The effectiveness of interventions to achieve coordinated multidisciplinary

care and reduce hospital use for people with chronic diseases

Progress to date and methodological challenges

Outline • Background to the ‘overview study’ • Aim and objectives • Selection of outcome measures • Methods and data analysis • Preliminary findings: hospitalisation • Methodological challenges

– Double counting of primary studies – Excluding studies on the basis of quality score – Grouping studies with similar interventions

Background • People with chronic diseases often require care crossing

multiple health and social care settings • These patients typically experience fragmented and poorly

coordinated management of their conditions • There will be a significant increase in the number of patients

with chronic diseases in the coming years, and associated increase in costs of management

• Government policy increasingly emphasises integrated care and developing new models of delivering healthcare services e.g. Better Care Fund

• Yet there is a paucity of evidence about what works, for which patients, in which settings, and for which outcomes

Aim and objectives Aim: To assess the effectiveness of interventions and integrated management models for chronic disease in terms of service provider and patient outcomes Objectives: 1. Describe and review the conceptual frameworks being used

to define integrated models of care for chronic disease 2. Describe and evaluate trends in service provision 3. Assess which models or individual elements are particularly

effective in delivering improved provider and patient outcomes

4. Identify gaps in the evidence base where further targeted systematic reviews of primary research may be useful

Selection of outcome measures Service providers: • Stakeholder meeting with representatives from each of

the Theme 4 case study sites, CCGs and others • Discussion to establish which questions and outcomes

are the most important to providers Patients: • Literature review to inform a short survey • List of commonly reported patient outcomes derived and

given to patients via CLAHRCWM PPI database • Input from Theme 4 PPI representative

Outcome measures chosen: • Healthcare utilisation: Including (re)admission rates,

length of hospital stay, A&E visits, clinic and GP resource use, institutionalisation rates

• Costs: Healthcare costs or savings from interventions

• Quality of life: Generic or disease specific measures

• Patient satisfaction: Impact of interventions or service models on patient satisfaction with care

• Care coordination: Interventions or service models which assess the effectiveness of providing care coordination and ‘patient centered’ care

Search strategy Medline Cochrane Library and DARE

Medline in Process Health Economics Evaluations Database

Applied Social Sciences Index and Abstracts (ASSIA)

TRIP database (systematic reviews and evidence synthesis)

PsycINFO PROSPERO

Health Management Information Consortium Web based searches

CINAHL EPPI-Centre Library

Embase Reference lists of included papers

Inclusion and exclusion criteria INCLUSION CRITERIA EXCLUSION CRITERIA

Published during or since 2000 Reviews with unsystematic methods

Published in English language Studies focusing on caregivers

Systematic reviews, meta-analysis, narrative reviews

Editorials, opinion pieces, commentaries, letters, conference proceedings

Comparison group includes usual care, no intervention or other interventions

Studies assessing integration in less economically developed countries

Adult patients with one or more chronic diseases Palliative or end of life care

Assess care models or interventions crossing the boundary between two or more healthcare settings

Interventions solely psychosocial or related to spirituality, mindfulness, health literacy or the use of CAM

Include data related to one or both provider outcomes and/or one or both patient outcomes

Interventions relating solely to lifestyle change or treatment/medication adherence

Study selection • Removal of duplicate records • Two reviewers screen titles and abstracts for relevance • Relevant reviews proceed to full text evaluation • Two reviewers screen full texts for outcomes of interest • Data extraction and quality assessment according to

pre-defined forms • For grey literature, relaxation of strict criteria on

methodological robustness and systematic methods • All disagreements resolved by discussion or arbitration

by a third reviewer if necessary

Data extraction Reference ID Research questions Who delivers the intervention?

Citation Study designs included Who co-ordinates the intervention?

Country of publication Number of studies included Source of intervention

Databases and search years Type of review Length of follow-up

Geographical scope Definition of intervention Intervention context

Language restriction Study population Primary and secondary outcomes

Healthcare setting(s) Number of participants Data on our outcomes of interest

Chronic disease(s) General description of intervention

Review summary and conclusions

Overall aim of review Specific features of intervention Any other information

Quality assessment • Centre for Evidence Based Medicine checklist: 5

questions, total score from 0-5 (5 = high quality) 1. Is the research question clearly stated? 2. Is it unlikely that important, relevant studies were

missed? 3. Were the inclusion criteria appropriate? 4. Were included studies sufficiently valid for the type of

question asked? 5. Were results similar from study to study?

