The effectiveness of interventions to achieve co-ordinated multidisciplinary care and reduce hospital use for people with chronic diseases: study protocol for a systematic review of reviews

Navigating outpatient care of patients with type 2 diabetes after hospital discharge - a qualitative longitudinal study

BACKGROUND

The transition from hospital to outpatient care is a particularly vulnerable period for patients as they move from regular health monitoring to self-management. This study aimed to map and investigate the journey of patients with polymorbidities, including type 2 diabetes (T2D), in the 2 months following hospital discharge and examine patients' encounters with healthcare professionals (HCPs).

METHODS

Patients discharged with T2D and at least two other comorbidities were recruited during hospitalization. This qualitative longitudinal study consisted of four semi-structured interviews per participant conducted from discharge up to 2 months after discharge. The interviews were based on a guide, transcribed verbatim, and thematically analyzed. Patient journeys through the healthcare system were represented using the patient journey mapping methodology.

RESULTS

Seventy-five interviews with 21 participants were conducted from October 2020 to July 2021. The participants had a median of 11 encounters (min-max: 6-28) with HCPs. The patient journey was categorized into six key steps: hospitalization, discharge, dispensing prescribed medications by the community pharmacist, follow-up calls, the first medical appointment, and outpatient care.

CONCLUSIONS

The outpatient journey in the 2 months following discharge is a complex and adaptive process. Despite the active role of numerous HCPs, navigation in outpatient care after discharge relies heavily on the involvement and responsibilities of patients. Preparation for discharge, post-hospitalization follow-up, and the first visit to the pharmacy and general practitioner are key moments for carefully considering patient care. Our findings underline the need for clarified roles and a standardized approach to discharge planning and post-discharge care in partnership with patients, family caregivers, and all stakeholders involved.

Development and implementation of multicomponent homecare interventions for multimorbid and frail older people based on Information and Communication Technologies: The MULTIPLAT_AGE project

The prevention and treatment of frailty condition among multimorbid older adults, in community and hospital settings, is becoming a healthcare priority. Growing evidence suggests that a multidimensional approach could help not only in the early identification of older patients' needs but also in designing personalized preventive interventions. However, in clinical practice, the effectiveness of such interventions is limited by a lack of continuity of care and poor compliance of patients. The widespread diffusion of the information and communication technology (ICT) could offer an excellent way to implement and monitor multidimensional and personalized interventions for multimorbid older adults. In this scenario, the MULTIPLAT_AGE, is a network project involving five research centers with the main objective to supply multidimensional interventions targeted to cognitive, motor, pharmacological, and functional domains including ICT-based: i) transitional care model from the hospital to a protected home area; ii) automatic home-care system to improve activities of daily living; iii) program to improve appropriate drug prescription in nursing-home residents; iv) tele-rehabilitation program to reduce the risk of falls and v) cognitive stimulation delivered by remote in older adults with neurological disorders. Each project is linked to the others by employing a shared online platform, in a perspective of technological-supplied multicomponent interventions according to the concept of "aging in place" as the best solution for the treatment and healthcare of older people. Here we describe the general framework of the MULTIPLAT_AGE, and we examine every single project, pointing out innovative aspects, and discussing the expected results.

The PRO-HOME Project. A multicomponent intervention for the protected discharge from the hospital of multimorbid and polytreated older individuals by using innovative technologies: A pilot study

BACKGROUD

Discharge planning from the hospital of frail older patients is an important step to avoid inappropriate long-stay hospitalizations and to prevent the risks related to the prolonged hospitalization. In this frame, we developed an experimental trial-'PRO-HOME', a multicomponent programme of interventions for multimorbid and polytreated hospitalized older patients.

AIM

The main aim of the study was to develop a protected discharge facility using a mini apartment equipped with advanced architectural and technological components to reduce the length of hospital stay of older participants (aged 65+ years old) admitted to the hospital for an acute event, deemed stable and dischargeable.

MATERIALS AND METHODS

This is a pilot randomized controlled study, comparing 30 hospitalized participants included in a multidimensional, transitional care programme based on information and communication technologies to 30 patients in standard usual care until hospital discharge.

