Integrated care for older people: methodological issues in conducting a systematic literature review

Rethinking Integrated Care: A Systematic Hermeneutic Review of the Literature on Integrated Care Strategies and Concepts

Policy Points Integrated care is best understood as an emergent set of practices intrinsically shaped by contextual factors, and not as a single intervention to achieve predetermined outcomes. Policies to integrate care that facilitate person-centered, relationship-based care can potentially contribute to (but not determine) improved patient experiences. There can be an association between improved patient experiences and system benefits, but these outcomes of integrated care are of different orders and do not necessarily align. Policymakers should critically evaluate integrated care programs to identify and manage conflicts and tensions between a program's aims and the context in which it is being introduced.

CONTEXT

Integrated care is a broad concept, used to describe a connected set of clinical, organizational, and policy changes aimed at improving service efficiency, patient experience, and outcomes. Despite examples of successful integrated care systems, evidence for consistent and reproducible benefits remains elusive. We sought to inform policy and practice by conducting a systematic hermeneutic review of literature covering integrated care strategies and concepts.

METHODS

We used an emergent search strategy to identify 71 sources that considered what integrated care means and/or tested models of integrated care. Our analysis entailed (1) comparison of strategies and concepts of integrated care, (2) tracing common story lines across multiple sources, (3) developing a taxonomy of literature, and (4) generating a novel interpretation of the heterogeneous strategies and concepts of integrated care.

FINDINGS

We identified four perspectives on integrated care: patients' perspectives, organizational strategies and policies, conceptual models, and theoretical and critical analysis. We subdivided the strategies into four framings of how integrated care manifests and is understood to effect change. Common across empirical and conceptual work was a concern with unity in the face of fragmentation as well as the development and application of similar methods to achieve this unity. However, integrated care programs did not necessarily lead to the changes intended in experiences and outcomes. We attribute this gap between expectations and results, in part, to significant misalignment between the aspiration for unity underpinning conceptual models on the one hand and the multiplicity of practical application of strategies to integrate care on the other.

CONCLUSIONS

Those looking for universal answers to narrow questions about whether integrated care "works" are likely to remain disappointed. Models of integrated care need to be valued for their heuristic rather than predictive powers, and integration understood as emerging from particular as well as common contexts.

Integrated Care Search: development and validation of a PubMed search filter for retrieving the integrated care research evidence

Background

Integrated care is an increasingly important principle for organising healthcare. Integrated care models show promise in reducing resource wastage and service fragmentation whilst improving the accessibility, patient-centredness and quality of care for patients. Those needing reliable access to the growing research evidence base for integrated care can be frustrated by search challenges reflective of the topic’s complexity. The aim of this study is to report the empirical development and validation of two search filters for rapid and effective retrieval of integrated care evidence in PubMed. One filter is optimised for recall and the other for precision.

Methods

An Expert Advisory Group comprising international integrated care experts guided the study. A gold standard test set of citations was formed from screening Handbook Integrated Care chapter references for relevance. This set was divided into a Term Identification Set (20%) for determining candidate terms using frequency analysis; a Filter Development Set (40%) for testing performance of term combinations; and a Filter Validation Set (40%) reserved for confirming final filter performance. In developing the high recall filter, recall was steadily increased while maintaining precision at ≥50%. Similarly, the high precision filter sought to maximise precision while keeping recall ≥50%. For each term combination tested, an approximation of precision was obtained by reviewing the first 100 citations retrieved in Medline for relevance.

Results

The gold standard set comprised 534 citations. The search filter optimised for recall (‘Broad Integrated Care Search’) achieved 86.0–88.3% recall with corresponding low precision (47–53%). The search filter optimised for precise searching (‘Narrow Integrated Care Search’) demonstrated precision of 73–95% with recall reduced to between 55.9 and 59.8%. These filters are now available as one-click URL hyperlinks in the website of International Foundation for Integrated Care.

Conclusions

The Broad and Narrow Integrated Care Search filters provide potential users, such as policy makers and researchers, seamless, reliable and ongoing access to integrated care evidence for decision making. These filters were developed according to a rigorous and transparent methodology designed to circumvent the challenges of information retrieval posed by this complex, multifaceted topic.

Finding the Integrated Care Evidence Base in PubMed and Beyond: A Bibliometric Study of the Challenges

Introduction:

Integrated care research evidence should be optimally visible and accessible to stakeholders. This study examines the contribution of specific databases to the discovery of integrated care evidence, and tests the usefulness of Medical Subject Heading (MeSH) indexing of this literature within PubMed.

Methods:

We used bibliometric methods to analyse the integrated care literature indexed within six databases between 2007 and 2016. An international expert advisory group assessed the relevance of citations randomly retrieved from PubMed using MeSH term ‘Delivery of Health Care, Integrated’.

