Inpatient care and treatment - virtual capacity: interview findings

Findings: Rapid Evidence Review

The following section presents a synthesis of the wider literature on VC, with a particular focus on four key outcomes:

1) Bed days saved

2) Length of stay (e.g. length of treatment in hospital and community settings)

3) Hospital readmissions/avoidance

4) Patient experience

Summary

• There is encouraging evidence for the use of VC in Scotland, particularly in relation to patient experience. Patient satisfaction is high, with people valuing the comfort and familiarity of their home environment, though satisfaction was lower when travel was required for treatment and some people expressed concerns around safety.
• VC services can save hospital bed days by providing an alternative to inpatient care.
• There is mixed evidence on hospital readmissions. Hospital at Home services had mixed evidence, though this may be explained by the levels of need of the population, and cardiac and respiratory services led to admission avoidance. Systematic reviews of studies on OPAT from the UK, Europe, and North America were inconclusive, some of which included comparisons with usual care.
• There are differences in how length of stay is defined and measured, denoting length of treatment via a VC service and as an inpatient. There is evidence that VC services can help to reduce hospital length of stay.
• There are gaps in the literature which warrant further research. Not all pathways had evidence on all four outcomes and whilst some studies specifically focused on Scotland, systematic reviews included studies from the UK, Europe, and North America. Furthermore, some of the findings are based on only one study, so caution needs to be exercised when drawing firm conclusions.
• This report does not undertake an assessment of methodological rigour as it was not a systematic review. Whilst limitations are reflected upon throughout, this caveat should be taken into account when interpreting the findings.

Question 1: Do Virtual Capacity services save bed days and/or save other hospital resources?

Hospital at Home

Hospital at Home or similar services in Scotland have saved hospital bed days.

OPAT

OPAT has been found to save bed days in Scotland and throughout the UK

Pulse oximetry for Covid

The evidence on COVID-19 monitoring via pulse oximetry saving hospital resources is inconclusive.

This section focuses on published data on bed days saved as well as evidence on other hospital resources being saved.

Hospital at Home

A survey by the Scottish Government was administered to all Health Boards to identify which NHS Boards were offering a Hospital at Home service and where this was not offered, what alternative treatments were in place (HIS, 2020). A total of 25 out of the 31 integrated authorities (IA’s) responded, with 10 IA’s stating that they had a Hospital at Home type system in place and 14 stating that they had alternative provisions in place. Although there was limited data on the type or number of patients admitted to Hospital at Home (or alternative services) and the total number of hospital bed days saved^[7], it was identified that bed days had been saved in IA’s with Hospital at Home in place. For example, it was reported that Lanarkshire’s Hospital at Home service admitted over 2,000 people in 2018, saving over 14,000 bed days. Likewise, City of Edinburgh Hospital at Home admitted 693 patients in 2018/19, saving over 2,500 bed days, and West Lothian Hospital at Home admitted 763 patients in 2018/10, saving over 3,000 bed days. Overall, this data suggests there is the potential to reduce bed days in Scotland via Hospital at Home, however there is variation in how the data is collected.

OPAT

Inpatient bed days have been saved due to the increasing use of OPAT in Scotland. Between January and August 2022, the number of inpatient days avoided per week was 1,453, and approximately 45,031 in total during this period, with further increases in OPAT clinical activity in Scotland expected (SAPG, 2022).

Findings from the BSAC National Outcomes Registry showed that bed days had been saved across the entire UK as a result of OPAT. A total of 57 organisations from across the UK submitted data and reported that 442,280 treatment days had been provided via OPAT (Gilchrist et al, 2022).

Covid remote health monitoring (pulse oximetry)

One of the reviews examined by McKinstry, Alboksmaty et al. (2022), showed that pulse oximetry for covid monitoring had potential to save hospital resources, though the authors found no explicit evidence that it was more effective than other remote monitoring interventions. Of the other studies looking at the use of pulse oximetry considered by McKinstry (2022), two did not support, or only provided extremely limited support to, the continued use of pulse oximetry to monitor Covid (Beaney et al., 2022; Lee et al., 2022).