RESULTS

We presented the study design of the PRO-HOME programme, including architectural and technological components, the enrolment procedures, the components of the intervention that is physical activity, cognitive training and life-style education and the evaluation method of the intervention based on the Comprehensive Geriatric Assessment to explore the changes in the individual domains that are target of the multicomponent intervention.

CONCLUSIONS

The final results will suggest whether the PRO-HOME programme represents a useful and feasible intervention to reduce the length of hospital stay of multimorbid and polytreated hospitalized older patients and improve their physical and cognitive performances and overall quality of life.

PATIENT OR PUBLIC CONTRIBUTION

Due to the characteristics of the population of interest of the PRO-HOME study, we involved in the study design and programme of the activities the participants enrolled in a previous smart home-based project named MoDiPro carried-out during a 3-year period. The elderly participants from the local population involved were asked, by means of focus groups, for feedback on their experience in MoDiPro, and their suggestions were integrated into the design phase of the current PRO-HOME project. The focus groups included open group interviews with a qualitative collection of the patients' feedback so that the participants could interact with each other.

Effect of Tuberculosis (TB) and Diabetes mellitus (DM) integrated healthcare on bidirectional screening and treatment outcomes among TB patients and people living with DM in developing countries: a systematic review

A systematic review (Prospero CRD42017075562) including articles published between 1 January 1990 and 31 October 2021 was performed to synthesize evidence on the effect of integrating tuberculosis (TB) and diabetes mellitus (DM) healthcare on screening coverage and treatment loss to follow-up as compared to non-integrated care services for TB and DM in low- to middle-income countries (LMICs). Searches were performed in PubMed, Web of Science, WHO Global Index Medicus, and Cochrane Central Library. This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and we adopted Cochrane data collection form for Randomized Controlled Trials (RCTs) and non-RCTs. Due to heterogeneity and limited data of studies included, meta-analysis was not performed. Of 6902 abstracts, 10 studies from South America, Asia, and Africa were included. One study from Zimbabwe showed 57% increase in DM screening among TB patients in integrated care as compared to non-integrated care; 95% CI: 54.1, 59.8. Seven studies with before-after comparison groups reported increased screening coverage during implementation of integrated healthcare that ranged from 10.1% in Mexico to 99.1% in China. Three studies reported reduction in loss to follow-up among TB patients in integrated care; two in China showed 9.2%, 95% CI: -16.7, -1.7, and -9.5%, 95% CI: -18.4, -0.7 differences, while a study from Mexico showed -5.3% reduction, 95% CI: -9.8, -0.9.With few and heterogenous included studies, the synthesized evidence is weak to establish effect of TB/DM integrated care. Therefore, further robust studies such as randomized clinical trials and well-designed observational studies are needed.

Evaluating Implementation and Outcomes of a Person-Centered Care Model for People with Dementia in the Rehabilitation In-Patient Setting: Project Protocol

BACKGROUND

While Australian guidelines promote person-centered healthcare (PCC) for persons with dementia, healthcare systems, routines, rules, and workplace cultures can pose challenges in the provision of PCC.

OBJECTIVE

To present a knowledge translation protocol of the PCC model in a sub-acute rehabilitation hospital.

METHODS

The two-year pre/post/follow-up translation project will include (n = 80) persons with dementia, (n = 80) adult family/carers of patient participants, (n = 60) healthcare staff (medical, nursing, allied health), and (n = 8) PCC staff champions. Champions will complete six half-days' training in PCC. Medical, nursing, and allied health staff will be provided with PCC learning manuals, complete six hours of online PCC education and attend six face-to-face PCC education sessions. Champions will provide ongoing support to staff in PCC practice. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework will be used to evaluate: i) outcomes for prospective patients provided with PCC, compared with a matched sample of retrospective patients (primary outcomes agitation incidence and severity); 2) champion and staff PCC knowledge, confidence, engagement, and practice quality; 3) person, family/carer, champion, and staff satisfaction with PCC; 4) PCC costs and benefits; and 5) organizational structures, systems and policies required to implement and maintain PCC in sub-acute healthcare.

