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• Response to Keenan et al comment
  Luigi Sedda, Abdollah Jalilian, Alison Unsworth and Martin Farrier
  Published on: 1 February 2024
• Misleading economic analysis
  Niall G Keenan, Matthew Knight, Dominique Auger, Martin Hawkings and Andrew Barlow
  Published on: 30 January 2024

• Published on: 1 February 2024

  Response to Keenan et al comment

  • Luigi Sedda, Senior Lecturer Lancaster University
  • Other Contributors:
    • Abdollah Jalilian, Senior Research Associate
    • Alison Unsworth, Head of Clinical Audit and Effectiveness
    • Martin Farrier, Associate Medical Director

  We are grateful to Niall Keenan, Matthew Knight, Domenique Auger, Martin Hawkings, and Andrew Barlow for their careful consideration of our article.

  However, we firmly reject the characterisation of our article as a 'misleading economic analysis’.

  Although virtual ward occupancy information is not included in the abstract, it was originally reported in the Discussion. This stated that, ‘This means that for a hospital with 100% occupancy (therefore providing 365 hospital bed days per bed) and 40 virtual ward beds at the capacity found in this study (24%), the virtual ward effect is an increase in the hospital capacity of 3.08 hospital beds per day (1123.62/365).’

  Furthermore, in the same section of the article, we explicitly mentioned that ‘increasing the capacity to use the 40 virtual ward beds and reducing the time from hospital admission to virtual ward admission can reduce the cost of a freed-day hospital bed’.

  We encourage readers not to solely rely on the abstract but to peruse the full article for a comprehensive understanding of the findings, recommendations, and limitations.

  Conflict of Interest:
  None declared.

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• Published on: 30 January 2024

  Misleading economic analysis

  • Niall G Keenan, Consultant Cardiologist / Clinical Lead for Virtual Ward / Clinical Advisory Group Chair for Virtual Wards West Hertfordshire Teaching Hospitals NHS Trust / NHS England East of England Virtual Ward Team
  • Other Contributors:
    • Matthew Knight, Consultant Respiratory Physician
    • Dominique Auger, Consultant Cardiologist
    • Martin Hawkings, Head of Clinical Improvement / General Practitioner
    • Andrew Barlow, Consultant Respiratory Physician / Divisional Director Medicine

  We read with interest this assessment of the virtual ward at Wrightington, Wigan and Leigh (WWL) Hospitals by Jalilian et al. While we welcome the development of the literature on virtual ward and hospital at home models of care, we do not agree with the economic analysis in the paper which as presented in the abstract has the potential to be highly misleading.

  The authors say that they spent £1.051 million for 40 virtual ward beds in 2022. They then calculate that because they had looked after 366 patients and the mean reduction in length of stay was 3.07 days that the cost per bed day saved was £935 (=£1 051 150/ (3.07 days×366 patients)). However they go on to state: “… £935 is calculated based on the WWL’s capacity to use the virtual beds, which was 24% of the potential 14 600 (24-hour) beds per year provided by 40 virtual ward beds… reference to 3508 total days spent by virtual ward patients).”
  What this actually means is that they spent £1,051,000 to staff and run 40 virtual beds for a year, only used 10 of them, and then found that this was not cost effective. This is hardly surprising; however because this detail is not given in the abstract it runs the risk of making the paper seriously misleading – as some of the coverage in the medical press has demonstrated. “Virtual ward costs twice that of inpatient care, study finds” Lawrence L, HSJ 25 January 2024..
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  We read with interest this assessment of the virtual ward at Wrightington, Wigan and Leigh (WWL) Hospitals by Jalilian et al. While we welcome the development of the literature on virtual ward and hospital at home models of care, we do not agree with the economic analysis in the paper which as presented in the abstract has the potential to be highly misleading.

  The authors say that they spent £1.051 million for 40 virtual ward beds in 2022. They then calculate that because they had looked after 366 patients and the mean reduction in length of stay was 3.07 days that the cost per bed day saved was £935 (=£1 051 150/ (3.07 days×366 patients)). However they go on to state: “… £935 is calculated based on the WWL’s capacity to use the virtual beds, which was 24% of the potential 14 600 (24-hour) beds per year provided by 40 virtual ward beds… reference to 3508 total days spent by virtual ward patients).”
  What this actually means is that they spent £1,051,000 to staff and run 40 virtual beds for a year, only used 10 of them, and then found that this was not cost effective. This is hardly surprising; however because this detail is not given in the abstract it runs the risk of making the paper seriously misleading – as some of the coverage in the medical press has demonstrated. “Virtual ward costs twice that of inpatient care, study finds” Lawrence L, HSJ 25 January 2024..
  https://www.hsj.co.uk/finance-and-efficiency/virtual-ward-costs-twice-th...
  The authors could just as easily have concluded that if the team at WWL had only opened 10 virtual beds, or had filled all 40 virtual beds then their costs would be £935 x 0.24 = £224 per bed day saved which would then be highly cost effective. This is without touching on other financial benefits such as less use of surge capacity enabling more elective work to be performed, and of course the benefit to patients of receiving care at home.
  The real conclusion of this study is that a. it can be difficult to accurately model and then fill virtual ward capacity, and that b. underutilisation is a major bar to cost effectiveness.

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  Conflict of Interest:
  Niall Keenan - Seconded to NHS England East of England Virtual Wards team. National Steering Group for Virtual Wards, NHSE.
  Matthew Knight - Chief Medical Officer Medefer.
  Andrew Barlow - Chief Medical Officer Virtue Health Ltd.

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