Resources
Introduction
Here we have gathered some helpful resources relating to Virtual Wards, and also wider digital home care. The good news is that there is a range of useful information, and people working in digital home care are very generous about sharing.
Here is a precis of some of the resources that we find most useful, and recommend often.
If we have missed a gem, please do let us know.
Overview
Virtual Wards webpage NHSE
This includes details of how to join the community of practice, links to guidance, newsletters, events and films - https://www.england.nhs.uk/virtual-wards/
NICE Virtual Wards resource page (National Institute for Health and Care Excellence)
This includes NICE guidelines relating to Virtual Wards, Quality Standards, their platform technology review and health economic assessments.
NHS Futures both Virtual Wards & the Innovation collaborative for digital health have relevant content for members
Nuffield Trust Virtual Wards Lessons so Far summary paper - March 2023
A good overview paper from the Nuffield Trust -
https://www.nuffieldtrust.org.uk/news-item/virtual-wards-the-lessons-so-far-and-future-priorities
Key Guidance documents
A Guide to Setting up Technology Enabled Virtual Wards
Enablers for Success: Virtual Wards
Supporting Clinical Leadership in Virtual Wards
A clear definition
The NHS England Virtual Ward definition is that a virtual ward must be a direct substitute for inpatient care and must have a tech enabled component.
"A virtual ward is a safe and efficient alternative to NHS bedded care that is enabled by technology. Virtual wards support patients who would otherwise be in hospital to receive the acute care, monitoring and treatment they need in their own home. This includes either preventing avoidable admissions into hospital or supporting early discharge out of hospital."
Large scale evaluation of Virtual Wards in the NHS
Evaluation of Virtual wards across the South East of England - NHS England and PPL - May 2024
This recent study, reported on 16 May 2024, is a very large scale evaluation of the impact of 22,000 admissions into 29 Virtual Wards across the South East of England.
This found them to have saved 9,000 hospital beds, reduce the rate of emergency admission and have a net financial benefit. The top three findings are -
Virtual Wards reduce emergency admissions to hospital
“Virtual wards in South East England are associated with a positive impact on avoided non-elective (NEL) hospital activity – on average 1 NEL admission ‘avoided’ was shown to be correlated with 2.5 virtual ward admission, with some more mature virtual wards achieving a 1:1 association between the ‘avoided’ NEL admissions and virtual ward activity.”
Virtual Wards have a net financial benefit - of £10m+ for those studied
“There is evidence of positive net financial benefits associated with the regional virtual ward provision – overall total annualised net benefit of £10.4 million, for the virtual wards analysed.”
The Impact of Virtual Wards increases over time as the model matures
“It is clear that the longer they run, the more likely virtual wards are to show impact, as volumes of admissions going through virtual wards increase, and costs per admission start to fall.”
Full Paper: https://ppl.org.uk/what-we-do/virtual-wards-consultancy/
Summary: https://www.england.nhs.uk/long-read/summary-of-south-east-region-virtual-wards-evaluation/
Cost effectiveness
Virtual wards economic evidence review - NICE - November 2023
“Our team has analysed the evidence and found that virtual wards and hospital at home models of care are usually reported as cost-saving. A key driver of cost savings is a reduction in hospital bed days achieved and the lower per diem cost of virtual wards and hospital at home.
Our team looked at 1,000 studies and found that there were 15 that met the criteria being used. In 13 out of the 15, the home-based models were found to be cost-saving and in 2 they were found to cost more than the hospital alternative. Most of the included studies, however, have been assessed as having limitations in relation to their methodological quality, so it is recommended that further studies are undertaken.”