RESULTS

We will identify if PCC benefits persons with dementia, staff, and healthcare services, and we will generate evidence on the educational and organizational resources required to embed PCC in practice.

CONCLUSION

Project findings will inform tailored PCC education applications for dissemination in healthcare and produce evidence-based PCC practice guidelines to improve healthcare for persons with dementia.

Challenges in Implementing Community-Based Healthcare Teams in a Low-Income Country Context: Lessons From Ethiopia's Family Health Teams

BACKGROUND

Addressing chronic diseases and intra-urban health disparities in low- and middle-income countries (LMICs) requires new health service models. Team-based healthcare models can improve management of chronic diseases/complex conditions. There is interest in integrating community health workers (CHWs) into these teams, given their effectiveness in reaching underserved populations. However healthcare team models are difficult to effectively implement, and there is little experience with team-based models in LMICs and with CHW-integrated models more generally. Our study aims to understand the determinants related to the poor adoption of Ethiopia's family health teams (FHTs); and, raise considerations for initiating CHW-integrated healthcare team models in LMIC cities.

METHODS

Using the Consolidated Framework for Implementation Research (CFIR), we examine organizational-level factors related to implementation climate and readiness (work processes/incentives/resources/leadership) and system-level factors (policy guidelines/governance/financing) that affected adoption of FHTs in two Ethiopian cities. Using semi-structured interviews/focus groups, we sought implementation perspectives from 33 FHT members and 18 administrators. We used framework analysis to deductively code data to CFIR domains.

RESULTS

Factors associated with implementation climate and readiness negatively impacted FHT adoption. Failure to tap into financial, political, and performance motivations of key stakeholders/FHT members contributed to low willingness to participate, while resource constraints restricted capacity to implement. Workload issues combined with no financial incentives/perceived benefit contributed to poor adoption among clinical professionals. Meanwhile, staffing constraints and unavailability of medicines/supplies/transport contributed to poor implementation readiness, further decreasing willingness among clinical professionals/managers to prioritize non-clinic based activities. The federally-driven program failed to provide budgetary incentives or tap into political motivations of municipal/health centre administrators.

CONCLUSION

Lessons from Ethiopia's challenges in implementing its FHT program suggest that LMICs interested in adopting CHW-integrated healthcare team models should closely consider health system readiness (budgets, staffing, equipment/medicines) as well as incentivization strategies (financial, professional, political) to drive organizational change.

Connecting the Dots between Social Care and Healthcare for the Sustainability Development of Older Adult in Asia: A Scoping Review

Globally, we face a rapid double growth of the ageing population that urges an integrated framework plan by connecting the health and social care disciplines as a shared and continuum of care approach. Bridging the gap between health and social care is required to meet the demand of ageing population needs, the readiness of the stakeholders, and community as a holistic approach. This article provides an overview of the evidence gap between social care and healthcare through a scoping review. Articles retrieved related to social and health care for older adults in the Asia region were identified through a compilation of PubMed, SAGE, Springer, and Google Scholar searches between the years 2015 to 2021. Only twelve articles were used for result generation. The majority highlights the constraint on financial support, issues related to culture, human resource competency and community participation. The systematic review of the current work provides valuable insight for future researchers and policymakers in designing sustainable development integrated long term care (LTC) framework models and plans.

Mobile Health to Improve Adherence and Patient Experience in Heart Transplantation Recipients: The mHeart Trial

