Table 2

Characteristics of included reviews

Author (year); country	Study types, n; participants n; databases	Condition(s); population(s); review type	Comparator; QA score; time scale	Intervention summary; health/social care settings	Findings of review by outcome (intervention vs control)
Case management
Hickam et al (2013);23 USA	RCTs, observational n=153 Not specified 5 databases, inception—2011	Chronic disease Adult patients with complex care needs Narrative	Care without a case management component 4 6–36 months	Intensive interventions: multiple face-to-face interactions, home visits vs less intensive interventions: infrequent contact Delivered by case managers working alone or within a MDT of health professionals. Primary, secondary, community	Admissions: 2 studies found case management to be more effective in patients with greater disease burden. A further 4 studies found case management to be effective when case managers have greater levels of personal contact with patients (low quality evidence). Costs (4 studies): 3 found no difference between groups. One study found higher overall costs in intervention group vs control.
Hutt et al (2004);24 UK	RCTs, CCTs, before/after n=20 n=18 002 ‘Major’ databases, 1996–2004	Chronic disease Over 65s with any chronic condition (mental health excluded) Narrative	Care without a case management component 3 At least 3 months	Home visits and/or periodic reassessment, ranging from case manager assessment at hospital or home with occasional telephone contact, to regular intensive contact where case managers arranged medical appointments and were contactable 24/7. Delivered by case manager (nurse or social worker). Primary, secondary, community.	Admissions (18 studies): 5 showed a significant reduction in admissions in intervention groups; 7 found no difference between groups; 4 found non-significant reductions, 2 found non-significant increases in admissions in the intervention group LoS (16 studies): 3/16 showed significant decrease, 2/16 showed non-significant increase, 11/16 showed no differences. A&E use (8 studies): 3 showed significant reduction, 2 showed significant increases, 2 showed non-significant increases. Costs (10 studies): 4 showed non-significant increases in intervention; 6 reported reductions although only 1 was significant.
Latour et al (2007);25 Netherlands	RCTs, CCTs, before/after n=10 n=5092 4 databases, inception-2005	Chronic disease Adult patients with acute or chronic conditions Narrative	Care without a case management component 3 3–18 months	Postdischarge nurse-led case management for complex patients, delivered in the outpatient setting. Needs assessment, service plans, monitoring, assessment, evaluation, follow-up via home visits and/or telephone. Secondary, community	Readmissions (9 studies): 3 high quality, 1 low quality reported positive results for intervention. 4 studies (2 high quality) showed no difference between groups; 1 presented insufficient data. LoS (6 studies): 2 showed significant reduction, 2 showed non-significant reduction, 2 showed no difference between groups. A&E use (4 studies): Strong evidence that intervention had no significant impact.
Manderson et al (2012);26 Canada	RCTs n=15 n=2317 5 databases, 1999–2011	Chronic disease Older people Narrative	Not specified 3 1–18 months	Care planning and coordination via phone support, home visits, liaison with medical and community services and/or education. APN, care coordinators, case managers. Primary, secondary, community	Costs (9 studies): 5 reported positive economic outcomes, 4 did not. Specific data and effect sizes not given.
Oeseburg et al (2009);27 Netherlands	RCTs n=9 n=15 746 3 databases, 1995–2007	Chronic disease Community dwelling patients Narrative	Care without a case management component 3 10–36 months	Home visits and/or telephone calls. Delivered by a case manager (nurse, social worker or nurse practitioner) who was either a member of a MDT or acted independently. Primary, secondary, community	Admissions (6 studies): 1 showed small reduction in favour of intervention (good quality). One found small increase in intervention group (weak quality). LoS (5 studies): One reported small reduction in days per year in hospital in intervention group. A&E use (5 studies): One reported small reduction in intervention, 1 reported an increase. 3 reported no difference. Costs (3 studies): 1 reported significant but trivial saving in intervention. Another found 19% cost reduction due to savings in nursing home, hospital and community costs. A third found costs to be higher in intervention (non-significant).
Stokes et al (2015);43 UK	RCTs, CCTs, before/after, time series n=36 n=23 711 6 databases, inception-2014	Chronic disease Adult patients with chronic diseases SR and meta-analysis	Care without a case management component 4 6–60 months	Community-based MDTs responsible for delivering and coordinating services; MDT care plan following case worker assessment, case manager constantly available to deal with problems. Delivered by care manager, nurse, pharmacist, GP collaborating with nurse. Primary, community	Costs: No significant effects found: Short term (0–12 months): SMD −0.00 CI −0/07 to 0.06 Longer term (13+ months): SMD −0.03 CI −0.16 to 0.10
Taylor et al (2005);44 UK	RCTs n=9 n=1428 24 databases, 1980–2005	COPD Patients with COPD in the community SR and meta-analysis	Conventional postdischarge care 4.5 3–12 months	Brief (1 month) or longer term (12 months) inpatient, outpatient or community-based interventions. All were led, coordinated or delivered by respiratory nurses via home visits, with or without telephone follow-up. Primary, secondary, community	Readmissions: Equivocal evidence for reduction in all-cause readmission at 12 months. One study found a 40% reduction in readmission for acute exacerbation and 57% reduction in all-cause readmission. Another found a significant reduction in readmissions. Three further studies found no effect.
