Does integrated care reduce hospital activity for patients with chronic diseases? An umbrella review of systematic reviews

Abstract

ObjectiveTo summarise the evidence regarding the effectiveness of integrated care interventions in reducing hospital activity.DesignUmbrella review of systematic reviews and meta-analyses.SettingInterventions must have delivered care crossing the boundary between at least two health and/or social care settings.ParticipantsAdult patients with one or more chronic diseases.Data sourcesMEDLINE, Embase, ASSIA, PsycINFO, HMIC, CINAHL, Cochrane Library (HTA database, DARE, Cochrane Database of Systematic Reviews), EPPI-Centre, TRIP, HEED, manual screening of references.Outcome measuresAny measure of hospital admission or readmission, length of stay (LoS), accident and emergency use, healthcare costs.Results50 reviews were included. Interventions focused on case management (n=8), chronic care model (CCM) (n=9), discharge management (n=15), complex interventions (n=3), multidisciplinary teams (MDT) (n=10) and self-management (n=5). 29 reviews reported statistically significant improvements in at least one outcome. 11/21 reviews reported significantly reduced emergency admissions (15–50%); 11/24 showed significant reductions in all-cause (10–30%) or condition-specific (15–50%) readmissions; 9/16 reported LoS reductions of 1–7 days and 4/9 showed significantly lower A&E use (30–40%). 10/25 reviews reported significant cost reductions but provided little robust evidence. Effective interventions included discharge management with postdischarge support, MDT care with teams that include condition-specific expertise, specialist nurses and/or pharmacists and self-management as an adjunct to broader interventions. Interventions were most effective when targeting single conditions such as heart failure, and when care was provided in patients’ homes.ConclusionsAlthough all outcomes showed some significant reductions, and a number of potentially effective interventions were found, interventions rarely demonstrated unequivocally positive effects. Despite the centrality of integrated care to current policy, questions remain about whether the magnitude of potentially achievable gains is enough to satisfy national targets for reductions in hospital activity.Trial registration numberCRD42015016458.

From programme theory to logic models for multispecialty community providers: a realist evidence synthesis

“…In another example, clinicians spent less time transferring patients to other hospitals after the hospital at home initiative reduced admission and length of stay for other patients. 76 We found only one study 104 about whether or not in-reach into hospitals ensures timely discharge of patients, but it was a SR. It found that transition from hospital to home was most effective when interventions to expedite it were initiated during the inpatient phase and continued post discharge.…”

“…Half of the SRs quantified the reductions, giving figures ranging from 25% to 43%. 104 In a quantitative study of PACT PCMH implementation by the US VHA, Nelson et al 106 found that greater continuity of care (i.e. all other providers all working with and communicating with patient's primary care provider) was associated with lower likelihood of hospitalisation and mortality.…”

“…Two SRs 104,105 and one quantitative study 106 found that MDT working reduces hospital readmission rates. Two 104,106 of these studies described the importance of specialist involvement in the MDT, and two 105,106 described that of care co-ordinators.…”

“…Two 104,106 of these studies described the importance of specialist involvement in the MDT, and two 105,106 described that of care co-ordinators. An umbrella review 104 (a SR of SRs) of case management found that the CCM, discharge management, complex interventions, patient self-management and MDTs, particularly when they focused on one specific health condition [in particular heart failure and chronic obstructive pulmonary disease (COPD)] and included condition-specific specialists (medical, nursing, pharmacist), together decreased emergency admissions. Half of the SRs quantified the reductions, giving figures ranging from 25% to 43%.…”

The role of general practice in reducing unplanned hospital admissions

“…Studies of multi-disciplinary teams have also shown promising results, particularly for heart failure and COPD. (Damery et al, 2016) There is little evidence that the use of other integrated care interventions, including collaborative case management and specialist disease clinics, can lead to reduced admissions.…”