Monday, November 10, 2014

Medical Literature Critique:

My letter to the editor was rejected by JAMA, so I am posting it here.  It apparently did not get enough points to qualify.  With the word restrictions they have in place, it's hard to write a cogent critique in the first place.

The Article in Question:

Conclusion:  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.

My letter to the Editor that was rejected by JAMA editors:

Dear Editor,

I read with interest the research article by Dr. Dhalla and his colleagues (1), including the accompanying editorial by Dr. Boling (2).  The authors noted no reduction in readmissions and death between the two groups.  Dr. Boling contrasts this finding with other studies that cite a reduction in readmissions (3-5).
Several important aspects that might prove insightful were not thoroughly discussed by either author.  First and foremost, the patients were Canadian, the studies cited by Dr. Boling involved patients in the United States.  While there are issues with access to primary physicians in Canada, they are nowhere nearly as bad as the United States, where a virtual ward model may be helpful. Secondly, patients who did not have health insurance and who were discharged outside the local catchment area were excluded.  The patients that were left in the study spoke English, had health insurance, and lived locally.
For this study, the virtual ward model is analogous to having the option of purchasing a platinum service contract when buying a new car. You may either opt for the standard manufacturer’s warranty, or for the fancier service contract with free oil changes, tire rotations, etc... In both groups of warranties (standard discharge verses virtual ward) the same model of cars (patients) will break down at a similar rate, requiring a trip to the mechanic (readmission).
The patient who is discharged from a hospital in Ontario under the standard care model and not feeling well will pick up the phone and call his or her provider. The provider will then act on the patient complaint, virtual ward or not.  In the United States, our patients without insurance or providers have no one to call in the first place.  In this case, the post discharge care (roadside assistance, to continue the analogy) is provided by an intact universal health insurance system; whereas the patients discharged from the hospital in the United Sates are at the mercy of whichever tow truck driver happens to drive by.  The Canadian primary providers may not know what happened in the hospital secondary to issues with communication and electronic health records, but they will act if called by a patient.  In summary, the key difference for the differing outcomes lies in the make and model of the vehicle, not the warranty provided.

Sunil K Sahai, MD, FAAP, FACP
Associate Professor of Medicine
The University of Texas MD Anderson Cancer Center

1.         Dhalla IA, O’Brien T, Morra D, et al. Effect of a postdischarge virtual ward on readmission or death for high-risk patients: A randomized clinical trial. JAMA. 2014;312(13):1305-12.
2.         Boling PA. Managing posthospital care transitions for older adults: Challenges and opportunities. JAMA. 2014;312(13):1303-4.
3.         Coleman EA, Parry C, Chalmers S, Min S. The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine. 2006;166(17):1822-8.
4.         Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. JAMA. 1999;281(7):613-20.
5.         Shaughnessy PW, Hittle DF, Crisler KS, Powell MC, Richard AA, Kramer AM, et al. Improving Patient Outcomes of Home Health Care: Findings from Two Demonstration Trials of Outcome-Based Quality Improvement. Journal of the American Geriatrics Society. 2002;50(8):1354-64.

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