Hospital-to-home transitional care reduces deaths, readmissions for heart failure

The use of “virtual wards” may be helpful in preventing death and rehospitalizations for patients with congestive heart failure, according to a study published April 30 in PLOS One.

Lead author Kelsey Uminski and colleagues distinguished virtual wards (VWs) from less intensive telemonitoring and case management interventions by ensuring the VWs met the following criteria:

  • The care provided is similar to that of an interdisciplinary team at a hospital.
  • Care is coordinated by at least two health professionals.
  • Care may be delivered at home, a local clinic or via telephone.
  • Care can include telemonitoring and case managers but must include clinical oversight from the medical team.

Using these guidelines, Uminski and colleagues searched databases to perform a review and meta-analysis of VWs’ effect on mortality and readmissions for congestive heart failure, as well as a combination of other chronic diseases. Evaluating rehospitalizations is especially important, the authors noted, considering some payment systems penalize hospitals for readmissions that are deemed avoidable.

Pooling the results of six heart failure studies involving 1,634 patients, the researchers found VWs were associated with a 41 percent reduction in all-cause mortality and a 39 percent reduction in heart failure-related rehospitalization. All-cause hospitalizations were only reduced by 14 percent, which was found to be a statistically insignificant difference.

Compared to heart failure, there was a lesser reduction in rehospitalizations specific to other chronic diseases, suggesting heart failure may be a particularly good fit for VWs.

“In theory, a VW could influence heart failure patient survival in 3 ways: 1) prevention of worsening heart failure, 2) improved early identification and treatment of life-threatening heart failure-related complications or 3) improved identification and treatment of life-threatening non-heart failure complications (e.g. myocardial infarction, arrhythmia, stroke, bleeding),” Uminski and colleagues wrote. “Any of the three pathways, if valid, could reduce mortality.”

The authors pointed out the VW criteria they outlined is different from “hospital at home” scenarios, which include acute care similar to what would be provided at a hospital—just in a different location. VW interventions are instead a way to transition patients from the hospital to home while still providing care in the hopes of reducing downstream complications. The duration of these programs differed widely in the study, from 30 days to one year.

“VWs often incorporate telehealth and case management features, but these aspects are integrated into interdisciplinary teams that regularly and virtually ‘round’ on patients in a way similar to a team of doctors, nurses and allied health professionals in a hospital medical ward,” the authors wrote.

The authors included only prospective, randomized trials in their analysis, but noted some of the studies had small sample sizes and a high risk of bias. There was high heterogeneity in studies evaluating the chronic diseases other than heart failure, possibly obscuring any observed correlations.

For this reason, the authors called for more studies to evaluate VWs for other specific conditions such as chronic obstructive pulmonary disease or chronic kidney disease. In addition, they said “greater standardization and consistency in the use of the term ‘virtual ward’ would help distinguish this intervention from case management, telemonitoring, and other transitional care interventions, facilitating future knowledge synthesis and translation.”