Does integrated care reduce hospital activity for patients with chronic diseases? An umbrella review of systematic reviews
DAMERY Sarah, FLANAGAN Sarah, COMBES Gill
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 post-discharge 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.