Thomas et al (2013);45 UK	RCTs n=10 Not specified 18 databases, inception-2010	Heart failure Adult patients SR and meta-analysis	Not specified 3 3–18 months	Specialist HF management education: Intensive: 4–6-week appointments Decreasing intensity: every 1–2 weeks for 3 months, then every 3 months Regular: 3–4-month appointments Tailored: appointments by patient need Primary, secondary	Admissions: At 3 months (RR 0.10, 95% CI 0.01 to 0.78). At 12 months (5 studies), 49% reduction in relative risk (RR 0.51, 95% CI 0.41 to 0.63). At 18 months (1 study), no difference between groups. Interventions with decreasing intensity showed 58% reduction (RR 0.42, 95% CI 0.27 to 0.65). No significance for other groups.
Chronic care model
Adams et al (2007);46 USA	RCTs n=32 Not specified 3 databases, inception-2005	COPD Adult patients with COPD SR and meta-analysis	Not specified 4 6 weeks to 24 months	At least one component of Wagner's CCM. Categorised according to the number of components an intervention included. Primary, secondary, community	Admissions: No difference in rates for interventions with 1 CCM component (n=7). Significant reduction for interventions with multiple CCM components (n=4); RR 0.78, 95% CI 0.66 to 0.94). LoS: 1 CCM component (4 studies): No difference between groups. Multiple components (2 studies): Significant reduction in intervention (−2.51 days, 95% CI −3.40 to −1.61). A&E use: 3 studies with 2+ CCM components found statistically significant reduction (RR 0.58, 95% CI 0.42 to 0.79). Costs (7 studies): 3 RCTs showed 34% to 70% cost reduction with intervention. One RCT showed non-significant cost reductions. Three before/after studies reported an 11% to 23% reduction in costs after intervention.
de Bruin et al (2012);28 Netherlands	RCTs, CCTs, before/after, case–control n=41 n=78 590 6 databases, 1995–2011	Chronic disease Adult patients with multiple chronic conditions Narrative	Not specified 4.5 Not specified	Studies categorised by number of CCM components they included. Multiple settings, from home care organisations and community centres to primary care, hospitals, specialist clinics. Some included newly established partnerships; others provided regular care in settings where it was not normally given. Primary, secondary, community	Admissions: 3/16 studies found significantly reduced admissions. Costs (5 studies): All reported negative incremental direct healthcare costs for patients receiving intervention. Costs ranged from −US$5708 to −US$204 per patient per year, primarily due to lower inpatient costs in the intervention group.
Gonseth et al (2004);47 Spain	RCTs, CCTs, n=27 Not specified 3 databases, inception-2003	Heart failure Over 65s with principle or secondary diagnosis of HF SR and meta-analysis	Care without a CCM component 4.5 3–48 months	Education, counselling, diet advice, self-care support, discharge planning, focus on hospital to home transition, medication management, clinic review, GP follow-up. Most delivered by nurses. Varied timing (eg, in-hospital or postdischarge), organisation (eg, home care or outpatient clinic visit), duration (from single home visit to intensive intervention lasting 12 months). Primary, secondary, community	Readmissions: Reduced regardless of follow-up length or whether intervention delivered at home or in clinic setting. All-cause (6 studies): 15% reduction in readmissions (RR 0.85, 95% CI 0.79 to 0.92). HF-specific (6 studies): 30% reduction in readmissions (RR 0.70, 95% CI 0.62 to 0.79). Costs (11 studies): 10 estimated the intervention reduced costs. One reported similar costs in intervention and usual care groups.
Hisashige (2013);69 Japan	SR and meta-analyses n=28 Not specified 9 databases, 1995–2010	Chronic disease Adult patients Review of reviews	Not specified 3.5 Not specified	All interventions had 1+ CCM component. Typically multidisciplinary approaches with clinical follow-up by specialists, home visits, hospital discharge planning or postdischarge follow-up, counselling in hospital and patient education or reminders. Primary, secondary, community	Admissions (22 studies): ‘Improvement with a reasonable amount of evidence’ with intervention seen in 63% of studies (14/22). Costs (16 studies): 6/16 (38%) observed ‘improvement in costs with a reasonable amount of evidence’. Costs tended to focus on healthcare costs and typically did not include estimates of intervention costs.
Kruis et al (2013);48 Netherlands	RCTs n=26 n=2997 5 databases, 1990-present	COPD Adult patients with clinical diagnosis of COPD SR and meta-analysis	Regular follow-up visits to healthcare providers 5 3–24 months	Multidisciplinary (2+ providers), multitreatment (2+ CCM components), 3+ months duration. Categorised as: Exercise dominant Self-management dominant Structured nurse/GP follow-up Exercise and self-management Self-management+structured follow-up Individually tailored education Primary, secondary, community	Admissions: All-cause: number of participants with one or more admissions over 3–12 months was 27 per 100 in control vs 20 per 100 in intervention (OR 0.68, 95% CI 0.47 to 0.99, p=0.04). Respiratory related: at 3 months (7 studies), significant reduction (0.68, 95% CI 0.47 to 0.99, p=0.04). At 12 months (1 study), no difference observed. LoS: Significantly lower in the intervention group. Mean difference −3.78 days (95% CI −5.90 to −1.67, p<0.001).
