NIHR DC Discover

NIHR Signal ‘Virtual wards’ reduce readmissions in people after hospitalisation for heart failure

Published on 14 August 2018

doi: 10.3310/signal-000633

People with heart failure who receive care via virtual wards following discharge from hospital have lower rates of heart failure-related readmission and death than people discharged to other types of care.

However, virtual wards did not show similar benefits when offered to people leaving hospital with other high-risk chronic diseases.

This systematic review included randomised controlled trials of virtual wards, defined as with four operational criteria to be intensive multidisciplinary team management provided in a community setting. Out of hospital care, typically by primary care physicians, was the most common control.

This study supports the idea that an enhanced and more rounded approach to care may improve post-discharge outcomes in people with heart failure. The review described interventions that are applicable to UK care models. The evidence may be a starting point for further evaluation or trials of these.

Share your views on the research.

Why was this study needed?

Unplanned readmissions of people within a short time after discharge from hospital are detrimental to both patients and healthcare systems. From 2009 to 2010, the cost to the NHS of readmission within 30 days of discharge was estimated to be £1.6 billion. For patients and carers, lack of support for managing recovery at home may increase the risk of complications requiring readmission.

Various models of enhanced post-discharge care are therefore being explored as ways to improve patient outcomes and make better use of healthcare resources.

UK-based virtual wards, where in operation, may differ from the interventions included in this review. The interventions identified were carefully screened to include four operational criteria to distinguish a virtual ward from less intensive telemonitoring or case-management.

What did this study do?

This systematic review included randomised controlled trials, published up to January 2017, involving adults within three months after discharge from hospital.

Virtual ward care provision was defined as being similar to hospital care provided by an interdisciplinary team, coordinated over time by at least two different types of health professional and delivered either in person at home, via telephone or at a local clinic. Care could include telemonitoring or case management with clear multidisciplinary oversight.

Control groups received post-discharge outpatient follow-up via primary care providers or hospital outpatient consultations. Ten studies of 4,820 people were included. The virtual ward interventions ranged from 30 days to one year, with contact with patients occurring at least fortnightly. Seven studies were European, though no trials were identified from the UK. The fact that case studies of similar pre-emptive care does exist within the UK suggests results will be of interest here.

Three studies (one in heart failure) were considered to be at high risk of bias. Sensitivity analysis excluding studies at highest risk of bias did not substantially alter the findings, which strengthens our confidence in the results.

What did it find?

  • In people with heart failure (six studies, 1,634 participants), all-cause mortality was lower in people who received virtual ward care (risk ratio [RR] 0.59, 95% confidence interval [CI] 0.44 to 0.78). Heart-failure related readmission was also reduced (RR 0.61, 95% CI 0.49 to 0.76).
  • There was no reduction in all-cause hospital readmission for people with heart failure who experienced virtual wards, and there was a lot of variation in studies for this outcome.
  • There were four studies of people with various high-risk chronic diseases (3,186 participants). The findings did not show any benefit of virtual wards in reducing either all-cause mortality (low variation between studies), or all-cause hospital readmission (high variation between studies).

What does current guidance say on this issue?

Existing NICE guidelines on chronic heart failure management (published in 2010) recommend that people are only discharged when their clinical condition is stable, and the management plan is optimised. Discharge plans should consider level of care and support that can be provided in the community.

For adults with social care needs, additional NICE guidelines (from 2015) recommend a specific named person being responsible for coordinating a person’s discharge plan. While recommendations do describe input from multidisciplinary teams and opportunities for home-based care, there is no explicit mention of virtual wards.

What are the implications?

This study supports the use of enhanced post-discharge support in heart failure. The reduction in and all-cause mortality during the course of studies are beneficial outcomes for both patients and healthcare systems.

The practical components of providing enhanced post-discharge care for people with heart failure are becoming clearer. At a local level, it may involve coordination of care between different healthcare professionals including GPs and offers the opportunity for telemonitoring of weight and blood pressure as in these studies.