Records from databases n=10,682

Records from other sources

n=11

After duplicate removal n=7,747

Titles and abstracts screened

n=7,747

Full text articles assessed

n=353

Included reviews n=81

Removal of duplicates n=2,946

Excluded after title and abstract screen

n=7,394

Full text articles

excluded n=272

Review characteristics • 81 reviews eligible for data extraction

• All published between 2004 to 2014

• 45 covered 3+ settings; 2 primary and secondary care, 8 primary and community/social care/home, 24 secondary care and community/social care/home

• 22 general chronic disease; 59 covered individual or multiple specific conditions

• Number of primary studies ranged from 4 to 560

• 45 narrative reviews, 32 systematic reviews with meta-analysis, 4 reviews of reviews

• Interventions highly heterogeneous in design, intensity, duration and outcomes reported

Methodological challenges

•Double counting of primary studies •Excluding papers on the basis of quality score •Grouping of interventions

Double counting • 81 reviews include a total of 1293 primary studies

• The same primary studies frequently occur in more than one included review

• Potentially problematic when synthesising results from multiple reviews on the same intervention

• Artificial inflation of effect size and over-estimation of effectiveness of intervention or service model

586

103

41 22 13 3 2 5 2 8 5 0

100

200

300

400

500

600

700

1 2 3 4 5 6 7 8 9 10 11

Number of times a single reference is cited

0

2

4

6

8

10

12

14

16

0 to 9 10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79 80 to 89 90 to 100

Num

ber o

f rev

iew

s

Percentage of references duplicated

Proportion of references duplicated, by review

Potential solutions • In a given intervention category, select only the most

recent high quality review and exclude previous reviews (after checking conclusion agreement)

• Only include reviews that had RCTs as their primary study design

• Include only studies with meta-analyses • Subdivide reviews on a specific intervention by time-

band (i.e. 2000-2005, 2005-2010, 2010-present) and analyse change in outcome over time for ‘drift’ in results

Excluding on QA score

QA SCORE NUMBER OF REVIEWS

1 3

1.5 7

2 6

2.5 5

3 14

3.5 8

4 20

4.5 5

5 13

• 21 of 81 reviews have QA score less than 3/5

• Real difference in quality at this cut-off point

• Very little, if any outcomes data can be extracted from the low scoring reviews

• Restrict inclusion to reviews with higher quality evidence?

Grouping interventions • Interventions could be categorised in an almost infinite

number of ways and most interventions overlap Professional

interventions

Financial or regulatory

interventions Organisational interventions

Provider orientated

Professional role change; MD teams;

service integration; continuity of

care

Patient orientated

Consumer participation in care governance; self-management

e.g. professional education

e.g. provider incentives or

penalties

Structural Changes to setting/site of service delivery; changes in medical record systems

0 studies 0 studies Nearly all included studies have elements of each

Top down… Category Case

manage-ment

Discharge planning

Shared care Care planning

Disease manage-ment

MD care

Integrated care

Revision of professional roles

✓ ✓ ✓ ✓ ✓ ✓

MDTs ✓ ✓ ✓ ✓ ✓ ✓ ✓

Formal service integration ✓ ✓ ✓ ✓ ✓ ✓ ✓

Continuity of care ✓ ✓ ✓ ✓ ✓ ✓

Self-management ✓ ✓ ✓ ✓ ✓

Changes to setting of service delivery

✓ ✓ ✓ ✓ ✓

Bottom up…

Recipient Facilitator(s) Key strategies

Method of contact Intensity

• Patient • Caregiver • Physician

• Nurse • MDT • OT/PT • Dietician • Social

worker • GP • Specialist

• Education • Advice • Goal

setting • Managing

risk factors

• Care plans

• In person home visit

• Phone • In person

clinic visit • Remotely

• Frequency • Duration • Complexity

(Re)admissions summary findings POSITIVE MIXED +ve / -ve NO DIFFERENCE

Prof. roles • Nurse led care (2)

MDTs • Pharmacist-led (1) • MDT (1)

Continuity of care

• Shared care (1) • Discharge man. (3)

• Transitional care hospital to home (4)

• Case man. (4) • Shared care (1) • Discharge man. (2)

Self-management

• Self-management (2) • Self-management (1)

Change to setting of service delivery

• Hospital at home (1) • Specialist HF clinics (1)

• Early supported discharge (1)

• Primary care follow up (1)

• E-health (1) • Early supported

discharge (1) • Primary c. f-up (1)

Formal service integration

• Comm. Based care (1) • Disease management

(5) • Integrated care (1)

• Disease management (6) • Integrated care (2)