Alexander (2021) also highlights that patients reported not needing to access healthcare resources as much and suggests that these results could indicate a positive effect on healthcare resources, but notes that there is no direct evidence of this.

Summary

The literature demonstrates that Hospital at Home and OPAT services save bed days, whilst the evidence on COVID-19 monitoring via pulse oximetry saving resources is inconclusive. No evidence was found specifically on respiratory services.

Question 2: Do Virtual Capacity services reduce length of stay and enable earlier discharge?

Hospital at Home

Evidence from a large RCT in the UK shows that Hospital at Home can support earlier discharge from hospital (Singh et al, 2022), though length of treatment can be slightly longer for people receiving Hospital at Home (in the home/community setting) compared to inpatients (Shepperd et al, 2021).

OPAT

There was only very limited evidence which suggested that length of OPAT treatment for adults was over double the duration of OPAT for children in entries to the National Outcomes Registry System.

Respiratory services

Treatment at home for COPD reported a statistically significant reduction in LoS

Pulse oximetry for Covid

There are encouraging findings for the use of pulse oximetry to reduce LoS.

Length of stay is measured in different ways in the literature. This refers to both the length of treatment via a VC service and also the length of hospital stay prior to referral to a VC service. So, length of stay here refers to length of treatment in both hospital and community settings.

Hospital at Home

There are differences in the quality of evidence on Hospital at Home. The largest RCT on Hospital at Home in the UK included an evaluation of length of treatment (for inpatients and people receiving Hospital at Home) and length of hospital stay for older people. The study was conducted with 1055 participants across nine hospital and community sites in the UK, including Scotland (Shepperd et al., 2021). Participants were randomised to receive usual inpatient care or comprehensive geriatric assessment via Hospital at Home. Participants had similar baseline characteristics. Shepperd et al’s (2021) work measured length of stay as the length of time an individual received treatment, including through Hospital at Home. It was reported that patients allocated to Hospital at Home had on average 6.89 Hospital at Home days compared to those receiving inpatient care who spent an average of 5.25 days in hospital (although the statistical significance and/or effect size of this difference is not reported).

The same study also reported that Hospital at Home reduces length of stay in hospital (Singh et al, 2022). Comparisons were made between hospital length of stay for inpatients and those receiving a Hospital at Home service. The authors concluded that receiving Hospital at Home resulted in three fewer days in hospital at one month follow up, though this reduced to one day at six month follow up (Singh et al, 2022).

A service audit exploring the effectiveness of caring for older people at home in Northern Ireland (similar to Hospital at Home in Scotland) found that length of treatment was significantly reduced in acute care at home, with an average of 4 days compared to 14 days observed in hospital care in a ward for older people (Tierney et al., 2021).

Other implementation evidence focuses on whether length of stay in hospital is reduced through early discharge to a Hospital at Home service. Pearson et al. (2017) report on a Hospital at Home programme in Devon for frail people aged 80 and over. The authors note that the outcomes of the quality improvement project “appear unremarkable” (Pearson et al., 2017, p. 391), as length of stay did not change. However, financial pressures, reduced community resources, and poor interagency working are important contextual factors that may have impacted delivery.

Edmond et al’s (2017) work additionally showed that the average length of stay in hospital for those initially accepted onto a Hospital at Home treatment for hip fracture was less compared to those that did not receive Hospital at Home treatment. However, as time progressed the difference in length of stay between those who did and did not receive Hospital at Home treatment for hip fractures declined. The authors noted that a potential explanation for this was the number of patients requiring treatment for hip fractures was rising but this was not being matched by a rise in Hospital at Home services.

Recent statistics from HIS (2023) also show that the length of treatment from a Hospital at Home service reduces over time. There was a 20% reduction in the length of treatment on a Hospital at Home service between April 2021/22 and March 2022/23 2022 across Scotland.

OPAT

Whilst no studies were found to compare the length of OPAT treatment and inpatient length of stay, Gilchrist et al (2022) examined length of OPAT treatment amongst adults and children included in the BSAC National Outcomes Registry between 2015 and 2019. They reported that the mean OPAT tretament for adults was 16.67 days, whilst this was 7.66 days for children (Gilchrist et al, 2022). This was due to adults having more complex pathologies, more co-morbidities, and more prosthetic infections compared to children.