All of these randomised controlled studies reviewed were from outside the UK, but case studies of similar multidisciplinary, pre-emptive virtual wards exist in the UK, and the learning from this systematic review may inform future adaptations and evaluation.

Citation and Funding

Uminski K, Komenda P, Whitlockt R, et al. Effect of post-discharge virtual wards on improving outcomes in heart failure and non-heart failure populations: a systematic review and meta-analysis. PLoS One. 2018;13(4):e0196114.

This project received no specific funding.

Bibliography

NICE. Chronic heart failure in adults: management. CG108. London: National Institute for Health and Care Excellence; 2015.

NICE. Home care: delivering personal care and practical support to older people living in their own homes. NG21. London: National Institute for Health and Care Excellence; 2015.

NICE. Transition between inpatient hospital settings and community or care home settings for adults with social care needs. NG27. London: National Institute for Health and Care Excellence; 2015.

Lewis G, Vaithianathan R, Wright L, et al. Integrating care for high-risk patients in England using the virtual ward model: lessons in the process of care integration from three case sites. Int J Integr Care. 2013;13:e046.

Why was this study needed?

Unplanned readmissions of people within a short time after discharge from hospital are detrimental to both patients and healthcare systems. From 2009 to 2010, the cost to the NHS of readmission within 30 days of discharge was estimated to be £1.6 billion. For patients and carers, lack of support for managing recovery at home may increase the risk of complications requiring readmission.

Various models of enhanced post-discharge care are therefore being explored as ways to improve patient outcomes and make better use of healthcare resources.

UK-based virtual wards, where in operation, may differ from the interventions included in this review. The interventions identified were carefully screened to include four operational criteria to distinguish a virtual ward from less intensive telemonitoring or case-management.

What did this study do?

This systematic review included randomised controlled trials, published up to January 2017, involving adults within three months after discharge from hospital.

Virtual ward care provision was defined as being similar to hospital care provided by an interdisciplinary team, coordinated over time by at least two different types of health professional and delivered either in person at home, via telephone or at a local clinic. Care could include telemonitoring or case management with clear multidisciplinary oversight.

Control groups received post-discharge outpatient follow-up via primary care providers or hospital outpatient consultations. Ten studies of 4,820 people were included. The virtual ward interventions ranged from 30 days to one year, with contact with patients occurring at least fortnightly. Seven studies were European, though no trials were identified from the UK. The fact that case studies of similar pre-emptive care does exist within the UK suggests results will be of interest here.

Three studies (one in heart failure) were considered to be at high risk of bias. Sensitivity analysis excluding studies at highest risk of bias did not substantially alter the findings, which strengthens our confidence in the results.

What did it find?

  • In people with heart failure (six studies, 1,634 participants), all-cause mortality was lower in people who received virtual ward care (risk ratio [RR] 0.59, 95% confidence interval [CI] 0.44 to 0.78). Heart-failure related readmission was also reduced (RR 0.61, 95% CI 0.49 to 0.76).
  • There was no reduction in all-cause hospital readmission for people with heart failure who experienced virtual wards, and there was a lot of variation in studies for this outcome.
  • There were four studies of people with various high-risk chronic diseases (3,186 participants). The findings did not show any benefit of virtual wards in reducing either all-cause mortality (low variation between studies), or all-cause hospital readmission (high variation between studies).

What does current guidance say on this issue?

Existing NICE guidelines on chronic heart failure management (published in 2010) recommend that people are only discharged when their clinical condition is stable, and the management plan is optimised. Discharge plans should consider level of care and support that can be provided in the community.

For adults with social care needs, additional NICE guidelines (from 2015) recommend a specific named person being responsible for coordinating a person’s discharge plan. While recommendations do describe input from multidisciplinary teams and opportunities for home-based care, there is no explicit mention of virtual wards.

What are the implications?

This study supports the use of enhanced post-discharge support in heart failure. The reduction in and all-cause mortality during the course of studies are beneficial outcomes for both patients and healthcare systems.