Non-adherence after heart transplantation (HTx) is a significant problem. The main objective of this study was to evaluate if a mHealth strategy is more effective than standard care in improving adherence and patients’ experience in heart transplant recipients. Methods: This was a single-center, randomized controlled trial (RCT) in adult recipients >1.5 years post-HTx. Participants were randomized to standard care (control group) or to the mHeart Strategy (intervention group). For patients randomized to the mHeart strategy, multifaceted theory-based interventions were provided during the study period to optimize therapy management using the mHeart mobile application. Patient experience regarding their medication regimens were evaluated in a face-to-face interview. Medication adherence was assessed by performing self-reported questionnaires. A composite adherence score that included the SMAQ questionnaire, the coefficient of variation of drug levels and missing visits was also reported. Results: A total of 134 HTx recipients were randomized (intervention N = 71; control N = 63). Mean follow-up was 1.6 (SD 0.6) years. Improvement in adherence from baseline was significantly higher in the intervention group versus the control group according to the SMAQ questionnaire (85% vs. 46%, OR = 6.7 (2.9; 15.8), p-value < 0.001) and the composite score (51% vs. 23%, OR = 0.3 (0.1; 0.6), p-value = 0.001). Patients’ experiences with their drug therapy including knowledge of their medication timing intakes (p-value = 0.019) and the drug indications or uses that they remembered (p-value = 0.003) significantly improved in the intervention versus the control group. Conclusions: In our study, the mHealth-based strategy significantly improved adherence and patient beliefs regarding their medication regimens among the HTx population. The mHeart mobile application was used as a feasible tool for providing long-term, tailor-made interventions to HTx recipients to improve the goals assessed.

What do older people want from integrated care? Experiences from a South Australian co-design case study

OBJECTIVES

The challenges of improving the integration of care for older people with complex care needs are well recognised. Evidence suggests that solutions should be co-designed with older people to ensure they are contextually relevant and person-centred.

METHODS

As a first step in a co-design project to improve integrated care for older people, seven interviews and three workshops were held with older people and service providers. Data collected via recordings, notes and journey maps were inductively analysed.

RESULTS

Five themes were identified: relationships and roles, patient capacity and safety, information and systems, multiway communication, and transitions and flow. This created a more holistic and person-centred picture of integrated care than typically derived from published literature.

CONCLUSIONS

Older people perceive integrated care from relational, organisational, informational and individual viewpoints. This reinforces the central importance of adopting a person-centred, as opposed to health system-focused, approach to designing and implementing integrated care solutions.

Interdisciplinary Mobile Health Model to Improve Clinical Care After Heart Transplantation: Implementation Strategy Study

Background

Solid organ transplantation could be the only life-saving treatment for end-stage heart failure. Nevertheless, multimorbidity and polypharmacy remain major problems after heart transplant. A technology-based behavioral intervention model was established to improve clinical practice in a heart transplant outpatient setting. To support the new strategy, the mHeart app, a mobile health (mHealth) tool, was developed for use by patients and providers.

Objective

The primary objective of this study was to describe the implementation of the mHeart model and to outline the main facilitators identified when conceiving an mHealth approach. The secondary objectives were to evaluate the barriers, benefits, and willingness to use mHealth services reported by heart transplant recipients and cardiology providers.

Methods

This was an implementation strategy study directed by a multidisciplinary cardiology team conducted in four stages: design of the model and the software, development of the mHeart tool, interoperability among systems, and quality and security requirements. A mixed methods study design was applied combining a literature review, several surveys, interviews, and focus groups. The approach involved merging engineering and behavioral theory science. Participants were chronic-stage heart transplant recipients, patient associations, health providers, stakeholders, and diverse experts from the legal, data protection, and interoperability fields.

Results

An interdisciplinary and patient-centered process was applied to obtain a comprehensive care model. The heart transplant recipients (N=135) included in the study confirmed they had access to smartphones (132/135, 97.7%) and were willing to use the mHeart system (132/135, 97.7%). Based on stakeholder agreement (>75%, N=26), the major priorities identified of the mHealth approach were to improve therapy management, patient empowerment, and patient-provider interactions. Stakeholder agreement on the barriers to implementing the system was weak (<75%). Establishing the new model posed several challenges to the multidisciplinary team in charge. The main factors that needed to be overcome were ensuring data confidentiality, reducing workload, minimizing the digital divide, and increasing interoperability. Experts from various fields, scientific societies, and patient associations were essential to meet the quality requirements and the model scalability.

Conclusions

The mHeart model will be applicable in distinct clinical and research contexts, and may inspire other cardiology health providers to create innovative ways to deal with therapeutic complexity and multimorbidity through health care systems. Professionals and patients are willing to use such innovative mHealth programs. The facilitators and key strategies described were needed for success in the implementation of the new holistic theory–based mHealth strategy.