Results:

Integrated care evidence is diffuse, spread across many journals. Between 2007 and 2016, integrated care citations grew substantially, with the rate of increase highest in Embase. PubMed contributes the largest proportion of unique citations (citations not included in any of the other databases analysed), followed by Embase, PsycINFO and CINAHL. On average, expert reviewers rated 42.5% of citations retrieved by MeSH term ‘Delivery of Health Care, Integrated’ as relevant to integrated care. When these citations were dual reviewed, inter-rater agreement was low.

Conclusion:

MeSH terms alone are insufficient to retrieve integrated care content from PubMed. Embase and CINAHL contain unique content not found in PubMed that should not be overlooked. A validated search filter is proposed to simplify the process of finding integrated care research for clinicians, managers and decision-makers.

Systematic review of the effectiveness, barriers and facilitators to general practitioner engagement with specialist secondary services in integrated palliative care

The general practitioner (GP) has a critical role in an integrated model of palliative care as they often know the patient and carer well, are experts in generalist care and have knowledge of health and social services in the community. Specialist palliative services have insufficient capacity to meet demand and those with non-cancer terminal conditions and those from rural and remote areas are underserved. Research has focused on improving access to palliative care by engaging the GP with specialist secondary services in integrated palliative care.

OBJECTIVES

(1) Evaluate the effectiveness of interventions designed to engage GPs and specialist secondary services in integrated palliative care; and (2) identify the personal, system and structural barriers and facilitators to integrated palliative care.

METHOD

MEDLINE, EMBASE and CINAHL were searched. Any study of a service that engaged the GP with specialist secondary services in the provision of palliative care was included. GP engagement was defined as any organised cooperation between the GP and specialist secondary services in the care of the patient including shared consultations, case conferences that involved at least both the GP and the specialist clinician and/or other secondary services, and/or any formal shared care arrangements between the GP and specialist services. The specialist secondary service is either a specialist palliative service or a service providing specialist care to a palliative population. A narrative framework was used to describe the findings.

RESULTS

17 studies were included. There is some evidence that integrated palliative care can reduce hospitalisations and maintain functional status. There are substantial barriers to providing integrated care. Principles and facilitators of the provision of integrated palliative care are discussed.

CONCLUSIONS

This is an emerging field and further research is required assessing the effectiveness of different models of integrated palliative care.

The effectiveness of inter-professional working for older people living in the community: a systematic review

Health and social care policy in the UK advocates inter-professional working (IPW) to support older people with complex and multiple needs. Whilst there is a growing understanding of what supports IPW, there is a lack of evidence linking IPW to explicit outcomes for older people living in the community. This review aimed to identify the models of IPW that provide the strongest evidence base for practice with community dwelling older people. We searched electronic databases from 1 January 1990-31 March 2008. In December 2010 we updated the findings from relevant systematic reviews identified since 2008. We selected papers describing interventions that involved IPW for community dwelling older people and randomised controlled trials (RCT) reporting user-relevant outcomes. Included studies were classified by IPW models (Case Management, Collaboration and Integrated Team) and assessed for risk of bias. We conducted a narrative synthesis of the evidence according to the type of care (interventions delivering acute, chronic, palliative and preventive care) identified within each model of IPW. We retrieved 3211 records and included 37 RCTs which were mapped onto the IPW models: Overall, there is weak evidence of effectiveness and cost-effectiveness for IPW, although well-integrated and shared care models improved processes of care and have the potential to reduce hospital or nursing/care home use. Study quality varied considerably and high quality evaluations as well as observational studies are needed to identify the key components of effective IPW in relation to user-defined outcomes. Differences in local contexts raise questions about the applicability of the findings and their implications for practice. We need more information on the outcomes of the process of IPW and evaluations of the effectiveness of different configurations of health and social care professionals for the care of community dwelling older people.

Nurses' responses to suicide and suicidal patients: a critical interpretive synthesis

AIMS AND OBJECTIVES

To provide an inclusive understanding of nurses' responses to suicide and suicidal patients that can benefit nursing practice and guide research. The question was 'What is a critical interpretive synthesis of accumulated nursing research on nurses' responses to suicide and suicidal patients?'

BACKGROUND

Various studies address nurses' responses to suicide and suicidal patients. An understanding of accumulated research-based literature about nurses' responses to suicide and suicidal patients may guide nurses to care for suicidal patients in ways that facilitate suicide prevention and recovery.

DESIGN

The design is reflexive and iterative.

METHOD

A Critical Interpretive Synthesis was conducted, which comprised of six phases: formulating the review question, searching the literature, sampling, determining quality, extracting data and conducting an interpretive synthesis. Qualitative content analysis and systematic review of literature was included in these phases.