Full Paper: https://www.nice.org.uk/about/what-we-do/our-research-work/hta-lab
Evidence Review
Evidence review - Knowledge Management team at Health Education England - May 2023
This comprehensive evidence review undertaken by HEE, now part of NHS England, includes at pages 18-67 relevant peer reviewed published research on virtual wards internationally, from 2020 to May 2023, alongside a number of other studies. There are a wide range of findings so I won't attempt to summarise here.
https://www.ewin.nhs.uk/sites/default/files/Virtual%20Wards_Evidence%20Brief.pdf
Systematic Reviews
Inpatient-level care at home delivered by virtual wards and hospital at home: a systematic review and meta-analysis of complex interventions and their components - BMC Medicine, April 2024
Key Findings Large scale systematic review of 69 studies 38 randomised and 31 non randomised with 37k participants demonstrated non-inferiority of tech enabled at home models when compared to hospital care in terms of readmission risk or - with less extensive evidence - mortality.
Results: “Conclusion - Low-certainty evidence suggests that none of technology-enabled care at home models we explored put people at higher risk of readmission compared with hospital-based care. Where limited evidence on mortality is available, there appears to be no additional risk of mortality due to use of technology-enabled at home models.“
Full Paper: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-024-03312-3
Does remote patient monitoring reduce acute care use? A systematic review - BMJ Open, March 2021
Key Findings Of the 91 studies reviewed (which were all medium or high quality) 49% found reductions in admissions and length of stay in the RM groups and 41% found reductions in A&E attendances. The rest found no impact.
“Results: From 2,050 identified records, 91 studies were included. Studies were medium-to-high quality. RPM for all disease conditions was reported to reduce admissions, length of stay and emergency department presentations in 49% (n=44/90), 49% (n=23/47) and 41% (n=13/32) of studies reporting each measure, respectively."
Full Paper: https://pubmed.ncbi.nlm.nih.gov/33653740/
Other publications based on UK Virtual Ward research
A Digital Respiratory Ward in Leicester, Leicestershire, and Rutland, England, for Patients with COVID-19: Economic Evaluation of the Impact on Acute Capacity and wider NHS resource use - JMIR Formative Research - Feb 2024
Key Findings: this recently published study of 310 patients on a COVID-19 Virtual Ward (described in the paper as a Digital Ward) included health economic analysis that found costs were markedly reduced in the Virtual Ward cohort. All other outcomes appeared similar other than readmissions were slightly reduced in the Virtual Ward cohort. It also found that the cost of the intervention was 12% of the estimated gross savings, these savings were $1,850 per patient (or £1,465 in a currency conversion in March 24).
Overall, the Digital Ward delivered estimated health care system savings of 846.5 bed-days and US $504,197 in net financial savings (this is £400,000) across the 2 key groups of patients - those on oxygen and those not on oxygen at acute discharge (both P<.001).
“Conclusions: The digital ward delivered increased capacity and substantial financial savings and did so with a high degree of confidence, at a very low absolute and relative cost.”
Smartphone-Based Remote Monitoring in Heart Failure With Reduced Ejection Fraction: Retrospective Cohort Study of Secondary Care Use and Costs - JMIR Cardio - June 2023
Key Findings: This recent study at Imperial College Healthcare NHS Trust of 146 patients on a Heart Failure Virtual Ward found that the likelihood of hospital admissions was reduced by 74% and of A&E attendance by 57%, in the VW group. Costs were also markedly reduced at one quarter of the costs of the control group, £465 per patient v £1,850.
“Results: A total of 146 patients (mean age 63 years; 42/146, 29% female) were included (73 in each group). The groups were well-matched for all baseline characteristics except hypertension (P=.03). RM was associated with a lower hazard of ED attendance (hazard ratio [HR] 0.43; P=.02) and unplanned admissions (HR 0.26; P=.02). There were no differences in elective admissions (HR 1.03, P=.96) or outpatient use (HR 1.40; P=.18) between the 2 groups. These differences were sustained by a univariate model controlling for hypertension. Over a 3-month period, secondary health care costs were approximately 4-fold lower in the RM group than the control group, despite the additional cost of RM itself (mean cost per patient GBP £465, US $581 vs GBP £1,850, US $2,313, respectively; P=.04).
Conclusions: This retrospective cohort study shows that smartphone-based RM of vital signs is feasible for HFrEF. This type of RM was associated with an approximately 2-fold reduction in ED attendance and a 4-fold reduction in emergency admissions over just 3 months after a new diagnosis with HFrEF. Costs were significantly lower in the RM group without increasing outpatient demand. This type of RM could be adjunctive to standard care to reduce admissions, enabling other resources to help patients unable to use RM.”