Quality Assessment of Systematic Reviews on Platform-Switching vs Platform-Matched Implants: An Overview

The objective of this study was to perform a quality analysis of systematic reviews with meta-analyses that focused on the comparison of platform-switching (implant-abutment mismatching) and platform-matched (PM) implants. The assessment of multiple systematic reviews (AMSTAR) and Glenny (Checklist) Scales were used to qualify the studies. PubMed, Scientific Electronic Library Online (SciELO), Web of Science (formerly ISI Web of Knowledge), and Cochrane databases were searched, by topic, for systematic reviews on dental implants with switching platforms. A total of 8 systematic reviews, including 7 studies with meta-analyses, were selected. The AMSTAR scale indicated a high (n = 6) to moderate (n = 2) score for the included studies. The quantitative analysis indicated that platform-switching implants preserved more bone tissue when compared with platform-matched implants (6 meta-analyses; P < .001, smaller mean difference: -0.29 mm, 95% CI: -0.38, -0.19 and greater mean difference: -0.49 mm, 95% CI: -0.73, -0.26). Quantitative analysis based on 7 systematic reviews with meta-analysis indicated positive peri-implant bone preservation for implants restored with an implant-abutment mismatching (PSW). Further, there is evidence to improve the design of current systematic reviews. Future systematic reviews in this thematic area should consider searches in gray literature and different databases and include only randomized controlled clinical studies.

What does integrated care mean from an older person's perspective? A scoping review

OBJECTIVE

To systematically map and synthesise the literature on older adults' perceptions and experiences of integrated care.

SETTING

Various healthcare settings, including primary care, hospitals, allied health practices and emergency departments.

PARTICIPANTS

Adults aged ≥60 years.

INTERVENTIONS

Integrated (or similarly coordinated) healthcare.

PRIMARY AND SECONDARY OUTCOME MEASURES

Using scoping review methodology, four electronic databases (EMBASE, CINAHL, PubMed and ProQuest Dissertation and Theses) and the grey literature (Open Grey and Google Scholar) were searched to identify studies reporting on older adults' experiences of integrated care. Studies reporting on empirical, interpretive and critical research using any type of methodology were included. Four independent reviewers performed study selection, data extraction and analysis.

RESULTS

The initial search retrieved 436 articles, of which 30 were included in this review. Patients expressed a desire for continuity, both in terms of care relationships and management, seamless transitions between care services and/or settings, and coordinated care that delivers quick access, effective treatment, self-care support, respect for patient preferences, and involves carers and families.

CONCLUSIONS

Participants across the studies desired accessible, efficient and coordinated care that caters to their needs and preferences, while keeping in mind their rights and safety. This review highlights the salience of the relational, informational and organisational aspects of care from an older person's perspective. Findings are transferable and could be applied in various healthcare settings to derive patient-centred success measures that reflect the aspects of integrated care that are deemed important to older adults and their supporters.

Multimorbidity and medication complexity: New challenges in heart transplantation

INTRODUCTION

Multimorbidity and therapeutic complexity are a recognized problem in the heart transplant (HTx) population. However, little is known about how best to quantify this complexity or the strategies that could reduce its burden.

METHODS

This single-center, observational study included adult heart transplant recipients (HTxR) >1.5 years from transplant. We assessed multimorbidity (>2 comorbidities) and the patient-level Medication Regimen Complexity Index Spanish version (pMRCI-S) score. We also analyzed the independent predictors of pMRCI-S and the impact of the index score on specific clinical variables.

RESULTS

We included 135 chronic-stage HTxR. Comorbidities significantly increased after HTx (6 ± 3 vs 2 ± 2, P-value < .001). Patients took 12 ± 3 chronic drugs/d, 58% of them to treat comorbidities. The mean total pMRCI-S score was 42 ± 11, higher than in several other chronic diseases. The medication category drugs to treat comorbidities predicted a higher total pMRCI-S score (OR = 3.12, 95% CI 2.8-3.43, P-value < .001). Therapeutic complexity after HTx had an impact on solid malignancies (OR = 1.1, 95% CI 1.02-1.18, P-value = .02) and renal function (OR=-0.81, 95% CI -1.21-(-0.42), P-value < .001).

