title: Effect of a postdischarge virtual ward on readmission or death for high-risk patients: a randomized clinical trial.
abstract: OBJECTIVE
  Hospital readmissions are common and costly, and no single intervention or bundle of interventions has reliably reduced readmissions. Virtual wards, which use elements of hospital care in the community, have the potential to reduce readmissions, but have not yet been rigorously evaluated.
  
  
  OBJECTIVE
  To determine whether a virtual ward-a model of care that uses some of the systems of a hospital ward to provide interprofessional care for community-dwelling patients-can reduce the risk of readmission in patients at high risk of readmission or death when being discharged from hospital.
  
  
  METHODS
  High-risk adult hospital discharge patients in Toronto were randomly assigned to either the virtual ward or usual care. A total of 1923 patients were randomized during the course of the study: 960 to the usual care group and 963 to the virtual ward group. The first patient was enrolled on June 29, 2010, and follow-up was completed on June 2, 2014.
  
  
  METHODS
  Patients assigned to the virtual ward received care coordination plus direct care provision (via a combination of telephone, home visits, or clinic visits) from an interprofessional team for several weeks after hospital discharge. The interprofessional team met daily at a central site to design and implement individualized management plans. Patients assigned to usual care typically received a typed, structured discharge summary, prescription for new medications if indicated, counseling from the resident physician, arrangements for home care as needed, and recommendations, appointments, or both for follow-up care with physicians as indicated.
  
  
  METHODS
  The primary outcome was a composite of hospital readmission or death within 30 days of discharge. Secondary outcomes included nursing home admission and emergency department visits, each of the components of the primary outcome at 30 days, as well as each of the outcomes (including the composite primary outcome) at 90 days, 6 months, and 1 year.
  
  
  RESULTS
  There were no statistically significant between-group differences in the primary or secondary outcomes at 30 or 90 days, 6 months, or 1 year. The primary outcome occurred in 203 of 959 (21.2%) of the virtual ward patients and 235 of 956 (24.6%) of the usual care patients (absolute difference, 3.4%; 95% CI, -0.3% to 7.2%; P = .09). There were no statistically significant interactions to indicate that the virtual ward model of care was more or less effective in any of the prespecified subgroups.
  
  
  CONCLUSIONS
  In a diverse group of high-risk patients being discharged from the hospital, we found no statistically significant effect of a virtual ward model of care on readmissions or death at either 30 days or 90 days, 6 months, or 1 year after hospital discharge.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT01108172.
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto3Department of Medicine, St Michael's Hospital, Toronto4Li Ka Shing Knowledge Institute of St Mich.
authors.forename: Irfan A
authors.initials: IA
authors.lastname: Dhalla
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada6Department of Medicine, Women's College Hospital, Toronto.
authors.forename: Tara
authors.initials: T
authors.lastname: O'Brien
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada7Trillium Health Partners, Mississauga, Ontario.
authors.forename: Dante
authors.initials: D
authors.lastname: Morra
authors.affiliation: Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto8Dalla Lana School of Public Health, University of Toronto, Toronto.
authors.forename: Kevin E
authors.initials: KE
authors.lastname: Thorpe
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada9Department of Medicine, Sunnybrook Health Sciences Centre, Toronto10Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto.
authors.forename: Brian M
authors.initials: BM
authors.lastname: Wong
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada9Department of Medicine, Sunnybrook Health Sciences Centre, Toronto.
authors.forename: Rajin
authors.initials: R
authors.lastname: Mehta
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada11Department of Medicine, University Health Network, Toronto.
authors.forename: David W
authors.initials: DW
authors.lastname: Frost
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada11Department of Medicine, University Health Network, Toronto.
authors.forename: Howard
authors.initials: H
authors.lastname: Abrams
authors.affiliation: Taddle Creek Family Health Team, Toronto.
authors.forename: Françoise
authors.initials: F
authors.lastname: Ko
authors.affiliation: Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto.
authors.forename: Patrick
authors.initials: P
authors.lastname: Van Rooyen
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada5Institute for Clinical Evaluative Sciences, Toronto, 13Department of Medicine, Mount Sinai Hospital, Toronto.
authors.forename: Chaim M
authors.initials: CM
authors.lastname: Bell
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto5Institute for Clinical Evaluative Sciences, Toronto, 14Women's College Research Institute, Women's College Hospital, Toronto.
authors.forename: Andrea
authors.initials: A
authors.lastname: Gruneir
authors.affiliation: NHS England, London, England.
authors.forename: Geraint H
authors.initials: GH
authors.lastname: Lewis
authors.affiliation: Toronto Central Community Care Access Centre, Toronto.
authors.forename: Stacey
authors.initials: S
authors.lastname: Daub
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto.
authors.forename: Geoff M
authors.initials: GM
authors.lastname: Anderson
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada5Institute for Clinical Evaluative Sciences, Toronto, 6Department of Medicine, Women's College Hospital, Toronto.
authors.forename: Gillian A
authors.initials: GA
authors.lastname: Hawker
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto5Institute for Clinical Evaluative Sciences, Toronto, 6Department of Medicine, Women's College Hos.
authors.forename: Paula A
authors.initials: PA
authors.lastname: Rochon
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto4Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto5Institute for Clinical Evaluati.
authors.forename: Andreas
authors.initials: A
authors.lastname: Laupacis
mesh_terms: D000328:Adult; D000368:Aged; D000553:Ambulatory Care / Q000379:methods*; D003153:Community Health Services; D003266:Continuity of Patient Care; D005260:Female; D006792:House Calls; D006801:Humans; D057194:Intention to Treat Analysis; D008297:Male; D008875:Middle Aged; D009026:Mortality; D010359:Patient Readmission / Q000706:statistics & numerical data*; D017216:Telemedicine