Respiratory

A UK based study comparing the effectiveness of a Hospital at Home treatment^[8] to usual care for COPD reported encouraging findings for the use of Hospital at Home treatment in relation to length of stay (Echevarria et al. 2018). It was reported that there was a statistically significant reduction in length of hospital stay over a 90 day period for the Hospital at Home treatment when compared to usual care (median number of days: 1 vs. 5).

Covid remote health monitoring (pulse oximetry)

There are encouraging findings for the use of pulse oximetry to reduce LoS. Dirikgil et al. (2021) found that telemonitoring interventions which included pulse oximetry were both safe and effective at reducing short-stay admissions (those under 24 hours).

Research on virtual wards established at University Hospitals Leicester NHS Trust to accelerate hospital discharge for people admitted with Covid-19 also reports reduced length of stay (Swift et al. 2022). Eligible patients were required to possess a smartphone, tablet, or laptop and submit daily readings from a thermometer and pulse oximeter. Their results were compared with readings from clinically similar patients before the establishment of the virtual ward. Before the establishment of the virtual ward, average LoS for inpatients was 5.5 days; average length of stay for virtual-ward patients was 3.3 days. This represents a 40% reduction in bed days, although without further statistical analysis, it is not possible to gauge the true significance or size of this difference. Additionally, half of the authors of the paper are employed by the company which owns the software used for sharing data between patients and clinicians, thereby presenting a potential conflict of interest. The findings are nonetheless encouraging for the use of pulse oximetry for Covid patients to reduce length of stay and save inpatient bed days.

Summary

VC services can reduce hospital length of stay. Length of treatment (e.g. on a VC service) varies depending on the study. Shepperd et al’s (2021) RCT reported a slight increased length of treatment for people receiving Hospital at Home, though statistical significance was not reported.

Question 3: Do Virtual Capacity services reduce the need for hospital readmissions and support admission avoidance?

Hospital at Home

There is mixed evidence on the impact on Hospital at Home treatment on hospital readmissions, as well as variations in the quality of evidence. A RCT found that patients in the UK treated under Hospital at Home initiatives sometimes had a higher risk of hospital readmission than inpatients at one month follow up, but not at six months (Shepperd et al., 2021). Service evaluations are conflicting, either showing no differences in readmissions (Edmond et al. 2017), higher rates of readmissions at 30 days, 3-month and 6-month follow-up (Tierney et al, 2021) or conversely had a ‘demonstratable effect^[9]’ on admission avoidance (Pickstone and Lee, 2019). However, it should be noted that service evaluations are less robust than RCT evidence.

OPAT

A lack of evidence was found that met the inclusion criteria for this review. The available evidence is limited due to comparing populations with different clinical characteristics, not reporting statistical significance, or not including comparators. However, as the interviews highlighted, the primary aim of OPAT is not to reduce hospital readmissions but instead to provide safe, effective treatment.

Cardiac services

A systematic review found that virtual wards can reduce heart failure related readmissions for patients with heart failure. Studies on heart failure found significant reductions in readmission rates for people using sensors (Cowie et al, 2022; Dauw et al., 2022).

Respiratory services

Published statistics from Scotland show that at-home respiratory treatment has led to admission avoidance. VC-type treatment for COPD suggests that such interventions reduce hospital readmissions (MacGillivray & Gray, 2019; Sharpe et al., 2021).

This section focuses on whether VC services reduce readmissions to hospital level care. Hospital level care applies regardless of whether this is provided as an inpatient or in the community, including at home. Evidence for the ability of VC services to reduce readmissions is mixed.

Hospital at Home

An increased risk of readmission or transfer to hospital for participants in the Hospital at Home group at one month was reported by Shepperd et al’s (2021) large robust UK based RCT. A 32% relative increase (which was statistically significant) was reported, but this was not maintained at six-month follow-up (Shepperd et al., 2021). This difference may be attributable to limited availability of overnight care for the Hospital at Home group and demonstrates the acuity of the population, with sufficient need for hospital based care (Shepperd et al., 2021).