CONCLUSIONS

The multimorbidity and pMRCI-S scores obtained in HTx population were worrisomely high. The pMRCI score is a sensitive method that allows identification of the factors determining therapeutic complexity after HTx and selection of strategies to reduce pMRCI-S values.

Impact of Complex Quality-Interventions on Patient Outcome: A Systematic Overview of Systematic Reviews

Quality of care and the increasing strategies to its promotion, especially in inpatient settings, led to the question which quality-interventions work best and which do not. The aim was to summarize and critically appraise the evidence on the effects of structure- and/or process-related quality-interventions on patient outcome in predominantly controlled and inpatient settings. A systematic overview of systematic reviews after electronic searches in Medline, Embase, Cinahl, and PsycINFO, supplemented by hand search and expert survey, was conducted. From a total of 1559 identified records, 37 reviews fulfilled the inclusion criteria. 26 reviews assessed process-related quality-interventions, 6 structure-related quality-interventions, and 5 combined structure- and process-related quality-interventions. In all, 19 reviews reported pooled effect estimates (meta-analysis). Based on the evidence of this systematic overview, stroke units and pathways can be recommended. Although patient-relevant improvements for interprofessional approaches and discharge planning have been reported, pooled effect estimated evidence are currently missing for these and other quality-interventions.

The global burden of multiple chronic conditions: A narrative review

Globally, approximately one in three of all adults suffer from multiple chronic conditions (MCCs). This review provides a comprehensive overview of the resulting epidemiological, economic and patient burden. There is no agreed taxonomy for MCCs, with several terms used interchangeably and no agreed definition, resulting in up to three-fold variation in prevalence rates: from 16% to 58% in UK studies, 26% in US studies and 9.4% in Urban South Asians. Certain conditions cluster together more frequently than expected, with associations of up to three-fold, e.g. depression associated with stroke and with Alzheimer's disease, and communicable conditions such as TB and HIV/AIDS associated with diabetes and CVD, respectively. Clusters are important as they may be highly amenable to large improvements in health and cost outcomes through relatively simple shifts in healthcare delivery. Healthcare expenditures greatly increase, sometimes exponentially, with each additional chronic condition with greater specialist physician access, emergency department presentations and hospital admissions. The patient burden includes a deterioration of quality of life, out of pocket expenses, medication adherence, inability to work, symptom control and a high toll on carers. This high burden from MCCs is further projected to increase. Recommendations for interventions include reaching consensus on the taxonomy of MCC, greater emphasis on MCCs research, primary prevention to achieve compression of morbidity, a shift of health systems and policies towards a multiple-condition framework, changes in healthcare payment mechanisms to facilitate this change and shifts in health and epidemiological databases to include MCCs.

What integrated care means from an older person's perspective? A scoping review protocol

INTRODUCTION

According to the 2013 WHO Global Forum on Innovation for Ageing Populations, disabilities and morbidities associated with ageing could be minimised by accessing preventive care. One way of improving the management of multimorbidity in the older population is through the provision of 'integrated care'. Although integrated care means different things to different people, it typically symbolises continuity in care, thus preventing older patients' from falling through gaps in the health care system. Many initiatives have attempted to improve the integration of care; however, these are typically designed from a particular policy or system perspective. Relatively little is known about patient expectations and experiences of integrated care, which is vital for developing and implementing better models of care. The proposed scoping review aims to map literature on older patients'' views, expectations, experiences and perspectives of integrated care.

METHODS AND ANALYSIS

Multiple electronic databases including PubMed, Web of Science, Embase, PsychInfo, Google Scholar, Cochrane Library, CINAHL and ProQuest Dissertations will be searched for appropriate articles between August and December 2017. Reference lists of selected articles will also be searched for similar articles. Two experienced researchers will conduct an initial search of the literature to identify relevant articles. Abstracts of the identified articles will be reviewed collectively by two researchers to identify potential further studies. Full texts of the potential studies will be sourced and screened for the inclusion criteria. Appropriate qualitative and quantitative methods will be used to extract data from each included study.

