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.
This booklet sets out research findings of the benefits of supporting people to self-manage. It also sets out the evidence for the impact of self-management education for patients, proactive telephone and psychosocial support, home-based self-monitoring and simplified dosing strategies and information. Self-management includes all the actions taken by people to recognise, treat and manage their own healthcare independently of or in partnership with the healthcare system. People feel more confident and engaged when they are encouraged to self-manage by professionals, therefore supporting self-management is key to prioritising person-centred care. Drawing on the findings from 228 systematic reviews, the paper concludes that the top three things that might most usefully be invested in are disease specific, generic and on-line self-management courses, proactive telephone support and self monitoring of symptoms and vital signs.
MILLER Kimberly J., et al
Background: Use of virtual reality and commercial gaming systems (VR/gaming) at home by older adults is receiving attention as a means of enabling physical activity.
Objective: to summarise evidence for the effectiveness and feasibility of VR/gaming system utilisation by older adults at home for enabling physical activity to improve impairments, activity limitations or participation.
Methods: A systematic review searching 12 electronic databases from 1 January 2000–10 July 2012 using key search terms. Two independent reviewers screened yield articles using pre-determined selection criteria, extracted data using customised forms and applied the Cochrane Collaboration Risk of Bias Tool and the Downs and Black Checklist to rate study quality.
Results: Fourteen studies investigating the effects of VR/gaming system use by healthy older adults and people with neurological conditions on activity limitations, body functions and physical impairments and cognitive and emotional well-being met the selection criteria. Study quality ratings were low and, therefore, evidence was not strong enough to conclude that interventions were effective. Feasibility was inconsistently reported in studies. Where feasibility was discussed, strong retention (≥70%) and adherence (≥64%) was reported. Initial assistance to use the technologies, and the need for monitoring exertion, aggravation of musculoskeletal symptoms and falls risk were reported.
Conclusions: Existing evidence to support the feasibility and effectiveness VR/gaming systems use by older adults at home to enable physical activity to address impairments, activity limitations and participation is weak with a high risk of bias. The findings of this review may inform future, more rigorous research.