Lemmens et al (2009);49 Netherlands	RCTs, before/after n=36 Not specified 2 databases, 1995–2008	COPD Adult patients with asthma or COPD SR and meta-analysis	Care with 0 or 1 CCM components 5 6 weeks to 24 months	Patient education+case management Patient education+case management+professional education Patient education with substitution of physician by nurse Professional and patient education combined with pharmacists having an active role in patient monitoring Primary, secondary, community	Readmissions: Group 1 (6 studies): 1 showed significant reduction Group 2 (6 studies): 3 showed significant reduction Group 3: No differences between groups Group 4 (8 studies): Ambiguous results in all studies.
Peytremann-Bridevaux et al (2008);50 Switzerland	RCTs, controlled before/after n=13 n=8179 5 databases, inception-2006	COPD Adult patients undergoing disease management SR and meta-analysis	Care without a CCM component 4 12 months	All included 2+ CCM components; at least 1 component must have lasted 12 months. Delivered by 2+ health professionals, eg, respiratory nurse, physiotherapist, GP, practice nurse, social worker, case manager, pulmonary care physician. Primary, secondary, community	Admissions (10 studies): 7 showed significant effects in favour of intervention; 3 found no reduction in admissions.
Steuten et al (2009);29 Netherlands	Any with data at two time points n=20 Not specified 2 databases, 2005–2007	COPD Mild, moderate, severe or very severe COPD Narrative	Care without a CCM component 3.5 2–24 months	All included 2+ CCM components. All included self-management and delivery system redesign. Several programmes additionally encompassed decision support and/or clinical information systems Primary, secondary, community	Readmissions: 8/15 studies reported a reduction in readmission rates (3 statistically significant). Relative risk of readmission ranged from 0.64 to 1.50. Statistically significant improvements all seen in studies with 3 or 4 intervention components. Studies with fewer components showed no significant reductions. Costs (3 studies): Differences found in individual domains, eg, higher prescription costs, lower hospital costs, reduced sick leave costs. No studies reported statistically significant findings.
Woltmann et al (2012);51 USA	RCTs n=78 Not specified 6 databases, inception-2011	Mental health Adult patients with mental health problems SR and meta-analysis	Not specified 5 3–36 months	Eligible interventions had to have at least 3 CCM components. Primary, secondary, community	Costs (21 studies): 10 reported p values. 9 of these reported no difference between intervention and control groups; 1 favoured control condition. No statistically significant findings in any study.
Discharge management
Bettger et al (2012);30 USA	RCTs, observational, n=44 Not specified 4 databases, 2000–2012	Stroke, Cardiac Patients hospitalised for stroke/MI Narrative	Not specified 4 Not specified	Hospital-initiated discharge support Community-based support models Provided by nurses, social workers, OTs, physicians, MDT. Delivered in person, in home/clinic or by telephone. Secondary, community	Readmissions: Hospital-initiated support: No impact on readmission rates in 6 studies focusing on stroke; no impact in 3 studies focusing on MI Community-based support: 1/4 stroke studies found significant reduction in readmissions; 5/5 MI studies found statistically non-significant trends towards reduced readmission rates
Brady et al (2005);31 Canada	Cost analyses, economic evaluations n=15 n=6201 6 databases, 1995–2002	Stroke Adult patients with clinical definition of stroke Narrative	Standard hospital discharge and rehabilitation 4 Up to 12 months	Stroke unit care and rehabilitation with specialised teams of physicians ESD with organised interdisciplinary teams to support patients at home Community rehabilitation via hospital outpatient clinics or home-based therapy Secondary, community	Costs: Stroke unit care (3 studies): Costs 3% to 11% lower (significant). ESD (6 studies): Non-significant trends towards costs of 4% to 30% lower for patients with mild/moderate disability. Two lower quality studies found ESD to cost more than usual care. Community rehabilitation (4 studies): 2 reported non-significant higher costs in intervention; 1 showed no difference, 1 reported mean direct cost to be 38% lower than day hospital rehabilitation.
Fearon et al (2012);52 UK	RCTs n=14 n=1957 Multiple databases to 2012	Stroke Adult patients admitted to hospital with stroke SR and meta-analysis	Standard discharge arrangements 5 3–12 months	MDT meeting regularly, coordinated discharge, postdischarge care and rehabilitation and care at home As above, but care handed over to existing community agencies for support after immediate postdischarge period Patients access to MDT in hospital until discharge, then care provided by community stroke services Medical, nursing, physiotherapy, OT, speech and language therapists. Secondary, community	Readmissions (7 studies): readmission rates similar in intervention to usual care (31% vs 28%). LoS (13 studies): Pooled results showed significant reduction (p<0.0001). Reduction more marked in hospital outreach group than community inreach group but not statistically significant (p=0.24). Costs (7 studies): Overall, costs ranged from 23% less for ESD group to 15% more compared to control. No subgroup cost analyses possible.