Full Paper: https://pubmed.ncbi.nlm.nih.gov/37351921/
Real World Evaluations: South & West Hertfordshire
Rapid Evaluation report: chronic obstructive pulmonary disease Virtual Ward enabled by technology - Sept 2023
Key Findings - this study found a number of benefits in the virtual ward group v control. It was undertaken by the Eastern Academic Health Science Network (now Health Innovation East) and Health Innovation Manchester.
"Overall, it is evident the virtual ward model represents a safe, effective alternative to inpatient care; improving outcomes, positively impacting patient experience and delivering cost efficiencies compared to traditional care pathways.
Analysis shows a positive impact on patient care across almost all measures, although some notable limitations should be considered including the size of the intervention cohort and the rapid nature of this evaluation.
- The virtual ward demonstrated favourable healthcare utilisation outcomes compared to the other cohorts, with an observed reduction in both inpatient length-of-stay, arising from increased clinical confidence, and a reduction in the number of repeat readmission events.
- Virtual ward patients at risk of deterioration are more likely than patients discharged without the virtual ward support to be identified in a timely way and escalated appropriately back into an acute inpatient setting.
- Patient experience was positively impacted, with the majority reporting feeling well prepared for their transition to the virtual ward and then safely cared for in the community.
- Staff gave positive feedback and clear recommendations for continued improvement, including developing additional patient information, future development of the technology pathway to support virtual consultations routinely, and enhanced referral routes.
- The virtual ward demonstrates a positive benefit-cost ratio based on both initial set-up costs and recurring resources required to sustain the model, suggesting a favourable economic case."
"The virtual ward represents a cost-beneficial model for caring for patients with acute COPD exacerbations, based on the impact on reducing length of stay and the number of repeat readmissions within 90 days of discharge. The virtual ward demonstrated a positive benefit-cost ratio of £1.12:1 under the lower, more conservative scenario, or £1.45:1 in the upper bound scenario, when considering all costs incurred over the evaluation period. The net-present value, the difference between costs and benefits realised, was £6,370 over the evaluation period, or £24,400 per annum with optimism bias correction (OBC) included."
Real World Evaluations: Northamptonshire
Rapid Evaluation of Northamptonshire Virtual Wards - Feb 2022
Key Findings - this study of 344 patients examined differences in the cohort of Virtual Ward patients without tech enablement (147) and those with (197). It was undertaken by KSS Insights, part of Kent, Surrey and Sussex Academic Health Science Network and found differences in LOS (19 days v 10 days respectively), staff patient ratios (higher in the tech enabled group) and costs (lower in the tech enabled group).
"According to the in-year analysis, the tech-enabled VW resulted in savings when compared with the traditional VW. Total in-year health economic outcomes of the tech-enabled VW, relative to the traditional VW (2020/21), demonstrated: • Total benefits (difference in benefits of tech-enabled VW when compared to traditional VW): £74k • Total costs (difference in costs between the techenabled when compared to traditional VW): £24k • Total net impact: £50k • Impact implementation cost ratio: 3.1, indicating that for every £1.00 invested in the tech-enabled VW, instead of the traditional VW, an additional return of £3.10 could be expected."
Real World Evaluations: Croydon
Rapid Evaluation of Croydon Virtual Ward Model - Dec 2021
Key Findings - this study of 250 patients found a number of benefits in the virtual ward group v control in terms of readmissions, cost savings and patient experience. It was undertaken by the Health Innovation Network, south London.
“Readmissions post discharge from the VW were higher in the control group than the virtual ward patients at both 7 and 28 days post discharge”. The cost savings identified were £742.44 per patient which totalled a saving of £186,610 for the group. “Virtual ward patients tended to be older, with 60% aged 60 or over and 25% over the age of 80. Feedback survey scores were largely very positive, with over 87% of patients giving positive agreement with each statement given in the questionnaire”.