ETHICS AND DISSEMINATION

The scoping review will synthesise findings from studies reporting on patients' views and expectations of integrated care. This review expects to find information relating to facilitators and barriers of integrated care from an older person's perspective. The findings from the review will be applied when working with stakeholders representing older people, healthcare, aged care and community providers, researchers and policy makers to develop and evaluate a more locally tailored and person-centred approach to integrated care.

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

OBJECTIVE

To summarise the evidence regarding the effectiveness of integrated care interventions in reducing hospital activity.

DESIGN

Umbrella review of systematic reviews and meta-analyses.

SETTING

Interventions must have delivered care crossing the boundary between at least two health and/or social care settings.

PARTICIPANTS

Adult patients with one or more chronic diseases.

DATA SOURCES

MEDLINE, Embase, ASSIA, PsycINFO, HMIC, CINAHL, Cochrane Library (HTA database, DARE, Cochrane Database of Systematic Reviews), EPPI-Centre, TRIP, HEED, manual screening of references.

OUTCOME MEASURES

Any measure of hospital admission or readmission, length of stay (LoS), accident and emergency use, healthcare costs.

RESULTS

50 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.

CONCLUSIONS

Although 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 NUMBER

CRD42015016458.

A protocol for a systematic review of clinical guidelines and published systematic reviews on the early detection of oral cancer

Background:

The predicted increase in incidence of oral cavity cancer (OCC) coupled with high mortality and poor prognosis – particularly when diagnosed at a late/advanced stage – highlights the need for prevention and early detection/screening to reverse these trends. Dental healthcare professionals in primary care settings have a pivotal role in this effort.

Aim:

The aim of this protocol is to detail the process for assessing the evidence for the best practice and methods of early detection/screening for OCC in primary care dental settings by undertaking a systematic review of global clinical guidelines and published systematic reviews.

Method:

Searches for clinical guidelines and systematic reviews will be conducted in the following databases: Cochrane library, Medical Literature Analysis and Retrieval System Online (Ovid), Excerpta Medical dataBASE, PubMed, Turning Research into Practice, SCOPUS and Web of Science Core Collection. Our search will extend to include Google Scholar and international professional organizations/associations websites. In addition, we will handsearch the bibliographies and undertake citation searches of the selected papers. Quality appraisal will be undertaken using the Appraisal of Guidelines for Research and Evaluation version II instrument for the clinical guidelines and both A MeaSurement Tool to Assess Systematic Reviews and Risk of Bias in Systematic Reviews tools for the systematic reviews. A narrative synthesis approach will be used to assess the evidence of extracted data, primarily taking account of quality appraisal and recency of publication.

Discussion:

The synthesis of evidence will determine best practice for OCC early detection/screening by primary care dental healthcare professionals and will evaluate the relationship between clinical guidelines and the evidence base available from systematic reviews in this area.

Multimorbidity in chronic disease: impact on health care resources and costs

Effective and resource-efficient long-term management of multimorbidity is one of the greatest health-related challenges facing patients, health professionals, and society more broadly. The purpose of this review was to provide a synthesis of literature examining multimorbidity and resource utilization, including implications for cost-effectiveness estimates and resource allocation decision making. In summary, previous literature has reported substantially greater, near exponential, increases in health care costs and resource utilization when additional chronic comorbid conditions are present. Increased health care costs have been linked to elevated rates of primary care and specialist physician occasions of service, medication use, emergency department presentations, and hospital admissions (both frequency of admissions and bed days occupied). There is currently a paucity of cost-effectiveness information for chronic disease interventions originating from patient samples with multimorbidity. The scarcity of robust economic evaluations in the field represents a considerable challenge for resource allocation decision making intended to reduce the burden of multimorbidity in resource-constrained health care systems. Nonetheless, the few cost-effectiveness studies that are available provide valuable insight into the potential positive and cost-effective impact that interventions may have among patients with multiple comorbidities. These studies also highlight some of the pragmatic and methodological challenges underlying the conduct of economic evaluations among people who may have advanced age, frailty, and disadvantageous socioeconomic circumstances, and where long-term follow-up may be required to directly observe sustained and measurable health and quality of life benefits. Research in the field has indicated that the impact of multimorbidity on health care costs and resources will likely differ across health systems, regions, disease combinations, and person-specific factors (including social disadvantage and age), which represent important considerations for health service planning. Important priorities for research include economic evaluations of interventions, services, or health system approaches that can remediate the burden of multimorbidity in safe and cost-effective ways.