Feltner et al (2014);53 USA	RCTs n=47 Not specified 5 databases, 2007–2013	Heart failure Adult patients with moderate to severe HF SR and meta-analysis	Standard discharge arrangements 4 3–6 months	At least one of: Patient/caregiver education Multidisciplinary HF clinic visits Home visits by nurse or pharmacist Telemonitoring Structured telephone support Transition coach/case management Interventions for provider continuity Secondary, community	Readmissions: Home visits (2 studies): Significant reduction in 30-day all-cause readmissions (RR 0.34, 95% CI 0.19 to 0.62) and 3–6-month all-cause readmissions (RR 0.75, 95% CI 0.68 to 0.86). Significant reduction in 3–6-month HF-specific readmissions (1 study), (RR 0.51, 95% CI 0.31 to 0.82). Multidisciplinary HF clinics (2 studies): Significant reduction in 3 to 6-month all-cause readmission (RR 0.70, 95% CI 0.55 to 0.89). No other intervention group had any significant benefits.
Jeppesen et al (2012);54 Norway, UK, Australia	RCTs n=8 n=870 7 databases, inception-2010 1 inception-2012	COPD Adult COPD patients in ED with acute exacerbation SR and meta-analysis	Standard discharge arrangements 4.5 6 months	Hospital at home: regular home visits by a trained respiratory nurse supported by the hospital team and telephone support. Secondary, community	Readmissions (8 studies): Significant reduction in intervention group. 9 fewer readmissions per 100 compared to inpatient care (RR 0.76, 95% CI 0.59 to 0.99, p=0.04). Costs (3 studies): 2 reported significant reduction in direct costs for intervention; 1 reported non-significant reduction. Authors stress low quality of economic evidence.
Lambrinou et al (2012);55 Greece	RCTs n=19 Not specified 3 databases, 2001–2009	Heart failure Adult patients with HF SR and meta-analysis	Standard discharge arrangements 4 3–35 months	Nurse-driven predischarge phase, incorporating discharge planning or inpatient education and/or evaluation. Telephone follow-up; HF clinic follow-up; home follow-up or a combination. Secondary, community	Readmissions: All-cause: Significantly reduced across all interventions (RR 0.85, 95% CI 0.76 to 0.94). Telephone, HF clinic, combined settings all non-significant. Home follow-up: RR 0.80 (95% CI 0.70 to 0.91). HF-specific: Significantly reduced across all interventions (RR 0.68, 95% CI 0.53 to 0.86). Telephone follow-up (RR 0.65, 95% CI 0.43 to 1.00) HF clinic: Non-significant. Home follow-up: RR 0.51 (95% CI 0.33 to 0.79) Combined settings: RR 0.58 (95% CI 0.45 to 0.73).
Langhorne et al (2005);56 UK	RCTs n=11 n=1597 Databases not specified	Stroke Inpatients with clinical diagnosis of stroke SR and meta-analysis	Standard hospital discharge and rehabilitation 5 3–12 months	ESD team coordination and delivery; MDT coordinate discharge and postdischarge care and rehabilitation at home ESD team coordination; postdischarge care by community agencies No ESD team; MDT care in hospital, postdischarge care by uncoordinated community services/healthcare volunteers Medical staff, nurses, physiotherapy, therapists, assistant staff, social workers Secondary, community	Readmissions (5 studies): similar rates between intervention and control (27% vs 25%; OR 1.14, 95% CI 0.80 to 1.63). LoS (9 studies): Overall, significant reduction in intervention of 7.7 days (95% CI 4.2 to 10.7). Reduction greater for hospital outreach than community inreach (15 days, 95% CI 9 to 22 vs 5 days, 95% CI 1 to 9). Controlling for stroke severity, greater reduction in severe vs moderate group (28 days, 95% CI 15 to 41 vs 4, 95% CI 2 to 6). Costs (5 studies): Intervention costs lower than control (range 4% to 30% lower; median reduction 20%). Significance not stated.
McMartin (2013);57 Canada	RCTs, SR, meta-analysis n=11 Not specified 6 databases, 2004–2011	Chronic disease Adults with chronic diseases SR and meta-analysis	Standard discharge arrangements 3 Not specified	Discharge planning vs usual care Comprehensive discharge planning with postdischarge support vs usual care, where postdischarge support could include home visits, telephone follow-up. Secondary, community	Readmissions: Discharge planning (11 studies): Moderate evidence that intervention is effective (RR 0.85, 95% CI 0.74 to 0.97). Discharge planning+postdischarge support: low quality evidence that this is more effective than discharge planning alone. LoS: Discharge planning more effective than usual care (mean reduction of 0.91 days, 95% CI 1.55 to 0.27). Discharge planning plus postdischarge support not more effective than discharge planning alone (mean reduction 0.37 days (95% CI 0.15 to 0.60).
Olson et al (2011);32 USA	RCTs, observational, registries n=62 Not specified 4 databases, 2001–2011	Stroke, cardiac Adults discharged after acute stroke or MI Narrative	No transitional care across multiple providers 3.5 12 months	Hospital-initiated discharge support Community-based support models Chronic disease management models Patient education, goal-setting Nurses, social workers, OTs, physicians, MDT to facilitate transition from hospital to home. In person, home/clinic or telephone. Secondary, community	Readmissions: Hospital-initiated support: (8 studies): 4 studies reported reduced readmission rates; 4 reported no difference between groups. No other intervention type showed any significant difference between groups.
