UPTAKE - Virtual Care: Virtual Home Hospital With Remote Monitoring to Reduce Acute Care Hospitalization (UPTAKE-VC)

May 11, 2026 updated by: University of Calgary

Using Personalized Risk and Digital Tools to Guide Transitions Following Acute Kidney Events - Virtual Care: Virtual Home Hospital With Remote Monitoring to Reduce Acute Care Hospitalization

Method: Randomized Controlled Trial Study Duration: 3 Years Study Centre(s) University of Calgary and University of Alberta Objectives: To fill care gaps by implementing strategies to reduce length of hospital stay, readmission rates, and improve long-term outcomes after Acute Kidney Injury (AKI). Number of Participants: Three Hundred and fifty four (n=354) Diagnosis and Main Inclusion Criteria: Hospitalized adults with AKI at high risk of hospital readmission or death

Study Intervention: Multi-component Digital Health Solutions, including:

  1. Computerized Clinical Decision Support (CDS) and
  2. Virtual Care Delivered through Hospital at Home (VC) Duration of administration: Determined by the Patient's clinical team Reference therapy: Usual Care Statistical Analyses: Descriptive Analysis, Regression

Study Overview

Status

Recruiting

Conditions

Intervention / Treatment

Detailed Description

  1. Background and Rationale

    Acute kidney injury (AKI) is a common and serious complication in hospitals. A major care gap for survivors of AKI is the fragmentation of care that exists as they transition from the hospital to their home. This contributes to a high risk of adverse long-term outcomes, including prolonged hospitalization, high rates of readmission, cardiovascular events, infections, progression to chronic kidney disease (CKD), kidney failure requiring dialysis, and death.

    To address this challenge, the investigators are implementing multi-component digital health solutions including Computerized Clinical Decision Support (CDS) and Digital Remote Patient Monitoring (dRPM) through Virtual Care (VC) programs in Alberta to reduce length of hospital stay and readmission rates and improve long-term outcomes after AKI.

    Evidence of the effectiveness of the two digital health solutions is available from Alberta and international clinical trials. Our team previously implemented a computerized CDS intervention for AKI risk assessment and prevention and achieved improved AKI prevention and reduced AKI incidence after cardiac procedures across the province. The investigators will use a similar approach to identify high risk patients with AKI and provide recommendations to improve the quality of their care, which is well suited to the evolving digital health infrastructure in Alberta.

    Providing hospital-level care at home through Virtual Care (VC) teams has been shown to reduce mortality and readmission rates. Alberta's VC program have existed in both Edmonton and Calgary since 2018 and have reported lower readmission rates, Emergency Department (ED) visits and use of Emergency Medical Services than observed with usual care. Patients reported that the program helped them regain their independence and function. Alberta's VC programs have implemented dRPM technology, which has been further associated with fewer days in hospital and emergency department visits. Patients reported better quality of care using this technology. The framework for dRPM and complex care planning is already in place in Alberta's Virtual Care programs. The investigators intend to utilize these programs to improve transitions of care through early facilitated discharge and enhanced follow-up of patients with AKI at high risk of hospital readmission, who require frequent monitoring and more intensive care strategies during this vulnerable period of transition in care.

  2. Research Question and Objectives

    • Implement and evaluate a transition of care intervention for patients with AKI.
    • Integrate digital health solutions that can achieve levels of monitoring and care in a patient's own home that are comparable to acute care, while transitioning care to the community setting.
    • Reduce the length of hospital stay and risk of hospital readmission for people with AKI.
    • Improve the long-term outcomes after hospitalization with AKI.
  3. Methods

The investigators will evaluate implementation initially in a Vanguard phase to establish feasibility and acceptability of the intervention, followed by an evaluation of implementation and effectiveness of the intervention in a larger Multicenter Randomized Controlled Trial (RCT). High risk patients with AKI and a predicted risk of readmission or death ≥20% will be identified using a Best Practice Alert (BPA) in Connect Care and participants will be randomized to care with or without virtual monitoring through the VC programs. All patients will receive the same baseline interventions refined in the Vanguard phase, while the intervention arm will additionally receive VC with dRPM following discharge.

High risk patients in the intervention arm will be navigated through the transition of care pathway by a trained nurse navigator. Patients will receive dRPM kits, and biometric data will be automatically uploaded to the web-based monitoring platform and reviewed by the nurse navigator. Patients will receive regular virtual assessments via telephone or videoconferencing (via the tablet) after in-patient discharge. Blood tests will be drawn at home by community paramedics as deemed necessary by the clinical team to assess kidney function and monitor for complications of AKI. Should concerns be identified that warrant in-person assessment, paramedic care teams will be sent for assessment and/or intervention. Upon completion of the intervention patients will be assessed for readiness to move to the subacute arms of the program and return to their primary care provider. If ongoing nephrologist or other specialist care is required, the nurse navigator will ensure appropriate follow up is arranged.

