Background: Each year, >130,000 older Canadians living with frailty have major, inpatient
surgery. The presence of frailty, a multidimensional state of vulnerability, is strongly
associated with adverse outcomes. Compared to similar patients without frailty, surgical
patients with frailty experience a 2- to 5-fold adjusted increase in the odds of
mortality, complications, patient-reported disability, length of stay, readmissions and
non-home discharge. However, despite the growing number of patients with frailty
presenting for surgery each year, a recent systematic review from our team demonstrates
that there are no evidence-based, frailty-specific interventions available to drive
improvements in outcomes for this vulnerable population. A promising intervention to
support independence and maintain older people at home after surgery is Virtual Recovery
After Surgery (VRAS), an innovative multidisciplinary program that has been providing
post-discharge remote monitoring and virtual care for surgical patients since 2021.
Patients receive virtual care from the VRAS nursing and anesthesiologist team following
surgical discharge, facilitated by Cloud DX software and monitoring equipment. Based on
our team's joint expertise in frailty and Postoperative Virtual Care (PVC), the
investigators have identified: 1) a crucial gap in care expressed by older patients with
frailty (the need for support and continuity of care via telehealth resources to support
transition of care to their homes), and 2) an intervention that could directly fill this
gap (frailty tailored PVC).
Overarching Aim: The objective of the VICTORY Trial is to determine the effect of virtual
care with CloudDX technology compared to standard care to see if it can result in an
increase in the number of days alive and at home that older people with frailty
experience in the 30 days after planned surgery. A secondary aim is to estimate the
probability that enrollment in a frailty-tailored PVC program will reduce healthcare
resource use and improve patient-reported outcomes and safety.
Methods:
Design, setting and participants: The VICTORY Trial is a multicenter, innovative clinical
trial using an individual patient, parallel-arm randomized controlled trial design of
1,000 older patients living with frailty being discharged from hospital after elective
surgery.
People ≥60 years old with frailty having elective surgery will be included.
Intervention: Patients randomized to the PVC program will be monitored at home by virtual
nurses for at least 7 days after hospital discharge. Participants will be provided with a
hospital-to-home kit that contains the following technologies: tablet computer (with
stand), wrist-based blood pressure cuff (for blood pressure, pulse and breathing rate),
finger worn pulse oximeter (for measuring oxygen levels), thermometer (for temperature)
and weigh scale (to monitor weight). Monitoring will include video visits with a nurse on
post-discharge days 1, 3, 5 and 7 and every other day until post-discharge day 14 if
needed. Patients will be asked to complete a daily survey that will include questions
about any symptoms they may be experiencing, their independence/dependence with
activities of daily living, and their experience with the PVC program. Depending on the
patient's recovery (including the assessments and surveys described), patients may
receive information electronically on how to manage certain challenges (i.e., confusion,
not eating enough), their care may be escalated to a physician, or they may be instructed
to come to the hospital.
Outcomes and sample size: The primary outcome is the number of days that each patient
spends alive and at home following surgery. Secondary outcomes are: resource use (index
length of stay, readmission, total hospital days, emergency department visits, time to
first acute hospital care, cost of care), patient-centered outcomes (delirium (4AT),
quality of life (EQ- 5D-5L), pain interference (PROMIS), satisfaction (likelihood to
recommend), goal attainment, and overall quality of transitional care received), safety
(medication issues, incidence of post-discharge falls).
Based on trial simulations, the investigators estimate that the most likely number of
participants required will be 1000 (500 per arm), which is adequate to achieve at least
90% power to declare superiority (defined as probability of any benefit = 99% (P(Odds
Ratio (OR)>1) = 99%) when the effect size, expressed as an OR from a cumulative logistic
model, is 1.5 and the control group number of days alive at home within 30 days is 16.
Expertise: Our team features multidisciplinary clinical and methodological experts,
nationally representative knowledge users and patient representatives.
Expected outcomes: The VICTORY Trial will: 1) advance the practice of PVC using
evidence-based, frailty-tailored approaches; 2) evaluate this frailty-tailored PVC
intervention in direct partnership with patients; and 3) produce robust, potentially
practice-changing research using innovative clinical trial methodologies that will inform
implementation.