The practical components of providing enhanced post-discharge care for people with heart failure are becoming clearer. At a local level, it may involve coordination of care between different healthcare professionals including GPs and offers the opportunity for telemonitoring of weight and blood pressure as in these studies.

All of these randomised controlled studies reviewed were from outside the UK, but case studies of similar multidisciplinary, pre-emptive virtual wards exist in the UK, and the learning from this systematic review may inform future adaptations and evaluation.

Citation and Funding

Uminski K, Komenda P, Whitlockt R, et al. Effect of post-discharge virtual wards on improving outcomes in heart failure and non-heart failure populations: a systematic review and meta-analysis. PLoS One. 2018;13(4):e0196114.

This project received no specific funding.

Bibliography

NICE. Chronic heart failure in adults: management. CG108. London: National Institute for Health and Care Excellence; 2015.

NICE. Home care: delivering personal care and practical support to older people living in their own homes. NG21. London: National Institute for Health and Care Excellence; 2015.

NICE. Transition between inpatient hospital settings and community or care home settings for adults with social care needs. NG27. London: National Institute for Health and Care Excellence; 2015.

Lewis G, Vaithianathan R, Wright L, et al. Integrating care for high-risk patients in England using the virtual ward model: lessons in the process of care integration from three case sites. Int J Integr Care. 2013;13:e046.

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

Published on 1 May 2018

Uminski, K.,Komenda, P.,Whitlock, R.,Ferguson, T.,Nadurak, S.,Hochheim, L.,Tangri, N.,Rigatto, C.

PLoS One Volume 13 Issue 4 , 2018

BACKGROUND: Unplanned hospital admissions in high-risk patients are common and costly in an increasingly frail chronic disease population. Virtual Wards (VW) are an emerging concept to improve outcomes in these patients. PURPOSE: To evaluate the effect of post-discharge VWs, as an alternative to usual community based care, on hospital readmissions and mortality among heart failure and non-heart failure populations. DATA SOURCES: Ovid MEDLINE, EMBASE, PubMed, the Cochrane Database of Systematic Reviews, SCOPUS and CINAHL, from inception through to Jan 31, 2017; unpublished data, prior systematic reviews; reference lists. STUDY SELECTION: Randomized trials of post-discharge VW versus community based, usual care that reported all-cause hospital readmission and mortality outcomes. DATA EXTRACTION: Data were reviewed for inclusion and independently extracted by two reviewers. Risk of bias was assessed using the Cochrane Collaboration risk of bias tool. DATA SYNTHESIS: In patients with heart failure, a post-discharge VW reduced risk of mortality (six trials, n = 1634; RR 0.59, 95% CI = 0.44-0.78). Heart failure related readmissions were reduced (RR 0.61, 95% CI = 0.49-0.76), although all-cause readmission was not. In contrast, a post-discharge VW did not reduce death or hospital readmissions for patients with undifferentiated high-risk chronic diseases (four trials, n = .3186). LIMITATIONS: Heterogeneity with respect to intervention and comparator, lacking consistent descriptions and utilization of standardized nomenclature for VW. Some trials had methodologic shortcomings and relatively small study populations. CONCLUSIONS: A post-discharge VW can provide added benefits to usual community based care to reduce all-cause mortality and heart failure-related hospital admissions among patients with heart failure. Further research is needed to evaluate the utility of VWs in other chronic disease settings.

Expert commentary

Emergency readmissions are bad news for patients and hospitals and are on the rise, so any intervention which can provide effective care for newly discharged high-risk patients is welcome. Virtual wards have a catchy name, but are these multi-disciplinary teams the answer?

International evidence from this review suggests they can reduce readmissions and mortality rates in patients with heart failure – but are less effective with more general chronic conditions patients.  

So maybe targeted virtual wards can help. But, as ever, the challenge will be to find sustained funding and staffing for a service which will be needed to complement, not replace, hospital-based care.

Dr Alison Porter, Associate Professor of Health Services Research, Swansea University Medical School