The remaining evidence comes from service evaluations. One service evaluation of a Hospital at Home type initiative in Northern Ireland found that patients using the service had higher readmission rates at 30 days, 3-month and 6-month follow-up (Tierney et al, 2021). Tierney and colleagues (2021) reported that people who received care at home were ‘frailer, more dependent and immobile nursing home residents’ (p2985) which potentially explained the higher admission rates observed. Despite this, length of stay was shorter, patients were less likely to require domiciliary care or rehabilitation on discharge from the service. This indicates that wider outcomes are positive for older adults using Hospital at Home services.

However, Hospital at Home increasing hospital readmissions was not supported by another service evaluation of two Hospital at Home services for individuals with hip fractures. Edmond et al. (2017)^[10] found no differences between those who did and did not participate in the programme for admission to hospital within 30 days of discharge.

Pickstone and Lee's (2019) service evaluation examined whether Hospital at Home reduced emergency department (ED) admissions over a 3-month period in autumn/winter 2016. The authors reported that the Hospital at Home service helped 397 people avoid ED attendance who would otherwise have attended. This amounts to around 38% of patients referred to the service. The authors conclude that there is a demonstrable effect on ED attendance from the Hospital at Home service, although this is still very small (total ED attendances over the study period were 119,718). Limitations to the study include that there are no robust comparison data for the types of conditions patients were presenting with.

OPAT

The interviews in part 1 highlighted that OPAT aims to provide alternative, safe, effective treatment for infections through admission avoidance and early supported discharge. The primary aim is therefore not to reduce readmissions. In many of the studies, patients were found to be allocated to OPAT or inpatient care depending on clinical characteristics. It is therefore likely that differences (e.g., severity of infection) exist between these two groups meaning that the following conclusions should be interpreted with caution.

A 2021 review by the SHTG (2021) synthesized the published evidence on OPAT from three systematic reviews which included studies from the UK, Europe, and North America. As reported by SHTG (2021), one systematic review compared OPAT with inpatient antimicrobial therapy (Mitchell et al., 2017). Of the studies measuring hospital readmission, the results of OPAT in comparison to inpatient care were inconclusive. A second systematic review compared the efficacy of OPAT with hospital-based parenteral antimicrobial therapy in children aged 16 and under (Bryant & Katz, 2018). The results were either not reported or not found to be statistically significant.

Other studies lack comparative data. For example, Sriskandarajah et al. (2018) conducted a systematic review evaluating OPAT in three age groups (mixed age, over the age of 60 and children < 18 years) and included observational studies only. Hospital readmission rates ranged from 1% to 14.3% in the mixed age group, 2.6% to 14.2% in adults over the age of 60, and 3.8% to 26% in children under 18 years (Sriskandarajah et al., 2018). Similarly, a study evaluating the use of OPAT for a specific infection (i.e., necrotising otitis externa) reported that nine out of 46 included cases (i.e., 19.6%) had unplanned readmission within 30 days after stopping OPAT. The absence of comparative data, however, makes it difficult to draw conclusions (Durojaiye et al., 2022).

Heart Failure

A systematic review exploring the impact of virtual wards on readmission rates found a reduction in heart failure related readmissions for patients with heart failure, though this was not reduced for all-cause readmissions (Uminski, 2018).

Further evidence is based on the use of sensors, though these are not currently being used in Scotland. Evidence supporting the effectiveness of a pulmonary artery pressure sensor in UK patients was reported with a reduction in the number of heart failure hospitalisations 12 months after the implant (pre-implant = 165 to post-implant = 12). This resulted in a significant reduction in risk for heart failure hospitalisations of 82% (Cowie et al., 2022).

A separate study evaluated a pulmonary artery pressure sensor in a European multicentre cohort and included UK patients (Duaw et al., 2022). A comparison of the total number of heart failure hospitalisations pre- and post-implantation at 3, 6 and 12 months showed that the number of these hospitalisations significantly reduced at 6- and 12-months post-implantation only. The number of first heart failure hospitalisations were also significantly reduced at 6- and 12-month post-implantation.

