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

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EMBASE, PubMed, the Cochrane Database of Systematic Reviews, SCOPUS and CINAHL, from inception through to Jan 31, 2017; unpublished data, prior systematic reviews; reference lists.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.

背景：在慢性疾病患者群体日益衰弱的当下，高危患者的非计划住院事件频发且医疗成本高昂。虚拟病房（Virtual Wards，VW）是一类新兴的医疗理念，旨在改善此类患者的诊疗结局。
目的：评估出院后虚拟病房作为常规社区护理替代方案，对心力衰竭及非心力衰竭患者的住院再入院率与死亡率的影响。
数据来源：检索自建库至2017年1月31日的Ovid MEDLINE、EMBASE、PubMed、Cochrane系统评价数据库、SCOPUS及CINAHL数据库；同时纳入未发表数据、既往系统评价及相关参考文献列表。
研究选择：纳入以出院后虚拟病房与常规社区护理为对照、报告了全因住院再入院率及死亡率结局的随机对照试验。
数据提取：由两名研究者独立完成纳入筛选与数据提取工作，并采用Cochrane协作网偏倚风险评估工具对研究偏倚风险进行评价。
数据合成：在心力衰竭患者中，出院后虚拟病房可降低死亡风险（共6项试验，n=1634；相对危险度RR=0.59，95%置信区间CI=0.44~0.78）。心力衰竭相关再入院率显著降低（RR=0.61，95%CI=0.49~0.76），但全因再入院率无明显改善。与之相反，对于未明确分型的高危慢性疾病患者，出院后虚拟病房并未降低其死亡率或住院再入院率（共4项试验，n=3186）。
局限性：本研究纳入的干预措施与对照方案存在异质性，且虚拟病房的标准化命名规范尚未统一，相关描述与应用缺乏一致性。部分试验存在方法学缺陷，且研究样本量相对较小。
结论：对于心力衰竭患者，出院后虚拟病房相较于常规社区护理可带来额外获益，能够降低全因死亡率及心力衰竭相关住院再入院率。未来仍需开展进一步研究，以评估虚拟病房在其他慢性疾病场景中的应用价值。