RESULTS

The results report the review question, literature review strategies, purposive sample (26 full-text studies published in peer reviewed journals, 1988-July 2009, conducted mostly in Europe and North American), quality determinants, data extraction into themes and an interpretive synthesis of four key concepts, i.e. critical reflection, attitudes, complex knowledge/professional role responsibilities, desire for support services/resources.

CONCLUSION

This understanding of accumulated research-based literature enhances contextual, conceptual and methodological perspectives. Contextually, gaps exist in international research. Conceptually, the four key concepts can serve as a useful guide for nurses to understand their own and other nurses' responses to caring for suicidal patients in various settings. Methodologically, the Critical Interpretive Synthesis approach moved a small body of knowledge that varied in quality measures beyond an aggregate understanding.

RELEVANCE TO CLINICAL PRACTICE

Understanding nurses' responses to suicide and suicidal patients may guide nurses to care for suicidal patients in ways that facilitate suicide prevention and recovery, thus addressing the urgent work of suicide prevention in the world.

Integrated care for severely disabled long-term care facility residents: is it better?

The demands of long-term care facilities (LTCFs) residents are complex which usually require a range of professionals and caregivers to provide treatment and care. To reduce this fragmentation of care, integrated care models are developed in modern health care system, and a gradual change from traditional LTCF care to integrated care has occurred in many countries. Although integrated care is assumed to improve the quality of care, evidences supporting these effects are insufficient. We recruited 7 private LTCF (74 residents) in northern Taipei and randomized them into integrated care model (N=42, mean age=82.8+/-8.0 years, 54.8% males) and traditional model (N=32, 81.7+/-8.8 years, 43.8% males). Integrated care model group was provided an actively working interdisciplinary team in addition to traditional nursing and personal care in traditional model group. Physical function, nutritional status and several quality indicators (unplanned feeding tube replacement, unplanned urinary catheter replacement, pneumonia, urinary tract infection and so on) were compared with both groups. Overall, LTCF residents in the integrated care model group showed significant improvement in serum levels of albumin (3.78+/-0.32 vs. 3.60+/-0.45, p=0.004) and hemoglobin (12.62+/-1.58 vs. 12.03+/-1.24, p=0.004) during the study period. Among selected quality indicators, subjects in integrated care model group were similar to traditional model group except that integrated care model group had a significantly reduced unplanned feeding tube replacement rate. In conclusion, the clinical effectiveness of integrated care model among severly disabled LTCF residents is minimal and a further cost-effectiveness study is needed to promote optimal quality of care in this setting.

Is integrated nursing home care cheaper than traditional care? A cost comparison

BACKGROUND

It is generally assumed that integrated care has a cost-saving potential in comparison with traditional care. However, there is little evidence on this potential with respect to integrated nursing home care.

AIMS AND OBJECTIVES

DESIGN/METHODS/SETTINGS/PARTICIPANTS: Between 1999 and 2003, formal and informal caregivers of different nursing homes in the Netherlands recorded activities performed for residents with somatic or psycho-social problems. In total, 23,380 lists were analysed to determine the average costs of formal and informal care per activity, per type of resident and per nursing home care type. For formal care activities, the total personnel costs per minute (in Euro) were calculated. For informal care costs, two shadow prices were used.

RESULTS

Compared to traditional care, integrated care had lower informal direct care costs per resident and per activity and lower average costs per direct activity (for a set of activities performed by formal caregivers). The total average costs per resident per day and the costs of formal direct care per resident, however, were higher as were the costs of delivering a set of indirect activities to residents with somatic problems.

CONCLUSIONS

The general assumption that integrated care has a cost-saving potential (per resident or per individual activity) was only partially supported by our research. Our study also raised issues which should be investigated in future research on integrated nursing home care.

Older persons' experiences of whole systems: the impact of health and social care organizational structures

AIMS

An in-depth case study of whole systems working.

BACKGROUND

This paper reports on the second part of a two-part study exploring whole systems working. Part 1 of the study focused on an in-depth review of the literature pertaining to continuity of care and service integration. The second part, reported here, focused on an in-depth case study of one whole system. Evaluation Informed by the findings of part 1 of the study, data collection methods included in-depth interviews, real-time tracking of 18 older people, focus groups and consensus conferencing. Different data sets were analysed individually and synthesized using matrices derived from the literature review findings.

KEY ISSUE

Key themes from data synthesis include: (1) access to the most appropriate services; (2) service fragmentation; (3) continuity of care; and (4) routinized care.

CONCLUSIONS

The four themes of the case study reflect the need to address issues of demarcation of professional responsibilities, complicated channels of communication, information flows, assessment and reassessment in whole systems working.

IMPLICATIONS FOR NURSING MANAGEMENT

The impact of disempowering relationships on actual continuity of care and perceptions of quality among service users and providers. Lessons need to be learnt from specialist services and applied to service delivery in general.