Discharge interventions for older patients leaving hospital: protocol for a systematic meta-review

BACKGROUND

There is an increased need for additional care and support services for the elderly population. It is important to identify what support older people need once they are discharged from hospital and to ensure continuity of care. There is a large evidence base focusing on enhanced discharge services and their impact on patients. The services show some potential benefits, but there are inconsistent findings across reviews. Furthermore, it is unclear what elements of enhanced discharge interventions could be most beneficial to older people. This meta-review aims to identify existing systematic reviews of discharge interventions for older people, identify potentially effective elements of enhanced discharge services for this patient group and identify areas where further work may still be needed.

METHODS/DESIGN

The search will aim to identify English language systematic reviews that have assessed the effectiveness of discharge interventions for older people. The following databases will be searched: Medline, Embase, PsycINFO, HMIC, Social Policy and Practice, CINAHL, the Cochrane Library, ASSIA, Social Science Citation Index and the Grey Literature Report. The search strategy will comprise the keywords 'systematic reviews', 'older people' and 'discharge'. Discharge interventions must aim to support older patients before, during and/or after discharge from hospital. Outcomes of interest will include mortality, readmissions, length of hospital stay, patient health status, patient and carer satisfaction and staff views. Abstract, title and full text screening will be conducted independently by two reviewers. Data extracted from reviews will include review characteristics, patient population, review quality score, outcome measures and review findings, and a narrative synthesis will be conducted.

DISCUSSION

This review will identify existing reviews of discharge interventions and appraise how these interventions can impact outcomes in older people such as readmissions, health status, length of hospital stay and mortality. The review could inform practice and will help identify where further research is needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015025737.

Assessment and prevention of behavioural and social risk factors associated with oral cancer: protocol for a systematic review of clinical guidelines and systematic reviews to inform Primary Care dental professionals

BACKGROUND

Tobacco and alcohol are recognised as the major risk factors for both oral cavity (mouth) and oropharyngeal (throat) cancers, with increasing acceptance of the role of human papillomavirus (HPV) in the aetiology of oropharyngeal cancers. In addition, there is a significant increased risk for oral cancer among lower socioeconomic groups, males and older age groups. There is a growing evidence for the potential role of primary care professionals in smoking cessation and reducing alcohol-related harm. However, there are uncertainties about the best approaches/strategies to assess risk factors associated with oral cancer, effective components of preventive interventions for behaviour change and implementation strategies in primary care dental settings. Thus, in order to contribute to the prevention of oral cancer effectively, dental professionals need to assess patients on the major risk factors (tobacco, alcohol and HPV/sexual behaviours) and deliver appropriate prevention, taking into account the patient's sociodemographic context.

AIM

The study aims to synthesise evidence on the best practice for undertaking an assessment of major behavioural risk factors associated with oral cancer and delivering effective behaviour change preventive interventions (e.g. advice, counselling, patient recall, signposting/referral to preventive services) by dental professionals in primary care dental settings.

METHOD

The study involves a systematic review and evidence appraisal. We will search for clinical guidelines and systematic reviews from the following databases: Cochrane Library, Ovid MEDLINE, EMBASE, Web of Science, PsychINFO, PubMed, TRIP and Google Scholar. We will also search websites of professional organisations/agencies and bibliographies/reference lists of selected papers. Quality will be assessed with the AGREE II (Appraisal of Guidelines for Research & Evaluation II) instrument for included clinical guidelines and the AMSTAR (A Measurement Tool to Assess Systematic Reviews) and ROBIS instruments for included systematic reviews. The best practice evidence will be assessed via a narrative synthesis of extracted data, considering publication quality.

DISCUSSION

This systematic review will synthesise evidence on the best practice for oral cancer risk factor assessment and prevention and evaluate the relationship between available clinical guidelines and the review evidence base. This collation of evidence will be useful for making recommendations for future intervention, research and guideline development.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015025289.