Full Paper: Rapid Evaluation of Croydon Virtual Ward Model - Health Innovation Network
Resources
Real world Evaluations: Leicester
An Economic Evaluation of Virtual Wards for Covid 19 in Leicester, Leicestershire and Rutland - June 2022
Key Findings: this study of 310 patients found a number of benefits in the virtual ward group including lower readmission rates and cost savings.
“The virtual ward delivered estimated health care system savings of 1,103 bed days, £529,719 in net financial savings” “The costs of the intervention were 9.7% of the estimated gross savings and the mean net saving per patient was £1,709 in the base case without including the savings associated with a likely reduction in re-admissions. The 30-day re-admission rate was 2.9%, which was substantially beneath alternative comparative data. The mean cost of the intervention was £184.38 per patient”.
Full paper: https://www.medrxiv.org/content/10.1101/2022.06.27.22276736v1.full.pdf
Real World Evaluations: Northern Ireland
An Economic Assessment of the South Eastern Trust Virtual Ward (Ulster and Bangor)
Key Findings: this study of 447 patients over 3 years found a number of benefits in the virtual ward group including reduced emergency attendances, lower costs (saving of £8.2m over 3 years) and high patient and GP satisfaction.
“812 A&E attendances were avoided over the 3 years”. “A patient satisfaction survey with a high 70% return rate indicated 100% very satisfied with the quality of care and 85% felt more confident in managing their own condition” “All Virtual Ward Co-ordinators had advanced training in health assessment and were independent prescribers so could diagnose and treat quickly, often averting A&E attendances as well as hospital admissions.”
“The costs avoided were calculated over the 3 year period at £8,804,529.The running costs over three years are approximated at £566,273. This equates to a total saving of £8,238,256.”
Full paper: Link is at page 7 of the Evidence Review above
Real World Evaluations: West Hertfordshire
Heart Failure virtual ward safely reduced acute length of stay: preliminary data on first 183 patients.
Key Findings: West Hertfordshire Teaching Hospitals NHS Trust established a Heart Failure Virtual Hospital and reviewed its impact on the first 183 patients between Dec 2021 and August 2022. The trust’s statistics show a 38% reduction in the readmission rate for acute care. 15.5% of hospital patients were readmitted, compared with 9.6% when on virtual wards.
Patient satisfaction was strong -
“83% of patients agreed that going home sooner from hospital aided their recovery”
“85% of patients agreed that they felt safe as a patient in the Virtual Hospital”
“88% of patients agreed that the frequency of contact and communication by the monitoring hub was about right.”
Full Paper: https://www.westhertshospitals.nhs.uk/msgs/hfvf.pdf
International publications - USA
Acute Hospital Care at Home in the United States: The Early National Experience - January 2024
Key Findings: In this recent, large scale study, the researchers examined data for 5,132 people receiving hospital-at-home care and the findings were that readmissions, escalations and mortality were all low in the group that received tech enabled virtual ward care.
Most were older, over 65 years with 42% aged 80 years or older, and medically complex: 42.5% had heart failure, 43.3% had COPD, 22.1% had cancer, and 16.1% had dementia. The escalation rate during hospitalization was 6.2%, and the mortality rate was 0.5%. At 30 days post-discharge, the mortality rate was 3.2%, the rate of skilled nursing facility use was 2.6%, and the readmission rate was 15.6%. Study undertaken 1 July 2022 - 30 June 2023.
Full Paper: https://www.acpjournals.org/doi/10.7326/M23-2264
International publications - Denmark
Is telehealthcare for heart failure patients cost-effective? An economic evaluation alongside the Danish TeleCare North heart failure trial - BMJ Open, January 2020
Key Findings: “The TeleCare North solution for monitoring heart failure was highly cost-effective. There were significant cost savings on hospitalisations, primary care contacts and total costs.” It demonstrated a per patient saving of over £5,000.
The study included 274 heart failure patients with self-reported New York Heart Association class II-IV. Cost-effectiveness was reported as incremental net monetary benefit (NMB). A micro-costing approach was applied to evaluate the derived savings in the first year in the public health sector. Quality-adjusted life-years (QALY) gained were estimated using the EuroQol 5-Dimensions 5-Levels questionnaire at baseline and at a 1-year follow-up.