Phillips et al (2004);58 USA	RCTs n=19 Not specified 7 databases, inception-2003	Heart failure Older patients with congestive heart failure SR and meta-analysis	Standard discharge arrangements 5 3–12 months	Postdischarge support as: Single home visit for HF education Increased clinic follow-up Frequent telephone contact for education, self-care, appointments Extended multidisciplinary home care Day hospital service in specialist HF unit Secondary, community	Readmissions: Group 1 (3 studies): 41% intervention, 53% control. Significant. (RR 0.76, 95% CI 0.63 to 0.93). Group 2 (4 studies): 41% intervention, 41% control. Non-significant. (RR 0.64, 95% CI 0.32 to 1.28). Group 3 (6 studies): 38% intervention, 49% control. Significant. (RR 0.79, 95% CI 0.69 to 0.91). Group 4 (4 studies): 30% intervention, 36% control. Non-significant. Group 5 (1 study): 7% intervention, 33% control. Significant. (RR 0.25, 95% CI 0.21 to 0.44). LoS (10 studies): Pooled analysis showed no significant difference between groups (mean days 8.4 vs 8.5, p=0.60). Costs (8 studies): 4 US based studies found significant costs reductions per patient per month of US$536 (95% CI −US$956 to −US$115). 4 non-US studies found no significant cost differences.
Phillips et al (2005);59 USA	RCTs n=7 n=949 5 databases, inception-2004	Heart failure Adult patients with heart failure SR and meta-analysis	Not specified 4 3–12 months	Specialist nurse-led clinics to manage discharge transitions. Categorised by: Complex interventions: discharge planning, postdischarge follow-up, no delay in continuity after discharge (3 studies) Less complex: no discharge planning and/or fewer components (4 studies) Secondary, community	Readmissions: All-cause: ‘Complex’ programmes non-significant (RR 0.30, 95% CI 0.04 to 2.60). ‘Less complex’ non-significant (RR 1.00, 95% CI 0.86 to 1.17). HF-specific: ‘Complex’ programmes significant reduction (RR 0.09, 95% CI 0.10 to 0.65. ‘Less complex’ significant reduction (RR 0.65, 955 CI 0.43 to 1.00). LoS: Complex interventions reduced LoS by 0.26 days compared to usual care (non-significant). Less complex interventions reduced LoS by 0.09 days (non-significant). Costs: Only reported for complex interventions. 3 studies showed non-significant potential savings of US$277 per patient per month.
Prieto-Centurion (2014);33 USA	RCTs n=5 n=1393 4 databases, inception-2013	COPD Exacerbation in previous 12 months Narrative	Not specified 3 6 or 12 months	Predischarge, postdischarge or bridging interventions across both periods. Education, health counselling, action plans delivered via telephone, home visits or consultation with primary care providers Primary, secondary, community	Readmissions: All-cause: 2/5 studies showed significant reduction at 12 months: 45% vs 67% hospitalised (p=0.028). COPD-specific: 1/5 studies showed significant reduction at 12 months: 32% vs 50% hospitalised (p=0.01).
Tummers et al (2012);34 Netherlands	RCTs, CCTs, n=15 n=3536 2 databases, inception-2011	Stroke Adult patients who had stroke Narrative	Standard hospital discharge and rehabilitation 3 3–12 months	Interventions grouped according to: ESD by MDT, home-based rehabilitation Stroke unit care with MDTs to reach rehabilitation goals before discharge Stroke service via network of providers organising services in all follow-up stages Primary, secondary, community	Costs: Group 1 (4 studies): 3 reported non-significant increases in intervention; 1 reported no difference between groups. Group 2 (2 studies): Both found stroke units to be more expensive than conventional care (borderline significance). Group 3 (3 studies): 2 reported a cost reduction in intervention group.
Winkel et al (2008);35 Denmark, Sweden	RCTs n=17 n=1122 5 databases, inception-2005	Stroke Adult patients who had been living at home before a stroke Narrative	Standard discharge arrangements 4 1–12 months	Delivered by MDTs which all included physiotherapists and OTs. Some also included nurse, social worker, GP and other specialist expertise, eg, geriatrician. ESD with hospital teams providing home rehabilitation after discharge ESD with no direct rehabilitation from hospital teams Community-based rehabilitation after discharge Primary, secondary, community	Readmissions: Group 1 (3 studies): No difference between groups. Group 2 (2 studies): No difference between groups. Group 3 (1 study): No difference between groups. Costs: Group 1 (2 studies): Intervention costs significantly lower than control at 3 and 12 months. Group 2 (1 study): ‘Some’ evidence that intervention costs are lower than control in 12 months after stroke. Group 3 (1 study): Costs for the most independent patients were lowest when rehabilitated in hospital rather than home. Interventions most cost-effective when delivered by hospital MDT.
Yu et al (2006);36 Hong Kong	RCTs n=21 n=4445 3 databases, 1995–2005	Heart Failure Adult patients with heart failure Narrative	Not specified 4 3–50 months	Postdischarge interventions delivered via home visits, HF clinic visits and/or telephone. Interventions comprised multidisciplinary care, case management and structured discharge planning and all included patient education and/or self-management Primary, secondary, community	Readmissions: 11 ‘effective’ programmes had significant reductions ranging from 29% to 85%. 10 others demonstrated no significant changes. Effective programmes included an in-hospital phase, patient education, self-care, surveillance and deterioration management. Involvement of cardiac nurses and cardiologists associated with increased likelihood of successful intervention. Costs: 8 ‘effective’ programmes did cost analysis, 7 of which showed a cost saving for the intervention over usual care.
