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.
Qualitative descriptive study.
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.
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.
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.
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.
To the Editor: It was most welcome to see hypertension receive due attention in the timely roadmap of the National Hypertension Taskforce of Australia.1 The authors described the pillars of “prevent”, “detect” and “treat effectively” and listed the appropriate high risk groups. However, one group, women with hypertensive disorders of pregnancy (HDP), was curiously omitted.
All women are screened for hypertension in pregnancy, and each year 5–10% are diagnosed with HDP. These women have a lifelong increased risk of cardiovascular disease (CVD). It is not merely a concern for older age groups. Disturbingly, there is a doubling in risk of cardiovascular events in the first ten years following pregnancy. The risk is multiplied by five times if the HDP was early onset.2 The ramifications are often unrecognised as blood pressure usually normalises within weeks of delivery and the needs of the newborn quickly supersede those of the mother.
An additional concern is that many women are not aware of the elevated risks of HDP. A New South Wales survey of 105 women with prior HDP found that only 18 (17%) knew of their increased cardiovascular risk.3 General practitioners need to be informed of their patient's HDP diagnosis to manage their long term cardiovascular risks. Lack of patient awareness and inaccurate or incomplete discharge summaries can hamper the general practitioner's awareness and subsequent treatment.
Women are already disadvantaged when it comes to cardiovascular health: appraisal of their risk factors is less likely, and prescription of evidence-based therapies is less common in young women (aged 35–54 years) compared with their male counterparts with the same risk of CVD.4 It was heartening to see relevant information on HDP added to the Australian CVD Risk Calculator5 in 2023, but there is a long way to go.
Pregnancy is an opportunity to detect, treat and educate women of childbearing age regarding hypertension. All women with HDP and their respective general practitioners should be informed of their diagnosis and increased CVD risk. In line with current national guidelines,6 all women with HDP should have an annual review of blood pressure and cardiovascular risk factors to facilitate early detection and treatment of hypertension — Pillars B and C of the roadmap. For the National Hypertension Taskforce of Australia roadmap to achieve its goal, this at-risk group should be included in the roadmap.
No relevant disclosures.
In reply: On behalf of the National Hypertension Taskforce of Australia, we welcome the above comment from Cosgrove and colleagues1 on our roadmap2 and fully appreciate the importance of hypertensive disorders of pregnancy (HDP) as a high risk condition for future development of established hypertension and cardiovascular disease (CVD).3 While not specifically mentioned as a high risk group in the roadmap, risk-based management of CVD is a critical component of the HEARTS package to be adopted and tailored to the Australian circumstances to diagnose and treat hypertension effectively, including HDP (Pillar C).2 Team-based and patient-centred care is another essential aspect and will allow implementation of systematic blood pressure screening and monitoring, delivered by general practitioners, physicians and, importantly, by obstetricians, as mentioned in the roadmap (Pillar B).2
Continuous monitoring of blood pressure postpartum seems particularly relevant in view of recent evidence indicating a 2.4-fold increased risk of hypertension ten years after the occurrence of HDP.4 Indeed, observed differences in non-invasive measures of CVD risk were predominantly driven by the hypertension diagnosis, regardless of HDP history, suggesting that the known long term risk of CVD after HDP may primarily be a consequence of hypertension development and uncontrolled blood pressure levels.4
Adding further to the complexity is the observation that both HDP and associated CVD disproportionally affect black women, as shown in an American study predominantly including women who self-identified as black. This highlights possible racial disparities4 and the need for further research and exploration of the underlying mechanisms.
Another important group of patients not mentioned specifically in the roadmap is adolescents, a cohort frequently lost in transition from paediatric to adult physician care.5 To remedy this, a call for Australian clinical practice guidelines for paediatric hypertension (including adolescents) has recently been published6 and development is underway.
While it was beyond the scope of the roadmap to address specific aspects of all patient groups affected, the guidance provided in the document under the principal pillars of prevent, detect and treat effectively, combined with adequate and timely implementation of the required framework, should allow us to substantially improve blood pressure control rates for all Australians and curb the enormous burden of hypertension on our society.
No relevant disclosures.
Warfarin (vitamin K antagonist) remains an established anticoagulant for patients at high risk of arterial and venous thromboembolism. The prompt reversal of the anticoagulant effect of warfarin is necessary in the context of major bleeding or emergency surgery because of its extended inhibition of vitamin K-dependent coagulation factors for days. The mainstay of urgent warfarin reversal has been vitamin K administration, and infusion of a three-factor prothrombin complex concentrate (3FPCC) and the option for the addition of fresh frozen plasma as a source of factor VII. With the upcoming introduction in Australia and New Zealand of a four-factor prothrombin complex concentrate (4FPCC), which replaces all the vitamin K-dependent clotting factors, this article updates the previously published warfarin reversal guidelines.
For urgent warfarin reversal, 4FPCC should be used instead of 3FPCC, using the same suggested dose. Vitamin K co-administration is still recommended for more sustained reversal.
The use of 4FPCC for urgent warfarin reversal obviates the need for co-administration of fresh frozen plasma.
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