Respiratory

Studies on the ability of VC services to reduce hospital readmissions for people with respiratory conditions are promising. VC-type treatment for COPD suggests that such interventions reduce hospital readmissions (MacGillivray & Gray, 2019; Sharpe et al., 2021).

Evidence supporting the use of remote care for primary-diagnosis COPD comes from the establishment of a Community Respiratory Team (CRT) in North West Glasgow (Carlsson et al., 2020; Levin et al., 2021). The CRT was established in 2013, and as of 2015 there was a 33.7% relative reduction in emergency admissions with COPD as a primary diagnosis in North West Glasgow compared to 2011. Control data from North East and South Glasgow (where there were no CRTs), did not show any decrease in emergency readmissions with COPD as a primary diagnosis over the same period. The service did not appear to have any effect where COPD was a secondary diagnosis.

Similarly, research from Turner et al. (2022) reported low hospital readmissions for those referred to the Greater Glasgow and Clyde NHS Trust Community Respiratory Response Team (CRRT). Patients were triaged based on the severity of their needs and received consultations via phone, video calls, and home visits from a multidisciplinary team. Low rates of hospital admissions were evident amongst those referred to the CRRT (12%). The authors conclude that there was a ‘significant decrease in the trend in COPD EAs’ in Greater Glasgow and Clyde compared to the rest of Scotland^[11], which was used as a control.

In their systematic review of research into reducing readmissions for COPD patients, Sharpe et al. (2021) observed a trend towards reduced all-cause admissions following at-home treatment. Multi-modal (e.g. self-management education, follow-up appointments, medication support and remote monitoring) and broader system-level treatments (e.g. advice on smoking cessation, self-management education, and medication support; telemonitoring; and initial treatment in a specialised respiratory hospital) also reduced COPD-related admissions. Sharpe et al.(2021) caution, however, that much of the evidence supported improved 30-day admission outcomes, rather than longer-term outcomes.

Rickards et al. (2021) also report on data collected from 103 COPD patients. This was not a RCT, but the results demonstrated that the community respiratory team could safely manage patients in their homes, including those whose arterial oxygen levels would normally indicate hospitalisation. The respiratory service helped patients safely avoid hospital readmission and provided early supported discharge.

However, 90 day readmission rates were found to be similar in a UK based study which compared a Hospital at Home treatment to usual care for COPD (Echevarria et al., 2018). It should be noted that a low-risk sample, as indicated by DECAF scores (a strong predictor of COPD inpatient mortality), were specifically recruited for this study which offers a possible explanation for the lack of difference between conditions for readmission rates.

While several of the studies above addressed COPD specifically, the Improving Adult Respiratory Care Together (ImpACT+) project, based in South Derbyshire, was implemented in 2018 to address all respiratory diseases. Support was provided from a multidisciplinary team and included virtual place based consultant led clinics and a telephone helpline. Subramanian et al. (2018) found that the service brought about a 6% decline in non-elective readmissions for all respiratory diseases, and a 9% reduction in emergency department readmissions for asthma.

Cox et al. (2017) report on a case-note review of a service for COPD patients in Lincolnshire. The Acute Respiratory Assessment Service led by specialist nurses was designed to avoid hospital readmissions for patients with a COPD diagnosis experiencing acute exacerbation. Case notes from 128 patients referred to the service from April 2014 to March 2015 were reviewed. Out of the 128 patients, only 5 were admitted to hospital due to respiratory issues. This is a very positive outcome, particularly given that on initial review, 21 patients were hypoxemic and would have needed to be admitted to hospital for further assessment, in line with NICE guidelines, if they did not have access to treatment from a respiratory nurse specialist. The authors also note that it is possible that educating patients in self-management could have supported the reduction in readmission rates.