Complex interventions
Dickens et al (2014);60 UK	RCTs n=32 n=3941 5 databases, inception-2013	COPD Adult patients with COPD SR and meta-analysis	Not specified 4 1–24 months	Multiple components and/or multiple professionals, given individually or in groups, or using technology. Could include education, rehabilitation, psychological therapy, social or organisational interventions. Delivered at home, in community, hospital or doctor clinic or combination of these. Primary, secondary, community	A&E use: Pooled effects showed interventions associated with 32% reduction (OR 0.68, 95% CI 0.57 to 0.80). Subgroups: General education (28 studies): OR 0.66, 95% CI 0.55 to 0.81. Exercise (11 studies): OR 0.60, 95% CI 0.48 to 0.76. Relaxation (4 studies): OR 0.48, 95% CI 0.33 to 0.70. Non-significant trends for interventions including skills training (p=0.35, 13 studies), relapse prevention (p=0.12, 11 studies).
Martinez-González et al (2014);70 Switzerland	SR, meta-analyses n=27 Not specified 4 databases, inception-2012	Chronic disease Adult patients with chronic diseases Review of reviews	Not specified 3 Not specified	Included any interventions based on disease management, case management, managed care, comprehensive care, multidisciplinary care, coordinated care, team care, CCMs. Primary, secondary, community	Admissions: 10/17 reviews demonstrated reduced admissions Readmissions: 7/12 reviews demonstrated reduced readmissions LoS: 9/13 reviews demonstrated shorter length of stay A&E use: 6/11 reviews showed reduced rates of ED visits Costs: 3/17 reviews demonstrated cost reductions
Takeda et al (2012);61 UK	RCTs n=25 n=5942 10 databases, inception to 2009	Heart failure Adults with at least one HF secondary care admission SR and meta-analysis	Not specified 5 6–24 months	All led by professionals from secondary or tertiary care. Interventions grouped as: Case management, telephone and home visits Specialist nurse-led HF clinics Multidisciplinary interventions to bridge the gap between acute and home settings Secondary, community	Readmissions: HF-specific (12 studies): Overall, significantly reduced (OR 0.57, 95% CI 0.43 to 0.75, p<0.0001). Subgroups: Group 1: Significant reduction at 6 months (3 studies) and 12 months (7 studies). OR 0.64 (95% CI 0.46 to 0.88) and OR 0.47 (95% CI 0.30 to 0.76), respectively. Group 2: No difference between groups. Group 3 (2 studies): Significant reduction OR 0.45, 95% CI 0.28 to 0.72). All-cause also significantly reduced with multidisciplinary interventions: (OR 0.46, 95% CI 0.30 to 0.69).
Multidisciplinary teams
Health Quality Ontario (2012);71 Canada	SR and meta-analyses n=24 Not specified 6 databases, 2008–2011	Heart failure, COPD Adult patients with heart failure or COPD Review of reviews	Usual care in general practice 3 Not specified	Interventions to provide formalised links between primary and specialist care via disease-specific education, medication review, physical activity and lifestyle counselling, self-care and follow-up. Delivered by intermediate care teams including GPs, specialists, nurses, social workers, pharmacists, dieticians. Primary, secondary, community	Admissions: All-cause (7 studies). Non-significant 4% RR reduction after 1 year (low quality). COPD-specific (4 studies). Significant 25% RR reduction after 1 year (moderate quality). HF-specific (6 studies). Non-significant 14% RR reduction after 1 year (low quality).
Health Quality Ontario (2013);37 Canada	SR, RCTs, observational studies n=20 Not specified 5 databases, 2002–2011	Chronic disease Adult patients with one or more chronic diseases Narrative	Not specified 3 Not specified	Informational, management and relational continuity. Assessed by: Duration (length of relationship) Density (number of visits with same provider in a set period) Dispersion (visits with distinct providers) Sequence (order of seeing providers). Primary, community	Admissions: Three studies. None reported any significant differences between intervention and control groups (low quality).
Holland et al (2005);62 UK	RCTs n=30 n=815813 databases inception-2004	Heart failure Adult patients with congestive heart failure SR and meta-analysis	Not specified 5 Not specified	Interventions with management by an MDT that included medical input plus one or more of specialist nurse, pharmacist, health educator, dietician or social worker: Education/self-management home visits Telephone follow-up only Intervention during hospital admission or hospital clinic attendance Primary, secondary, community	Admissions: All-cause (21 studies): Significant reduction in intervention (RR 0.87, 95% CI 0.79 to 0.95, p=0.002). Significant heterogeneity. HF-specific (16 studies): Significant reduction in intervention (RR 0.70, 95% CI 0.61 to 0.81, p<0.0001). LoS (10 studies): Significant reduction in mean inpatient days of 1.9 in intervention (95% CI 0.71 to 3.1). Home-based interventions reduced mean days in hospital. Interventions solely delivered in hospital, clinic or primary care showed no significant benefits.
