed these changes as permanent, the status from other provinces remains unknown. The foundations to support virtual care as a key modality for health care delivery in Canada have been built, and further developments may strengthen its viability as a long-term option.

Integrating hospital and community care: using a community virtual ward model to deliver combined specialist and generalist care to patients with severe chronic respiratory disease in their homes

Background

Chronic respiratory diseases are responsible for significant patient morbidity, mortality, and healthcare use. Community virtual ward (CVW) models of care have been successfully implemented to manage patients with complex medical conditions.

Aims

To explore the feasibility and clinical outcomes of a CVW model of care in patients with chronic respiratory disease.

Methods

Patients known to specialist respiratory services with Chronic Obstructive Pulmonary Disease (COPD) and/or asthma were admitted to the CVW for disease optimisation and exacerbation management. Individualised management plans were delivered in the patients’ home by hospital-based respiratory and community nursing teams, incorporating remote technology to monitor vital signs. Symptoms and health status at admission and discharge were compared.

Results

Twenty patients were admitted. One-quarter of patients had asthma, 50% COPD, and 25% combined asthma/COPD. Patients had severe disease, mean (SD) FEV₁ 50(20) % predicted, and an average 6.4(5.7) exacerbations of disease in the previous 12 months. Patients received personalised disease and self-management education. All acute exacerbations (n = 11) were successfully treated in the community. The average length of CVW admission was 10(4) days. By discharge, 60% of COPD and 66% of asthma patients recorded improvements in symptoms score exceeding the minimal clinically important difference. Fifty percent had clinically meaningful improvements in health status.

Conclusion

A CVW model facilitates the delivery of combined specialist and generalist care to patients with chronic respiratory disease in the community and improves symptoms and health status. The principles of the model are transferable to other conditions to improve overall health and reduce emergency hospital care.

Strategies to prevent hospital readmission and death in patients with chronic heart failure, chronic obstructive pulmonary disease, and chronic kidney disease: A systematic review and meta-analysis

BACKGROUND

Readmission following hospital discharge is common and is a major financial burden on healthcare systems.

OBJECTIVES

Our objectives were to 1) identify studies describing post-discharge interventions and their efficacy with respect to reducing risk of mortality and rate of hospital readmission; and 2) identify intervention characteristics associated with efficacy.

METHODS

A systematic review of the literature was performed. We searched MEDLINE, PubMed, Cochrane, EMBASE and CINAHL. Our selection criteria included randomized controlled trials comparing post-discharge interventions with usual care on rates of hospital readmission and mortality in high-risk chronic disease patient populations. We used random effects meta-analyses to estimate pooled risk ratios for all-cause and cause-specific mortality as well as all-cause and cause-specific hospitalization.

RESULTS

We included 31 randomized controlled trials encompassing 9654 patients (24 studies in CHF, 4 in COPD, 1 in both CHF and COPD, 1 in CKD and 1 in an undifferentiated population). Meta-analysis showed post-discharge interventions reduced cause-specific (RR = 0.71, 95% CI = 0.63-0.80) and all cause (RR = 0.90, 95% CI = 0.81-0.99) hospitalization, all-cause (RR = 0.73, 95% CI = 0.65-0.83) and cause-specific mortality (RR = 0.68, 95% CI = 0.54-0.84) in CHF studies, and all-cause hospitalization (RR = 0.52, 95% CI = 0.32-0.83) in COPD studies. The inclusion of a cardiac nurse in the multidisciplinary team was associated with greater efficacy in reducing all-cause mortality among patients discharged after heart failure admission (HR = 0.64, 95% CI = 0.54-0.75 vs. HR = 0.87, 95% CI = 0.73-1.03).

CONCLUSIONS

Post-discharge interventions reduced all-cause mortality, cause-specific mortality, and cause-specific hospitalization in CHF patients and all-cause hospitalization in COPD patients. The presence of a cardiac nurse was associated with greater efficacy in included studies. Additional research is needed on the impact of post-discharge intervention strategies in COPD and CKD patients.

A Cost-Minimization Analysis of Nurse-Led Virtual Case Management in Late-Stage CKD

Introduction

Interventions are needed to improve early detection of indications for dialysis before development of severe symptoms or complications. This may reduce suboptimal dialysis starts, prevent hospitalizations, and decrease costs. Our objectives were to explore assumptions around a nurse-led virtual case management intervention for patients with late-stage chronic kidney disease (CKD) with a 2-year Kidney Failure Risk Equation (KFRE) estimated risk of kidney failure ≥80% and to estimate how these assumptions affect potential cost savings.

Methods

We performed a cost-minimization analysis by developing a decision analytic microsimulation model constructed from the perspective of the health payer. Our primary outcome was the break-even point, defined as the maximum amount a health payer could spend on the intervention without incurring any net financial loss or gain. The intervention group received remote telemonitoring, including daily measurement of several health metrics (blood pressure, oxygen saturation, and weight), and a validated symptom questionnaire accompanied by nurse-led case management, whereas the comparator group received usual care. We assumed patients received the intervention for a maximum of 2 years.

Results

The break-even point was $7339 per late-stage CKD patient enrolled in the intervention. Based on the distribution of time receiving the intervention, we determined a maximum monthly intervention cost of $703.37. In probabilistic sensitivity analyses, we found that 75% of simulations produced break-even points between $3929 and $9460.

Conclusion

Nurse-led virtual home monitoring interventions in patients with CKD at high risk of kidney failure have the potential for significant cost savings from the perspective of the health payer.

Interventional radiology training: where will technology take us?

Interventional radiology is a relatively young specialty, and it is undergoing a period of considerable growth. The benefits of a minimally invasive approach are clear, with smaller incisions, less pain, and faster recovery times being the principal benefits compared to surgical alternatives.

Trainees need to acquire the technical skills and the clinical acumen to accurately deliver targeted treatment and safely follow up patients after the procedure. The need to maintain an efficient interventional radiology service whilst also giving sufficient time for trainee education is a challenge. In order to compensate for this, novel technologies like virtual reality (VR), augmented reality (AR), cadaveric simulation, and three-dimensional (3D) printing have been postulated as a means of supplementing training.

In this article, we outline the main features of these innovative strategies and discuss the evidence base behind them. Benefits of these techniques beyond pure clinical training include the standardization of educational cases, access to training at any time, and less risk to patients. The main disadvantage is the large financial outlay required. Therefore, before widespread uptake can be recommended, further research is needed to confirm the educational benefit of these novel techniques, both in and of themselves and in comparison to existing clinical-based education.