“Results: Data for 274 patients were included in the main analysis. The telehealthcare solution provided a positive incremental NMB of £5,164. The 1-year adjusted QALY difference between the telehealthcare solution and the usual care group was 0.0034 (95% CI: -0.0711 to 0.0780). The adjusted difference in costs was -£5,096 (95% CI: -8736 to -1456) corresponding to a reduction in total healthcare costs by 35%. All sensitivity analyses showed the main results were robust.”
Full Paper: https://pubmed.ncbi.nlm.nih.gov/31992604/
International publications - Germany
Health-economic evaluation of home telemonitoring for COPD in Germany: evidence from a large population-based cohort - European Journal of Health Economics, Sept 2017
Key Findings: Reductions in mortality, costs and healthcare utilization from those in the home monitoring group. Impact was greatest for those with very severe COPD. 651 patients and 7,047 in the control (standard care group).
"Telemonitoring cut total costs by €895 per patient (p < 0.05) compared to COPD standard care, mainly driven by savings in COPD-related hospitalisations in (very) severe COPD patients (−1056 €, p < 0.0001).
Telemonitoring enrollees used healthcare (all-cause and COPD-related) less intensely with shorter hospital stays, fewer inpatient stays and smaller proportions of people with emergency department visits and hospitalisations (all p < 0.0001)."
Full paper: https://pubmed.ncbi.nlm.nih.gov/27699567/
Studies focusing on Virtual Wards for Covid 19 in the UK
The impact of post-hospital remote monitoring of COVID-19 patients using pulse oximetry: A national observational study using hospital activity data - June 2022
Key Findings: This was a large study looking at data from 139,619 patients early in the pandemic Aug 2020-Feb 2021. It was unable to find impact on readmission rates or length of stay linked to care at a Trust that had access to a Covid virtual ward (CVW).
However as linked patient data was not available to the researchers, major assumptions had to be made, including that any patient discharged from a Trust with a CVW, would have attended that ward.
Findings “We found no evidence of early discharges or changes in readmissions associated with the roll out of COVID Virtual Wards across England. Our analysis made pragmatic use of national-scale hospital data, but it is possible that a lack of specific data (for example, on which patients were enrolled and on potentially important confounders) may have meant that true impacts, especially at a local level, were not ultimately discernible. It is important that future research is able to make use of better quality - preferably linked - data, from multiple sites.”
Full Report: https://discovery.ucl.ac.uk/id/eprint/10149015/1/CO@H%20impact%20paper.pdf
Studies focusing on Virtual Wards for Covid 19 in the UK
At the link are a range of studies including a systematic review conducted by the RSET team on remote monitoring for Covid 19
How the Public views Virtual wards - June 2023
How do the public and NHS staff feel about virtual wards?
Key Findings: this was a very large survey of 8,300+ people commissioned by the Health Foundation. It found that the UK public is, overall, supportive of virtual wards (by 45% to 36%).
"Support for virtual wards is higher among disabled people and those with a carer – groups that typically have greater health needs and who might therefore be expected to be more intensive users of virtual wards. Nearly three-quarters of the UK public (71%) are open to being treated through a virtual ward under the right circumstances, while 27% said they would not be – suggesting that, if implemented well, virtual wards should be acceptable to a large majority of service users. Interestingly, a higher proportion of the public, 78%, told us that they would be happy ‘to monitor their own health at home using technologies, instead of in a hospital’ – describing a scenario often seen as part of a broader virtual ward service, but avoiding the term ‘virtual ward’ – with only 13% saying they would not. Here people over 65 were most keen with 85% saying they would be happy. NHS staff in the survey were clearly supportive of virtual wards (by 63% to 31%)." Issues flagged included people not understanding the term virtual ward and those in socio economic groups D & E being less positive than other groups to receive care at home. It included 7,100 nationally representative members of the public (aged 16 years and older) and 1,251 NHS staff members