Systems approach to health service design, delivery and improvement: a systematic review and meta-analysis

Abstract

ObjectivesTo systematically review the evidence base for a systems approach to healthcare design, delivery or improvement.DesignSystematic review with meta-analyses.MethodsIncluded were studies in any patients, in any healthcare setting where a systems approach was compared with usual care which reported quantitative results for any outcomes for both groups. We searched Medline, Embase, HMIC, Health Business Elite, Web of Science, Scopus, PsycINFO and CINAHL from inception to 28 May 2019 for relevant studies. These were screened, and data extracted independently and in duplicate. Study outcomes were stratified by study design and whether they reported patient and/or service outcomes. Meta-analysis was conducted with Revman software V.5.3 using ORs—heterogeneity was assessed using I2 statistics.ResultsOf 11 405 records 35 studies were included, of which 28 (80%) were before-and-after design only, five were both before-and-after and concurrent design, and two were randomised controlled trials (RCTs). There was heterogeneity of interventions and wide variation in reported outcome types. Almost all results showed health improvement where systems approaches were used. Study quality varied widely. Exploratory meta-analysis of these suggested favourable effects on both patient outcomes (n=14, OR=0.52 (95% CI 0.38 to 0.71) I2=91%), and service outcomes (n=18, OR=0.40 (95% CI 0.31 to 0.52) I2=97%).ConclusionsThis study suggests that a systems approaches to healthcare design and delivery results in a statistically significant improvement to both patient and service outcomes. However, better quality studies, particularly RCTs are needed.PROSPERO registration numberCRD42017065920.

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“… 6 In a recent systematic review, Komashie and colleagues point to a diversity of challenges facing healthcare, such as multimorbidity, the complex nature of healthcare delivery and a range of organisational and cultural concerns. 7 In response, they argue for the adoption of a systems approach to strengthen the quality and delivery of healthcare. Such an approach acknowledges the interconnectedness that exists between all components within the healthcare sector, whilst emphasising the value of adopting adaptive iterative implementation of interventions.…”

Systems Approaches to Healthcare Systems Design and Care Delivery: An Overview of the Literature

“…Based on the working definition of a systems approach offered earlier in this paper, we sought to understand how well current practice of systems approach aligned with such definition. The assessment was aimed at 35 studies that were included in a recently published systematic review and meta-analysis (Komashie et al, 2021). The studies were assessed based on the extent to which they considered 'Systems' in their approach to improvement, the extent to which they considered 'Systems in the intervention, consideration of 'Design' and consideration of 'Risk'.…”

“…There is, clearly, considerable interest in assessing the evidence-base for the approach, however, these reviews have not been comprehensive enough and lack focus on patient and service outcomes. Taking a broader approach, a more recent systematic review and meta-analysis that looked at healthcare without time limits has found, across 35 included studies, that a systems approach to healthcare is significantly likely to lead to improvements in both patient and service outcomes (Komashie et al, 2021).…”

“…It is evident that the healthcare sector continues to face significant challenges that require a design and systems approach (Cameron et al, 2019;Reid et al, 2005;Tallack et al, 2020). Over the last two decades, however, there has been a rapid growth in the application of systems-informed approaches to healthcare design and improvement as seen in both the academic and grey literature (Bashford et al, 2018;Hafner and Shiffman, 2013;Komashie et al, 2021;Patou et al, 2020;Ravitz et al, 2018). With such increased application of a systems approach in healthcare, healthcare practitioners and policymakers have become interested in understanding the evidence-base for the approach but very few systematic syntheses of such evidence exist.…”

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“…Ciccone et al (2019) discuss the incorporation of a systems design perspective into dementia care during which interventions are usually centred on utilising smart health ICED21 technologies to improve healthcare systems through behaviour data collection, processing and application, targeting cognitive decline. The evidence base for a systems approach to healthcare design, delivery, or improvement has been systematically reviewed by Komashie et al (2021); and they observe statistically significant positive patient and service outcomes in studies that used a systems-related approach in any healthcare setting (e.g. an entire national health system, university hospitals, suburban areas, specific care units, diverse health domains) with any patients (e.g.…”