Implementation of interventions to reduce preventable hospital admissions for cardiovascular or respiratory conditions: an evidence map and realist synthesis

Abstract

Background In 2012, a series of systematic reviews summarised the evidence regarding interventions to reduce preventable hospital admissions. Although intervention effects were dependent on context, the reviews revealed a consistent picture of reduction across different interventions targeting cardiovascular and respiratory conditions. The research reported here sought to provide an in-depth understanding of how interventions that have been shown to reduce admissions for these conditions may work, with a view to supporting their effective implementation in practice. Objectives To map the available evidence on interventions used in the UK NHS to reduce preventable admissions for cardiovascular and respiratory conditions and to conduct a realist synthesis of implementation evidence related to these interventions. Methods For the mapping review, six databases were searched for studies published between 2010 and October 2017. Studies were included if they were conducted in the UK, the USA, Canada, Australia or New Zealand; recruited adults with a cardiovascular or respiratory condition; and evaluated or described an intervention that could reduce preventable admissions or re-admissions. A descriptive summary of key characteristics of the included studies was produced. The studies included in the mapping review helped to inform the sampling frame for the subsequent realist synthesis. The wider evidence base was also engaged through supplementary searching. Data extraction forms were developed using appropriate frameworks (an implementation framework, an intervention template and a realist logic template). Following identification of initial programme theories (from the theoretical literature, empirical studies and insights from the patient and public involvement group), the review team extracted data into evidence tables. Programme theories were examined against the individual intervention types and collectively as a set. The resultant hypotheses functioned as synthesised statements around which an explanatory narrative referenced to the underpinning evidence base was developed. Additional searches for mid-range and overarching theories were carried out using Google Scholar (Google Inc., Mountain View, CA, USA). Results A total of 569 publications were included in the mapping review. The largest group originated from the USA. The included studies from the UK showed a similar distribution to that of the map as a whole, but there was evidence of some country-specific features, such as the prominence of studies of telehealth. In the realist synthesis, it was found that interventions with strong evidence of effectiveness overall had not necessarily demonstrated effectiveness in UK settings. This could be a barrier to using these interventions in the NHS. Facilitation of the implementation of interventions was often not reported or inadequately reported. Many of the interventions were diverse in the ways in which they were delivered. There was also considerable overlap in the content of interventions. The role of specialist nurses was highlighted in several studies. The five programme theories identified were supported to varying degrees by empirical literature, but all provided valuable insights. Limitations The research was conducted by a small team; time and resources limited the team’s ability to consult with a full range of stakeholders. Conclusions Overall, implementation appears to be favoured by support for self-management by patients and their families/carers, support for services that signpost patients to consider alternatives to seeing their general practitioner when appropriate, recognition of possible reasons why patients seek admission, support for health-care professionals to diagnose and refer patients appropriately and support for workforce roles that promote continuity of care and co-ordination between services. Future work Research should focus on understanding discrepancies between national and international evidence and the transferability of findings between different contexts; the design and evaluation of implementation strategies informed by theories about how the intervention being implemented might work; and qualitative research on decision-making around hospital referrals and admissions. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Interventions to manage use of the emergency and urgent care system by people from vulnerable groups: a mapping review

“…l The role of technology and health informatics, briefly touched on by this report, requires further examination, particularly relating to the identification and co-ordination of frequent users. 64 l The findings of the review further indicate the potential for realist evaluation approaches, 63,65,66 especially as several interventions identified seem to be heavily context dependent.…”

Synthesis for health services and policy: case studies in the scoping of reviews

“…The review was conducted in multiple stages between September 2017 and April 2019 and published in 2020. 44 The review topic was initially stated in broad terms:…”

“…For attribution the title, original author(s), the publication source -NIHR Journals Library, and the DOI of the publication must be cited. Studies were included if they were conducted in the UK, the USA, Canada, Australia or New Zealand; recruited adults with a cardiovascular or respiratory condition; and evaluated or described an intervention that could reduce preventable admissions or re-admissions 44 The mapping review: . .…”

“…helped to inform the sampling frame for the subsequent realist synthesis. We also engaged with the wider evidence base (using supplementary searches) through systematic reviews, opinion pieces and direct reference to individual study reports, particularly when authors themselves established a connection to the UK context 44 The review made use of the pre-existing Sheffield HSDR Evidence Synthesis Centre Public Involvement Advisory Group, which provided input at various stages. (How many, and how they were selected for consulting about this review was not stated.)…”

“…Following identification of the initial programme theories, the review team extracted data into evidence tables. The resultant hypotheses functioned as synthesised statements around which we developed an explanatory narrative Reproduced with permission from Chambers et al 44 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https:// creativecommons.org/licenses/by/4.0/…”