Clinicians' Perspective on Implementing Virtual Hospital Care for Low Back Pain: Qualitative Study

Barriers, facilitators and next steps for sustaining and scaling virtual hospital services in Australia: a qualitative descriptive study

OBJECTIVE

To describe the barriers to and facilitators of implementing and delivering virtual hospital (VH) services, and evidence and practice gaps where further research and policy changes are needed to drive continuous improvement.

STUDY DESIGN

Qualitative descriptive study.

SETTING, PARTICIPANTS

Online semi-structured interviews and a focus group were conducted between July 2022 and April 2023 with doctors, nurses and leadership staff involved in VH services at three sites in New South Wales, Australia.

MAIN OUTCOME MEASURES

Barriers to and facilitators of implementing and delivering VH services in sites with differing operating structures and levels of maturity, and evidence and practice gaps relating to VH services.

RESULTS

A total of 22 individuals took part in the study. Barriers, facilitators, and evidence and practice gaps emerged within five major themes: scope and structure of VH services; development and implementation of VH models of care; delivery of VH models of care; evaluation of VHs and VH models of care; and sustainment and scalability of VH services. Facilitators of VH success included hybrid approaches to care, partnerships with external services, and skills of the VH workforce. Barriers and gaps in evidence and practice included technical challenges, the need to define the role of VH services, the need to evaluate the tangible impact of VH care models and technologies, and the need to develop funding models that support VH care delivery. Participants also highlighted the perceived impacts and benefits of VH services on the workforce (within and beyond the VH setting), consumers, and the health care system.

CONCLUSIONS

Our findings can help inform the development of new VH services and the improvement of existing VH services. As VH services become more mainstream, gaps in evidence and practice must be addressed by future research and policy changes to maximise the benefits.

Process and implementation evaluation of a virtual hospital model of care for low back pain (Back@Home)

OBJECTIVES

Low back pain was the sixth most common reason for an ED visit in 2022-2023 in Australia, one-third of these patients were subsequently admitted to hospital. Therefore, we have assessed whether some patients could be diverted to alternate clinical pathways, via admission to a virtual hospital (rpavirtual), and be cared for remotely in their own homes.

METHODS

Ethics approval was granted for protocols X21-0278 & 2021/ETH10967 and X21-0094 & 2021/ETH00591. We conducted a mixed-method process evaluation, using the RE-AIM framework (reach, effectiveness, adoption, implementation and maintenance) to answer key questions regarding the Back@Home model of care.

RESULTS

This preliminary evaluation describes a cohort of the first 50 patients who received care between 13 February and 31 July 2023. The service had high levels of reach and adoption, very low levels of ED representation, and no AEs. Virtual care cost a median of AU$2215 (interquartile range = AU$1724-AU$2855) per admission. Patients admitted virtually had the same high satisfaction with care as traditionally admitted patients and reported less pain and better physical function.

CONCLUSIONS

Preliminary findings suggest that this model of care is a safe, acceptable, and feasible alternative to hospitalisation for non-serious low back pain, in a select cohort of patients meeting inclusion criteria. Further data collection will inform whether Back@Home has had an impact on length of stay or traditional admission rates.

UK physiotherapists' perceptions on providing face-to-face and virtual rehabilitation for patients with Greater Trochanteric Pain Syndrome (GTPS): A cross-sectional survey

BACKGROUND

Greater Trochanteric Pain Syndrome (GTPS) is a prevalent and debilitating cause of lateral hip pain. Physiotherapists often prescribe exercises and educate patients on self-management strategies. Virtual consultations have increased since COVID-19. Rehabilitating patients with GTPS virtually may offer benefits to patients and healthcare providers.

OBJECTIVES

Understand physiotherapists' perceived effectiveness of providing rehabilitation for people with GTPS virtually compared to face-to-face.

DESIGN

Cross-sectional survey.

METHODS

An internet-based survey was distributed via Twitter (now X). The survey included participant characteristics and 5-point Likert scales to rate the perceived effectiveness (higher score is more effective) of each consult method to deliver treatments for GTPS. Descriptive and inferential statistics were calculated to compare effectiveness between consultation types.

RESULTS

54 physiotherapists responded. Overall, physiotherapists felt they were more effective at managing patients face-to-face compared to virtually with median scores of 5 (IQR 4-5) to 3 (IQR 2-4) respectively (P < 0.001). Physiotherapists rated themselves more effective at delivering exercise interventions and most educational components face-to-face compared to virtually. Coaching exercises and checking exercise technique received the lowest rating with virtual consults. Higher levels of post-graduate education and confidence in technology were associated with higher perceptions of virtual consults (P < 0.05). There has been a significant increase in virtual practice since COVID-19 (P < 0.001), despite few physiotherapists receiving training.

CONCLUSION

Physiotherapists rated themselves as more effective in treating patients with GTPS face-to-face compared to virtually in almost all aspects of rehabilitation. However, virtual consultations still scored highly in self-management support and specific aspects of exercise and education.

A Virtual Hospital Model of Care for Low Back Pain, Back@Home: Protocol for a Hybrid Effectiveness-Implementation Type-I Study

BACKGROUND

Low back pain (LBP) was the fifth most common reason for an emergency department (ED) visit in 2020-2021 in Australia, with >145,000 presentations. A total of one-third of these patients were subsequently admitted to the hospital. The admitted patient care accounts for half of the total health care expenditure on LBP in Australia.

OBJECTIVE

The primary aim of the Back@Home study is to assess the effectiveness of a virtual hospital model of care to reduce the length of admission in people presenting to ED with musculoskeletal LBP. A secondary aim is to evaluate the acceptability and feasibility of the virtual hospital and our implementation strategy. We will also investigate rates of traditional hospital admission from the ED, representations and readmissions to the traditional hospital, demonstrate noninferiority of patient-reported outcomes, and assess cost-effectiveness of the new model.

METHODS

This is a hybrid effectiveness-implementation type-I study. To evaluate effectiveness, we plan to conduct an interrupted time-series study at 3 metropolitan hospitals in Sydney, New South Wales, Australia. Eligible patients will include those aged 16 years or older with a primary diagnosis of musculoskeletal LBP presenting to the ED. The implementation strategy includes clinician education using multimedia resources, staff champions, and an "audit and feedback" process. The implementation of "Back@Home" will be evaluated over 12 months and compared to a 48-month preimplementation period using monthly time-series trends in the average length of hospital stay as the primary outcome. We will construct a plot of the observed and expected lines of trend based on the preimplementation period. Linear segmented regression will identify changes in the level and slope of fitted lines, indicating immediate effects of the intervention, as well as effects over time. The data will be fully anonymized, with informed consent collected for patient-reported outcomes.

RESULTS

As of December 6, 2023, a total of 108 patients have been cared for through Back@Home. A total of 6 patients have completed semistructured interviews regarding their experience of virtual hospital care for nonserious back pain. All outcomes will be evaluated at 6 months (August 2023) and 12 months post implementation (February 2024).

CONCLUSIONS

This study will serve to inform ongoing care delivery and implementation strategies of a novel model of care. If found to be effective, it may be adopted by other health districts, adapting the model to their unique local contexts.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/50146.