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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