Effect of a Postdischarge Virtual Ward on Readmission or Death for High-Risk Patients: A Randomized Clinical Trial

Study Questions:

What is the impact of a “virtual ward” on the risk of readmission or death among high-risk patients following discharge from hospitalization?

Methods:

This was a parallel-group, randomized trial conducted in Toronto, Ontario. Eligible patients were discharged from the general internal medicine ward and determined to be at high-risk for readmission (based on LACE score: length of stay, acuity of the admission, comorbidities, and emergency department visits in the previous 6 months). Patients were randomized to usual care or a virtual ward model of transitional care. The virtual ward team included care coordinators, part-time pharmacist, part-time nurse or nurse practitioner, a full-time physician, and a clerical assistant. The care plan in the virtual ward began following discharge (and the virtual ward care team did not have contact with the patient prior to discharge). The care coordinator (similar to a case manager) performed a home visit within a few days. The primary outcome was the composite of readmission to any hospital or death within 30 days of discharge.

Results:

Although there was a trend toward fewer 30-day events in the intervention group (203 of 959 patients, 21.2%), compared to the usual care group (235 of 956 patients, 24.6%), this difference did not meet statistical significance (p = 0.09), and there were no significant differences in primary or secondary outcomes at 30 or 90 days, 6 months, or 1 year. Furthermore, subgroup analysis did not detect any differences between intervention and usual care groups. A minority of patients in each group had an index hospitalization for heart failure (8% in usual care vs. 9% in virtual ward). Those in the virtual ward group received an average of 2.8 home visits and were enrolled for a mean length of stay of 35.5 days.

Conclusions:

In this randomized trial, a “virtual ward” model of transitional care did not reduce short- and long-term rates of readmission and mortality in high-risk patients.

Perspective:

Although the authors provide a compelling argument against a “virtual ward” model of transitional care to reduce adverse outcomes following an index hospitalization for patients at high risk for readmission, the limitations of the intervention should be considered. The authors acknowledge a number of limitations in executing the virtual ward, including barrier related to communication between the virtual ward interprofessional team and the patient’s primary care team and multiplicity of different information technology systems. It may also be useful to initiate such interventions prior to hospital discharge (i.e., with the care team meeting the patient in the hospital). And there may be benefits to a more intensive model of transitional care, particularly when home visits are conducted by a nurse practitioner or physician.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Pharmacists, Risk, Patient Care Team, House Calls, Nurse Practitioners, Heart Failure, Comorbidity, Ontario, Emergency Service, Hospital, Patient Discharge, Nurses, Hospitalization, Primary Health Care, Length of Stay


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