Summary

There is variation in the extent to which VC reduced readmissions to hospital across the four identified areas. VC reduced COPD readmissions for people using community respiratory response teams in Greater Glasgow and Clyde (Carlsson et al., 2020; Levin et al., 2021; Turner et al, 2022). There is also positive evidence for people with heart failure. Systematic Reviews show that Virtual Wards and the use of sensors reduce readmissions (Uminski, 2018; Cowie et al., 2022; Duaw et al, 2022). Evidence on Hospital at Home is mixed, and may be impacted by a lack of overnight care and the clinical needs of the population. Included studies on OPAT published within the inclusion timeframe allocated people to OPAT or inpatient care depending on clinical characteristics, and therefore should be interpreted with caution.

Question 4: What is the patient experience of Virtual Capacity services?

Hospital at Home

Evidence from the UK (Sheppard et al. 2021; Mäkelä et al. 2020) suggests that patient satisfaction is generally higher for those being treated at home compared to inpatients.

OPAT

Evidence shows that patient satisfaction may vary by factors such as age group and also identified both strengths and weaknesses to the at-home OPAT treatment they received.

Pulse oximetry for Covid

Evidence from Scotland suggests that patients are reassured by self-monitoring their Covid symptoms (Alexander, 2021).

Cardiac services

Patient experience of cardiac services reported improvements in quality of life, although this was not statistically significant (Cowie et al. 2022).

Respiratory services

Evidence from England suggests that patients report a positive experience from receiving treatment at home for respiratory conditions.

Norman et al. (2023) conducted a systematic review of virtual capacity services including Hospital at Home, virtual wards, and remote monitoring for people with respiratory conditions, heart failure, Covid-19 and frailty. They report that patient satisfaction “may be slightly higher” in patients treated by Hospital at Home than inpatients (Norman et al, 2023, p6).

Hospital at Home

There has been broadly positive feedback from patients who have received Hospital at Home. In their randomised controlled trial, Shepperd et al. (2021) reported that patient satisfaction scores were found to be higher across various outcomes (e.g. being involved with decision making and the length of time waiting for care to begin) in patients who received Hospital at Home at one-month follow-up compared to patients admitted to hospital. In the same study, Singh et al (2022) reported that 74 patients randomised to receive inpatient care subsequently moved to the Hospital at Home group. Reasons for this included patients choosing Hospital at Home care, demonstrating a preference for home based care.

Further patient satisfaction is evidenced in a qualitative study with patients and their carers. Semi-structured interviews explored experiences of care at home in comparison to inpatient hospital care. Mäkelä et al. (2020) found that some older people who received Hospital at Home reported being able to continue with their day-to-day activities while unwell. This enabled people to maintain their usual routine within their own home and facilitated independence. A familiar setting was also reported to be beneficial to patients who experienced confusion, but only if it was combined with family supervision. Managing risks in the home and organising social resources, including family members and wider networks of support, was also highlighted as being important (Mäkelä et al, 2020)

Whilst Gardner et al. (2019) support the potential for improved alignment with daily routines, concerns around safety and a lack of rapid access to clinicians overnight were also highlighted. Furthermore, a lack of patient and carer involvement in assessment processes across both hospital and Hospital at Home settings was reported (Gardner et al, 2019; Mäkelä et al, 2020).

OPAT

A patient feedback survey was part of the 10-year retrospective analysis by Durojaiye et al. (2018). Satisfaction and acceptance of the OPAT service was high. For instance, 99% of the respondents rated the service as ‘very good or excellent’, 98% would choose OPAT again for future treatment and 97% felt that the treatment ‘met their expectations’.

There are different ways that OPAT can be provided, including through self-administration. A small scale qualitative study utilising semi-structured interviews focussed on perceptions of self-administration as part of the OPAT service. The interviews were conducted with adults receiving OPAT in Scotland, but who did not self-administer (Tonna et al, 2019). Several facilitators to self-administration were identified. These included quality of life being improved (e.g., ability to return to work), having the skills to self-administer OPAT at home, and staff providing support and reassurance. Despite this, barriers were also identified to self-administration. These included not knowing that self-administration was an option, believing that it is safer for OPAT (i.e. IV medications) to be delivered in the hospital environment, and concerns about self-administration in case of difficulties.

