Telehospitalist program reduced length of stay at a rural VHA hospital, study finds

Readmission rates did not improve with telemedicine, but patients and clinicians at both the hub and spoke hospitals were highly satisfied with a Veterans Health Administration (VHA) telehospitalist pilot program.

A telehospitalist program can successfully provide inpatient coverage and address rural staffing needs, a study of one program's implementation found.

To determine clinical outcomes and staff and patient satisfaction with a Veterans Health Administration (VHA) telehospitalist program, researchers studied a quality improvement program in which a tertiary VHA hospital acted as the telehospitalist hub to a rural, 10-bed inpatient medical unit. Researchers assessed satisfaction via anonymous surveys to inpatient and administrative staff at one and 12 months after implementation. Results were published online Feb. 17 by the Journal of Hospital Medicine.

There were 822 admissions during the preimplementation period and 550 admissions during the postimplementation period. Five hundred two patient encounters were staffed by the telehospitalist in the pilot phase, with an average of 6.25 encounters per day.

The average daily census decreased from 5.0 patients per day during preimplementation to 3.1 patients per day during postimplementation. Telehospitalist program implementation was associated with a significant reduction in length of stay (LOS), from 3.0 days to 2.3 days. Readmission rates varied, ranging from below 10% to above 30%, and were slightly higher in the postimplementation period, although the difference was not statistically significant. Readmission rates for heart failure, chronic obstructive pulmonary disease, and pneumonia did not change. In-hospital mortality and 30-day standardized mortality did not change significantly, but the 12-month rolling average of the observed/expected 30-day standardized mortality improved from 1.40 to 1.08.

Most telehospitalists reported being satisfied or very satisfied (89%) with the program, and all local clinicians rated their experience as good or excellent (100%). Communication with patients, families, and local staff was noted as being “positive” or “mostly positive.” The telehospitalists reported confidence in the accuracy of their diagnoses and rated the quality of care as being equal to that of a face-to-face encounter. The patient satisfaction survey showed a significant improvement in care coordination (18%; P=0.02) and a nonsignificant improvement in communications about medications (5%; P=0.054).

Connectivity problems were common, the study authors noted. Internet connectivity was inconsistent, leading to disruption in video communications, but updated technology led to improvements during the sustainability phase, they said. Other challenges included differences in culture and concerns about liability. The credentialing process was complicated and delayed bringing in telehospitalists, the authors said. They recommended that other programs ensure adequate technological quality and address staff concerns in a timely manner.

“Reduction in LOS is one of the primary measures of efficiency in hospital care; reducing LOS while maintaining the quality of care lowers hospital costs,” the authors wrote. “The reduction in LOS in our study could be attributed to greater continuity of care, engagement/experience of the telehospitalists, or other factors. This decrease in LOS and slight reduction in admissions resulted in an overall lower daily census during the study period and impacted efficiency.”