Koshman et al (2008);63 Canada	RCTs n=12 n=2060 10 databases inception-2007	Heart failure Adult patients with heart failure SR and meta-analysis	Heart failure care without pharmacist involvement 4 6–12 months	Pharmacists providing HF and medication education through self-monitoring support, compliance facilitation. Either via directed care where pharmacist is the key driver, or collaborative care with pharmacist as part of MDT. Secondary, community	Admissions: All-cause (11 studies): Significant reduction (OR 0.71, 95% CI 0.54 to 0.94). No difference between directed and collaborative care model. HF-specific (11 studies): Significant reduction (OR 0.69, 95% CI 0.51 to 0.94). Collaborative care model associated with greater reduction in HF-specific admission than directed care (OR 0.42, 95% CI 0.24 to 0.74 vs OR 0.89, 95% CI 0.68 to 1.17, p=0.02).
McAlister (2004);64 UK	RCTs n=29 n=5039 7 databases, inception-2003	Heart failure Adult patients with HFSR and meta-analysis	Not specified 4 1–12 months	Multidisciplinary HF clinic MDT providing specialised follow-up outside hospital Telephone follow-up with primary care attendance in the event of deterioration Self-care education Primary, community	Admissions: Groups 1+2: HF hospitalisation significantly reduced (RR 0.74, 95% CI 0.63 to 0.87); all-cause hospitalisation significantly reduced (RR 0.81, 95% CI 0.71 to 0.92). Group 3: HF hospitalisation significantly reduced (RR 0.66, 95% CI 0.52 to 0.83). All-cause hospitalisation no significant effect. Group 4: HF hospitalisation significantly reduced (RR 0.66, 95% CI 0.52 to 0.83). All-cause hospitalisation significantly reduced (RR 0.73, 95% CI 0.57 to 0.93). Costs (18 studies): 15 found cost savings; 3 found neutral costs.
Medical Advisory Secretariat (2009);65 Canada	RCTs n=8 n=2692 4 databases, inception-2008	Heart failure Adult patients with HF SR and meta-analysis	Care not provided by multiple practitioners 4 At least 12 months	All included a team of nurse and physician and/or general practitioner, one of which specialised in HF management. Varying combinations of disease-specific education, diet, lifestyle, exercise counselling, self-care support, follow-up. Delivered directly (clinic based programme) or indirectly (telephone based, physician supervised, nurse-led). Primary, secondary, community	Readmissions: All-cause (7 studies): Non-significant increase in intervention group. Significant 12% reduction when care delivered through a direct (clinic) model. HF-specific (6 studies): Non-significant RR reduction of 14% in intervention. LoS (7 studies): Patients receiving intervention generally had shorter LoS whether measured as mean duration (4 studies) or total bed days (3 studies). A&E use (1 study): 77% of intervention patients vs 84% of control patients had an ED visit within 12 months (p=0.029).
Roccaforte et al (2005);66 Canada	RCTs n=33 Not specified 4 databases, 1980–2004	Heart failure HF patients followed up in outpatient setting SR and meta-analysis	Referral to family physician or home care services after discharge 5 3–22 months	Multidisciplinary approach, starting during hospitalisation, continuing for up to 12 months postdischarge, delivered by various professionals Approach centred on specific health professionals, eg, HF specialist nurses or case managers, focused on particular care components, eg, therapy adherence Primary, secondary, community	Readmissions: All-cause: 7/32 studies found significant reductions (OR 0.76, 95% CI 0.69 to 0.94). HR-specific: 8/20 found significant reductions (OR 0.58, 95% CI 0.50 to 0.67). By subgroup: Group 1: All-cause and HF-specific readmissions significantly reduced (OR 0.58, 95% CI 0.47 to 0.71) and (OR 0.58, 95% CI 0.45 to 0.75), respectively. Group 2: All-cause and HF-specific readmissions significantly reduced (OR 0.82, 95% CI 0.74 to 0.91) and ()R 0.61, 95% CI 0.51 to 0.73), respectively. LoS (12 studies): Significant reduction of −1.49 days (95% CI −2.03 to −0.95 days).
Sikich (2012);38 Canada	HTAs, SR, RCTs, n=6 n=1370 6 databases, 1995–2010	COPD Adult patients with COPD Narrative	Care not provided by multiple practitioners 4 3–12 months	Interventions based on CCM components, delivered by various professionals as a team in one organisation or range of organisations together as a unique team. Most teams included a respiratory specialist and/or a physician. Primary, secondary, community	Admissions: All-cause (4 studies): Statistically significant 25% RR reduction in favour of intervention (p<0.0001) (moderate evidence). COPD-specific (3 studies): Statistically significant 33% RR reduction in favour of intervention (p=0.002) (moderate evidence). A&E use: All-cause (2 studies): Both showed non-significant reduction (RR 0.64, 95% CI 0.31 to 1.33). COPD-specific (1 study): Significant reduction (RR 0.59, 95% CI 0.43 to 0.81).