Further qualitative research highlights variation in views regarding different OPAT models. A qualitative analysis explored experiences of OPAT through 28 semi-structured interviews and a focus group with adults on short and long-term IV antimicrobial treatment (Minton et al, 2017; Twiddy et al. 2018). Differences in preference regarding OPAT models were apparent between older and younger participants (Minton et al, 2017; Twiddy et al. 2018). While nurses visiting the patients' home was viewed as more preferable for older adults, younger patients preferred attending outpatient clinics for short-term treatment.

Participants indicated that the different models of OPAT (outpatient clinic, nurse attending the home and self-administering OPAT at home) had their own strengths and weaknesses (Minton et al, 2017; Twiddy et al. 2018). Benefits of OPAT included avoiding hospital admission, less interference with everyday life (e.g., work) and being able to be treated at home. The option to ask questions and follow-up once treatment had concluded and having clear communication with the OPAT team was also considered important by patients (Twiddy et al. 2018).

Weaknesses related to transportation (Minton et al, 2017). Travelling via public transport was perceived as difficult and high parking fees were also a barrier. Furthermore, patients who required a cannula or port reported being worried about the impact this would have on their day-to-day life. For example, patients who took public transport with the visibility of a cannula feared being judged by others.

Respiratory

Patients in England receiving treatment at home for respiratory conditions described a positive experience (Cox et al., 2017). More specifically, Cox et al. (2017) reported that all patients who completed a satisfaction questionnaire stated they were “extremely likely” to recommend the service. Survey responses also indicated that patients were very satisfied with the service, valued being included in their care and were given information about their care and treatment.

The use of a Hospital at Home service for COPD was also positively received with 90% of patients across both settings (i.e., Hospital at Home and usual inpatient care) stating that they would prefer a Hospital at Home service for future COPD treatment (Echevarria et al., 2018). The facilitators and barriers to a Hospital at Home service for COPD have also been identified in a qualitative study in Northeast England (Dismore et al., 2019). Positives for the service included: being relaxed in their own home and being able to have more mobility, for instance moving their oxygen equipment, viewing recovery as quicker at home, better diet and sleep, and home being more convenient for family and friends (e.g., travel and limited visiting hours in hospital). Barriers to providing the Hospital at Home service for COPD were identified from people who provided reasons for not participating in the study, which included being worried about being home alone when ill and concerns for their privacy.

Heart Failure

Cowie et al. (2022) reported improved quality of life at 12 month follow up in an evaluation of people with a pulmonary artery pressure sensor in the UK. However, it should be noted that this was not statistically significant.

Covid remote health monitoring (pulse oximetry)

Data on Covid Remote Health Pathways (RHPs) demonstrates high patient satisfaction levels. An evaluation of data collected from NHS Highland and NHS Lanarkshire during the RHP pilot found that patients were reassured by self-monitoring.^[12] (McKinstry et al., 2021). Furthermore, out of 39 participants who completed an experience survey, the majority felt positive about remote monitoring (liked it or felt it was “OK”) and found it easy to use. Participants found it reassuring, reported spending less time travelling to and attending appointments , and most stated that they would use the service again (Alexander, 2021).

These positive results were also reflected in an evaluation of a new Covid RHP launched in 2022 (Alexander, 2022). The pathway utilised pulse oximetry measurements and a National Contact Centre to support patient onboarding, with symptoms being monitored by SMS or telephone. Although numbers of patients involved were small in both 2021 and 2022, and while survey respondents were self-selecting, the results are nonetheless encouraging.

Further evidence regarding the use of home monitoring for Covid-19 is synthesised in two systematic reviews. McKinstry (2022) concludes that patient experience of these interventions is universally positive. It is important to highlight however that this refers to remote monitoring in the whole, which includes use of apps, SMS, and telephone services as well as pulse oximetry monitoring.

Summary

There is evidence that patients tend to be broadly satisfied with VC provision. Qualitative evidence demonstrates that patients valued being in the comfort and familiarity of their own home, and the reduced disruption to daily routines. Patients were at times less satisfied in relation to safety concerns and having to travel for treatment. Differences in preferences over different VC models were also evident.