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Does integrated care reduce hospital activity for patients with chronic diseases? An umbrella review of systematic reviews
  1. Sarah Damery,
  2. Sarah Flanagan,
  3. Gill Combes
  1. Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
  1. Correspondence to Dr Sarah Damery; s.l.damery{at}bham.ac.uk

Abstract

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.

  • umbrella review
  • integrated care
  • chronic disease
  • review of reviews
  • resource use
  • hospital activity

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Footnotes

  • Contributors SD, GC and SF designed the study and the literature search strategy. SD and SF undertook data cleaning, title and abstract screening, full paper assessment, data extraction and analysis of all data, with input from GC as needed. SD drafted and revised the paper and is guarantor for the work. SF and GC critically revised the paper for intellectual content. All authors gave final approval of the manuscript and are accountable for all aspects of the accuracy and integrity of the work.

  • Funding This research was funded by the National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care West Midlands (CLAHRCWM).

  • Disclaimer The study sponsor and funder had no role in the study design, in the collection, analysis and interpretation of data, in the writing of the report and in the decision to submit the article for publication.

  • This paper presents independent research funded by the National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care West Midlands (CLAHRCWM). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

  • Data access All authors had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

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