The evidence around virtual hospitals



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Dr Gabriel Moore is the Manager of the Knowledge Exchange Program in the Evidence for Action Division of Sax Institute. Dr Moore has led the development of knowledge exchange services for policy and practice agencies for more than 10 years, including Evidence Check rapid reviews and the Institute’s knowledge brokering program. Her research focuses on knowledge mobilisation, rapid reviews and the process and effectiveness of knowledge brokering.

The demands of COVID-19 have spurred rapid uptake of new healthcare practices. Sax Institute, Knowledge Exchange Program Manager, Dr Gabriel Moore, assesses the evidence surrounding tele-health and virtual medicine, which has become an important resource for Australian healthcare during the pandemic, and says the early signs are promising.

The COVID-19 pandemic has profoundly changed the way we live and how we access services. In healthcare in particular, it has prompted reforms that may otherwise have taken many years. A clear example of this is the widespread uptake of tele-medicine, with tele-health items introduced during the pandemic now being provided to millions of Australians. 

Although COVID-19 may have accelerated the move towards telemedicine, the trend long pre-dates it. As populations age and chronic conditions become more prevalent, governments around the world have recognised the need to relieve the burden on healthcare by reducing costly hospitalisations, re-admissions and length of hospital stays. To this end, governments and healthcare providers have been exploring the ‘virtual hospital’ model as one possible solution.

Virtual hospitals aim to provide the same level of care as a bricks-and-mortar hospital, but without the need for physical infrastructure such as wards and hospital beds. Of course, many things can only be done in an actual hospital, but there are a range of services that virtual hospitals can conceivably provide, including identifying patients at high risk of hospitalisation; assessing their health needs; transitioning patients out of hospital care following discharge; developing care plans and providing direct treatment and rehabilitation. These services are provided at the patient’s home, either in person or via phone, internet or other technologies.

Does telemedicine really work?

The Sydney Local Health District (SLHD) is one of many across the country feeling the pressures of a growing and ageing population, placing strain on services. It has begun operating its own virtual hospital at Royal Prince Alfred Hospital (rpavirtual), which will ultimately provide in-home nursing care to over 1,000 patients using video, phone and SMS.

But what is the evidence that this model actually works and where does it work best? To answer these questions, SLHD commissioned the Sax Institute to take a closer look at the literature on telemedicine and virtual hospitals.

It turns out that the evidence for the efficacy of virtual services in many areas is pretty good. We identified 20 reviews and studies that mostly looked at tele-healthcare only, or tele-healthcare combined with remote tele-monitoring. These studies largely found that the interventions were either as good as or better than usual care at reducing hospitalisations, re-admissions, emergency department visits and length of stay.

Clinically, studies again showed outcomes as good as usual care for heart-related or all-cause mortality, as well as for quality of life, hypo- and hyperglycaemia, BMI, cholesterol levels, blood pressure and mental health. The evidence also suggests that tele-monitoring, or the electronic transmission of health data, could have a significant impact on all-cause and heart failure related mortality. We suggest such tele-monitoring should be routinely included in all virtual hospital services.

Overall, we found that the strongest clinical evidence for tele-healthcare and tele-monitoring was for patients with heart failure or coronary artery disease, for diabetes and for stroke rehabilitation. There is not so much evidence around its efficacy for cancer, and the evidence for respiratory disease was not conclusive.

Who staffs the virtual hospital and what technology do they use?

In terms of who is best suited to provide virtual hospital services, we found that nurses had a central role in the initial patient triage and in-home visiting, providing phone support and education. But we also found that teams were largely multidisciplinary, reflecting the diversity of the conditions or diseases the studies reported on. They included GPs, hospital physicians, allied health practitioners and specialists.

As for the best technological means of delivering virtual services, the strongest evidence we found was for tele-monitoring, videoconferencing or consultation and structured telephone support, usually delivered by a nurse. Eleven of the reviews and studies we looked at reported use of the internet as key to providing effective tele-health and tele-monitoring services. For example, several studies found remote, internet-based monitoring of blood pressure and BMI to be as good as or more effective than usual care.

Overall, the picture of tele-health and tele-monitoring that emerges from our review of the evidence is a positive one, even if the studies we looked at were quite heterogeneous. Clearly more research needs to be done, particularly on the effectiveness of complete virtual models of care, such as we might expect to find in a virtual hospital model.

I’m confident that as more resources are poured into virtual models of care, the research will follow and we will get an even better idea of what works – and what doesn’t – in the world of virtual medicine.
 


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