Smith et al (2007);39 Ireland	RCTs, CCTs, before/after, time series n=20 Not specified 7 databases, inception-2006	Chronic disease Patients in a primary and secondary shared care service Narrative	Care not provided by multiple practitioners 5 Not specified	Liaison meetings attended by specialists and primary care staff to discuss and plan ongoing patient management; shared care record carried by the patient, computer-assisted shared care and email with data available to primary and secondary care Primary, secondary	Admissions (7 studies): Mixed results. Intervention was associated with a reduction in admissions in older patients and those with higher baseline morbidity. Costs (11 studies): 3 performed full economic analyses, of which 2 reported incremental cost savings in intervention. Seven studies reported direct costs: 1 showed higher costs in intervention; 6 reported mixed results (4/6 showed intervention more expensive than control, 2/6 reported lower costs in intervention).
Smith et al (2012);40 Ireland*	RCTs, CCTs, before/after, time series n=10 n=3357 9 databases, various–2011	Chronic disease Patients with multimorbidity in primary care or community Narrative	Not specified 5 2–24 months	Any intervention to improve outcomes for patients with multimorbidity in primary or community care delivered by an MDT. 6 studies assessed MDT interventions. Primary, community	Admissions (5 studies): One study found significant reduction in admissions with intervention; 4 found no difference between groups. Costs (4 studies): One reported no difference between groups; one had no results available; one reported a non-significant marginal benefit for intervention, one reported net savings in intervention costs but did not account for other costs.
Self-management
Franek (2013);41 Canada	SR, RCTs, meta-analyses n=10 n=6074 5 databases, 2000–2012	Chronic disease Adult patients with chronic disease Narrative	Care from the usual provider 3.5 4–12 months	Stanford chronic disease programme: 6 weekly 2.5 hour sessions with 10–15 participants, in community settings, with volunteer lay facilitators assisting patients to make their own management choices and reach self-selected goals. Primary, secondary, community	Admissions (3 studies): No significant difference in admission rates between intervention and control in any study (low quality evidence). LoS (5 studies): None showed any significant differences between groups at 6 months. A&E use (5 studies): No significant differences between groups.
Harrison et al (2015);67 Canada	RCTs n=7 n=1115 7 databases, inception-2014	COPD Adult patients hospitalised following acute exacerbation SR and meta-analysis	Not specified 3.5 2 weeks-12 months	Action plans involving symptom monitoring, education and at least 2 of 7 self-management skills (self-efficacy, problem solving, resource use, collaboration, emotional/role management, goal setting). Delivered by nurses when patient is in hospital, or within 1 month of discharge. Secondary, community	Readmissions (5 studies). Meta-analysis found no significant differences at 12 months between intervention and control groups in terms of the number of patients readmitted to hospital. Mean difference 1.32, CI 0.71 to 2.46 (p=0.38).
Jovicic et al (2006);42 Canada	RCTs n=6 n=857 6 databases, inception-2005	Heart failure Adult patients with HF Narrative	Not specified 4 3–12 months	Education and limited follow-up: patients taught to monitor condition and recognise symptom exacerbation; follow-up phone call and face to face or digital education. Delivered by nurses or AHPs. Secondary, community	Readmissions: All-cause (5 studies): Significant reduction in intervention (OR 0.59, 95% CI 0.44 to 0.80). HF-specific (3 studies): Significant reduction in intervention (OR 0.44, 95% CI 0.27 to 0.71). Costs (3 studies): All reported annual savings for intervention vs usual care of between US$1300 and US$7515.
Smith et al (2012);40 Ireland	RCTs, CCTs, before/after, time series n=10 n=3357 9 databases, various–2011	Chronic disease Patients with multimorbidity in primary care or community Narrative	Not specified 5 2–24 months	Any patient-orientated intervention to promote self-management in patients with multimorbidity in primary or community care. Four studies assessed self-management interventions. Primary, community	Admissions (2 studies): One reported significant reduction in favour of intervention. The other found no difference between groups. Costs (2 studies): One reported cost savings per participant due to reduction in admission rates in intervention group. The other found no difference between groups.
Zwerink et al (2014);68 Netherlands	RCTs, controlled trials, n=31 n=3688 6 databases, 1995–2011	COPD Patients with clinical diagnosis of COPD SR and meta-analysis	Not specified 5 2–24 months	Structured interventions to improve self-health and self-management skills. At least 2 of action plan, exercise programme, smoking cessation, dietary advice, medication review, coping with breathlessness advice, CBT, motivational interviewing, goal setting, feedback. Primary, secondary, community	Admissions: All-cause (6 studies): 310 patients per 1000 admitted within 12 months in intervention vs 428 control. Statistically significant reduction (OR 0.60, 95% CI 0.40 to 0.89). COPD-specific (9 studies): 190 patients per 1000 admitted within 12 months in intervention vs 293 control. Statistically significant reduction (OR 0.57, 95% CI 0.43 to 0.75). LoS (5 studies): No differences between groups.

*Smith et al40 listed twice due to focus on MDT interventions and self-management interventions.
AHP, allied health professional; CBT, cognitive–behavioural therapy; CCM, chronic care model; CCT, controlled clinical trial; ED, emergency department; ESD, early supported discharge; HF, heart failure; HTA, health technology assessment; LoS, length of stay; MDT, multidisciplinary team; MI, myocardial infarction; OT, occupational therapy; QA, quality assessment; RR, relative risk; SMD, standardised mean difference; SR, systematic review.