Overview study on integrated care for chronic diseases (theme 4) - Gill Combes and Sarah Damery

1. The effectiveness of interventions to
achieve coordinated multidisciplinary
care and reduce hospital use for
people with chronic diseases
Progress to date and methodological
challenges

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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?

12. 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

13. 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

14. Methodological challenges
•Double counting of primary studies
•Excluding papers on the basis of quality score
•Grouping of interventions

15. 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

17. 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

18. 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
Numberofreviews
Percentage of references duplicated
Proportion of references duplicated, by review

19. 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

20. 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?

21. 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

22. 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
✓ ✓ ✓ ✓ ✓

23. 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

24. (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)