BackgroundThere is increasing interest in innovative methods to carry out systematic reviews of complex interventions. Theory-based approaches, such as logic models, have been suggested as a means of providing additional insights beyond that obtained via conventional review methods.MethodsThis paper reports the use of an innovative method which combines systematic review processes with logic model techniques to synthesise a broad range of literature. The potential value of the model produced was explored with stakeholders.ResultsThe review identified 295 papers that met the inclusion criteria. The papers consisted of 141 intervention studies and 154 non-intervention quantitative and qualitative articles. A logic model was systematically built from these studies. The model outlines interventions, short term outcomes, moderating and mediating factors and long term demand management outcomes and impacts. Interventions were grouped into typologies of practitioner education, process change, system change, and patient intervention. Short-term outcomes identified that may result from these interventions were changed physician or patient knowledge, beliefs or attitudes and also interventions related to changed doctor-patient interaction. A range of factors which may influence whether these outcomes lead to long term change were detailed. Demand management outcomes and intended impacts included content of referral, rate of referral, and doctor or patient satisfaction.ConclusionsThe logic model details evidence and assumptions underpinning the complex pathway from interventions to demand management impact. The method offers a useful addition to systematic review methodologies.Trial registration numberPROSPERO registration number: CRD42013004037.

BackgroundDemand management defines any method used to monitor, direct, or regulate patient referrals. Strategies have been developed to manage the referral of patients to secondary care, with interventions that target primary care, specialist services, or infrastructure. AimTo review the international evidence on interventions to manage referral from primary to specialist care. Design and settingSystematic review. MethodIterative, systematic searches of published and unpublished sources public health, health management, management, and grey literature databases from health care and other industries were undertaken to identify recent, relevant studies. A narrative synthesis of the data was completed to structure the evidence into groups of similar interventions. ResultsThe searches generated 8327 unique results, of which 140 studies were included. Interventions were grouped into four intervention categories: GP education (n = 50); process change (n = 49); system change (n = 38); and patient-focused (n = 3). It is clear that there is no 'magic bullet' to managing demand for secondary care services: although some groups of interventions may have greater potential for development, given the existing evidence that they can be effective in specific contexts.

BackgroundDemand management describes any method used to monitor, direct or regulate patient referrals. Several strategies have been developed to manage the referral of patients to secondary care, with interventions targeting primary care, specialist services, or infrastructure.ObjectiveThis research aimed to conduct an inclusive systematic review and logic model synthesis in order to better understand factors impacting on the effectiveness of interventions targeting referral between primary and secondary medical health care.DesignThe approach combined systematic review with logic modelling synthesis techniques to develop an evidence-based framework of factors influencing the pathway between interventions and system-wide changes.SettingPrimary health care.Main outcome measuresReferral from primary to secondary care.Review methodsSystematic searches were undertaken to identify recent, relevant studies. Quality of individual studies was appraised, with consideration of overall strength of evidence. A narrative synthesis and logic model summary of the data was completed.ResultsFrom a database of 8327 unique papers, 290 were included in the review. The intervention studies were grouped into four categories of education interventions (n = 50); process change interventions (n = 49); system change interventions (n = 38); and patient-focused interventions (n = 3). Effectiveness was assessed variously in these papers; however, there was a gap regarding the mechanisms whereby these interventions lead to demand management impacts. The findings suggest that, although individual-level interventions may be popular, the stronger evidence relates only to peer-review and feedback interventions. Process change interventions appeared to be more effective when the change resulted in the specialist being provided with more or better quality information about the patient. System changes including the community provision of specialist services by general practitioners, outreach provision by specialists and the return of inappropriate referrals appeared to have evidence of effect. The pathway whereby interventions might lead to service-wide impact was complex, with multiple factors potentially acting as barriers or facilitators to the change process. Factors related, first, to the doctor (including knowledge, attitudes and beliefs, and previous experiences of a service), second, to the patient (including condition and social factors) and, third, to the influence of the doctor–patient relationship. We also identified a number of potentially influential factors at a local level, such as perceived waiting times and the availability of a specialist. These elements are key factors in the pathway between an intervention and intended demand management outcomes influencing both applicability and effectiveness.ConclusionsThe findings highlight the complexity of the referral process and multiple elements that will impact on intervention outcomes and applicability to a local area. Any interventions seeking to change referral practice need to address factors relating to the individual practitioner, the patient and also the situation in which the referral is taking place. These conclusions apply especially to referral management in a UK context where this whole range of factors/issues lies well within the remit of the NHS. This work highlights that intermediate outcomes are important in the referral pathway. It is recommended that researchers include measure of these intermediate outcomes in their evaluation of intervention effectiveness in order to determine where blocks to or facilitators of system-wide impact may be occurring.Study registrationThe study is registered as PROSPERO CRD42013004037.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

7.1 Objective This review aimed to evaluate the current evidence for what impact different Liaison Psychiatry (LP) services are having on Emergency Departments (ED). Mental Health (MH) problems contribute to 12 million annual US ED attendances and 5% in the UK. 7.2 Methods Databases were searched for articles describing LP services for adult MH patients attending EDs which reported ED care-related outcomes, published since 2000. Articles were screened and relevant articles quality assessed and narratively synthesized. 7.3 Results 3653 articles were identified and 17 included in the review. Study designs were overall of poormoderate quality, using retrospective before-and-after study designs. LP services were categorized into four models. Models with MH personnel integrated into the ED team or triage reduced patient waiting time to be seen, may reduce patients leaving without being seen and have high staff satisfaction. Co-located MH space or personnel reduced patient waiting times. Care agreements with existing psychiatry teams ED T ED T evidence about patient satisfaction, costs, and onward care. 7.4 Conclusions Waiting times are shortened by MH personnel integrated into the ED and are more satisfactory to staff than other LP models. The involvement of a psychiatrist in the LP team improves the care quality. All models may improve safety for patients but most evaluations are of poor quality and therefore there is still insufficient evidence to recommend one service model over another and further robust research is required.

PurposeThe purpose of this paper is to report how an evaluation tool originally developed for Age-Friendly Cities was pilot-tested in the context of the Dementia Friendly Community (DFC) initiative of the city of Sheffield/UK. It presents finding and outputs on which other communities with dementia friendly agendas can draw.Design/methodology/approachThe original evaluation tool was adapted to a focus on dementia friendliness. Data collection involved scoping conversations, documentary analysis, interviews and group discussions. Following evidence appraisal, Sheffield’s approach to dementia friendliness was assessed. A local steering group was central to the study.FindingsThe evidence indicates areas of strength in Sheffield’s approach to dementia friendliness: involvement of older people; service provision; collaboration; monitoring and evaluation. Scope for improvement was identified around resource allocation, and use of existing guidance on dementia friendliness. Recommendations for policy and practice include enhancing pooling of resources, more detailed recording of resources allocated to dementia-related activity, and collection of evidence on how people affected by dementia have shaped the city’s DFC initiative. Key research outputs are an adaptable logic model and an emerging evaluation framework for DFCs.Research limitations/implicationsThe study was a short pilot with limited resources. Its findings and outputs must be considered preliminary.Originality/valueThe findings and outputs provide a basis for further research. The study has suggested key components of an evaluation framework for DFCs. It is informing ongoing work to develop such a framework.