Study Type

Interventional

Enrollment (Estimated)

354

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Locations

  • Canada
    • Alberta
      • Calgary, Alberta, Canada, T2N 1N4
        • Recruiting
        • University of Calgary
        • Contact:
        • Principal Investigator:
          • Matthew T James, MD PhD FRCPC
      • Edmonton, Alberta, Canada, T6G 2G3
        • Recruiting
        • University of Alberta
        • Contact:
        • Principal Investigator:
          • Neesh Pannu, MD SM FRCPC

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Adult
  • Older Adult

Accepts Healthy Volunteers

No

Description

Inclusion Criteria:

  • Age ≥ 18 years old.
  • AKI identified in hospital using Kidney Disease Improving Global Outcomes (KDIGO) criteria17.
  • Hospitalization > 48 hours.
  • LACE (L= Length patient Stay in the hospital, A= Acuity of Admission of patient in the hospital, C= Comorbidity and E= Emergency Visit.) Score 12 or higher.
  • Meets all inclusion criteria of Virtual Home Hospital programs of Calgary and Edmonton zones.

Exclusion Criteria:

  • Non-Alberta residents.
  • Resides outside the catchment areas for the Calgary and Edmonton Virtual Home Hospital programs.
  • C1 or C2 goals of care.
  • Hospitalization > 30 days.
  • Will be discharged to long-term care.
  • Kidney failure receiving dialysis.
  • Already admitted in Virtual Home Hospital Program

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Health Services Research
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Single

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Virtual Care
Participants will receive virtual care through Virtual Home Hospital programs in Alberta for their hospital to home transition of care.
Other: Virtual Care
Participants will go through Virtual hospital programs following the processes established by these programs in Alberta.
No Intervention: Usual Care
Participants will be discharged as per usual care practices from hospital to their home.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
the number of days alive out of hospital
Time Frame: Up to 45 days from the date of randomization
the number of days alive out of hospital
Up to 45 days from the date of randomization

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
the time as inpatient in hospital
Time Frame: Up to 45 days from the date of randomization
the time as inpatient in hospital
Up to 45 days from the date of randomization
death
Time Frame: from the date of randomization up to 45 days, or date of death from any cause, whichever came first,
death records from health administrative data.
from the date of randomization up to 45 days, or date of death from any cause, whichever came first,
hospital readmission
Time Frame: Up to 45 days from the date of randomization
hospital readmission records from health administrative data.
Up to 45 days from the date of randomization
Emergency Department visits
Time Frame: Up to 45 days from the date of randomization
Emergency Department visit records from health administrative data.
Up to 45 days from the date of randomization
Estimated Glomerular Filtration (eGFR)
Time Frame: At 90 days after the date of randomization
eGFR
At 90 days after the date of randomization
Urine Albumin Creatinine Ration (ACR)
Time Frame: At 90 days after the date of randomization
ACR laboratory test
At 90 days after the date of randomization
total number of physician visits
Time Frame: Up to 45 days from the date of randomization
total number of physician visits
Up to 45 days from the date of randomization
number of physician visits by specialty
Time Frame: Up to 45 days from the date of randomization
primary care vs. non-primary care
Up to 45 days from the date of randomization
Changes to medication prescription
Time Frame: Up to 45 days from the date of randomization
Changes to medication prescription (including starting, stopping, or dose adjustment) of an Angiotensin-Converting Enzyme Inhibitors (ACEI)/Angiotensin receptor blockers (ARB), diuretic, SGLT2 inhibitor, or NSAID or administration of IV fluid
Up to 45 days from the date of randomization
laboratory testing
Time Frame: Up to 45 days from the date of randomization
Number of creatinine/eGFR, electrolytes, and urine protein quantification
Up to 45 days from the date of randomization
patient experience care transition measure
Time Frame: At 45 days after the date of randomization
Online Survey
At 45 days after the date of randomization
Euro Qol- 5 Dimension (EQ5D)
Time Frame: At 45 days after the date of randomization
Online Survey to assess quality of life mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each dimension is scored on a 5-level severity ranking that ranges from "no problems" to "extreme problems
At 45 days after the date of randomization

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

University of Calgary

Collaborators

Alberta Health services

Investigators

  • Principal Investigator: Matthew James, MD, University of Calgary

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

August 10, 2024

Primary Completion (Estimated)

August 10, 2026

Study Completion (Estimated)

October 31, 2026

Study Registration Dates

First Submitted

July 29, 2024

First Submitted That Met QC Criteria

August 2, 2024

First Posted (Actual)

August 5, 2024

Study Record Updates

Last Update Posted (Actual)

May 14, 2026

Last Update Submitted That Met QC Criteria

May 11, 2026

Last Verified

April 1, 2026

More Information

Terms related to this study

Additional Relevant MeSH Terms

Other Study ID Numbers

  • REB23-0762

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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