Virtual ward transition systems (VWs) were associated with significantly fewer deaths and hospital readmissions in patients with a primary diagnosis of heart failure (HF), but not in patients with other primary diagnoses, such as chronic obstructive pulmonary disease (COPD), or in those at high risk for hospital readmission, according to a systematic review and meta-analysis published in JAMA Network Open.
“A number of jurisdictions and health authorities, including my own, have initiated ‘virtual ward transitional care teams’ to coordinate the discharge and follow-up of patients after hospital discharge who are deemed to be at ‘high risk’ for readmission after discharge. Our question was how strong was the evidence for these VW interventions and were they better suited for some patients than others,” explains Finlay A. McAlister, MD, MSc.
The systematic review and meta-analysis included 24 randomized clinical trials (RCTs) that collectively enrolled 10,876 patients and assessed the impact of VW systems on numerous outcomes, including all-cause mortality, hospital readmissions, ED visits, and length of stay during readmissions and associated costs. All studies were carefully selected to ensure they assessed VWs and not telemonitoring programs. Unlike telemonitoring programs, VWs include assessment of patients within their homes by skilled healthcare professionals.
14% Fewer Deaths With VWs
Among the 10 RCTs enrolling patients with a primary diagnosis of HF, postdischarge VWs were associated with 14% fewer deaths (Table; relative risk [RR], 0.86; 95% CI, 0.76-0.97). No mortality benefit was observed in the three RCTs enrolling patients with COPD (RR, 1.11; 95% CI, 0.69-1.79) or the two including patients deemed at high risk for readmission (RR, 0.97; 95% CI, 0.84-1.12). When considering all non-HF RCTs, the relative risk was 0.93 (95% CI, 0.83-1.04).
16% Fewer Readmissions in Patients With HF
Among the 23 RCTs that evaluated postdischarge hospital readmissions, VWs were associated with 16% fewer hospital readmissions in patients with HF (RR, 0.84; 95% CI, 0.74-0.96). There was no significant difference in hospital readmissions in patients with COPD (RR, 0.97; 95% CI, 0.62-1.51) or in those considered at high risk for readmission (RR, 1.00; 95% CI, 0.95-1.06). When considering the non-HF RCTs, the relative risk was 0.96 (95% CI, 0.88-1.05).
Less ED Visits & Shorter LOS With VWs
In patients with HF, VWs were associated with 35% fewer ED visits and a 2-day shorter length of stay when hospital readmissions occurred, Dr. McAlister says. He notes that VW programs were also cost-saving for these patients. Of the seven RCTs that compared expenses between VWs and usual care, all three that reported significant cost-savings (eg, $5,000 to $10,000 per patient) enrolled HF cohorts. The four that enrolled non-HF cohorts were cost-neutral.
One Size Does Not Fit All
“One size does not fit all—not all patients appear to derive benefit from VWs, and further research is required to define what other groups, beyond patients with HF, are likely to benefit most from VW programs,” Dr. McAlister says. He explains that while VWs should ideally be targeted toward the patients most likely to derive benefit from them, these individuals are difficult to identify. He adds that “risk prediction tools and even experienced clinicians cannot accurately do so.” Therefore, he continues, when VW programs are implemented, they should be “rolled out with a robust evaluation that captures traditional metrics like mortality, ED visits, readmission rates, and cost, but also patient-reported outcomes and experience measures like satisfaction, comfort, and perception of care continuity.”