The Effectiveness of Integrated Care Pathways for Adults and Children in Health Care Settings: A Systematic Review

Allen, Davina; Gillen, Elizabeth; Rixson, Laura

doi:10.11124/jbisrir-2009-182

Cited by 40 publications

(23 citation statements)

References 14 publications

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“…This finding is consistent with systematic reviews that evaluate other structured multidisciplinary care pathways in hospital settings where clinical care is predictable. [122][123][124][125] Our overall results suggest that enhanced recovery programmes do not compromise patient safety but this evidence was based on variably defined outcomes. Differences in morbidity rates between enhanced recovery and conventionally treated patients were observed but these were not consistent.…”

Section: Discussionmentioning

confidence: 99%

Initiatives to reduce length of stay in acute hospital settings: a rapid synthesis of evidence relating to enhanced recovery programmes

Paton

Chambers

Wilson

et al. 2014

Health Services and Delivery Research

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BackgroundThere has been growing interest in the NHS over recent years in the use of enhanced recovery programmes for elective surgery to deliver productivity gains through reduced length of stay, fewer postoperative complications, reduced readmissions and improved patient outcomes.ObjectivesTo evaluate the clinical effectiveness and cost-effectiveness of enhanced recovery programmes for patients undergoing elective surgery in acute hospital settings. To identify and critically describe key factors associated with successful adoption, implementation and sustainability of enhanced recovery programmes in UK settings. To summarise existing knowledge about patient experience of enhanced recovery programmes in UK settings.Data sourcesEight databases, including Database of Abstracts of Reviews and Effects, International Prospective of Systematic Reviews, NHS Economic Evaluation Database and MEDLINE, were searched from 1990 to March 2013 without language restrictions. Relevant reports and guidelines and reference lists of retrieved articles were scanned to identify additional studies.Review methodsSystematic reviews, randomised controlled trials (RCTs), economic evaluations, and UK NHS cost analysis studies were included if they evaluated the impact of enhanced recovery programmes on any health- and cost-related outcomes. Eligible studies included patients undergoing elective surgery in an acute hospital setting. Implementation case studies and surveys of patient experience in a UK setting were also eligible for inclusion. Quality assessment of systematic reviews, RCTs and economic evaluations was based on existing Centre for Reviews and Dissemination processes. All stages of the review process were performed by one researcher and checked by a second with discrepancies resolved by consensus. The type and range of evidence precluded meta-analysis and we therefore performed a narrative synthesis, differentiating between clinical effectiveness and cost-effectiveness, implementation case studies and evidence on patient experience.ResultsSeventeen systematic reviews of varying quality were included in this report. Twelve additional RCTs were included; all were considered at high risk of bias. Most of the evidence focused on colorectal surgery. Fourteen innovation case studies and 15 implementation case studies undertaken in NHS settings were identified and provide descriptions of factors critical to the success of an enhanced recovery programme. Ten relevant economic evaluations were identified evaluating costs and outcomes over short time horizons. Despite the plethora of studies, robust evidence was sparse. Evidence for colorectal surgery suggests that enhanced recovery programmes may reduce hospital stays by 0.5–3.5 days compared with conventional care. There were no significant differences in reported readmission rates. Other surgical specialties showed greater variation in reported reductions in length of stay reflecting the limited evidence identified.LimitationsFindings relating to other clinical outcomes, cost-effectiveness, implementation and patient experience were hampered by a lack of robust evidence and poor reporting.ConclusionsThere is consistent, albeit limited, evidence that enhanced recovery programmes may reduce length of patient hospital stay without increasing readmission rates. The extent to which managers and clinicians considering implementing enhanced recovery programmes can realise reductions and cost savings will depend on length of stays achieved under their existing care pathway. RCTs comparing an enhanced recovery programme with conventional care continue to be conducted and published. Further single-centre RCTs of this kind are not a priority. Rather, what is needed is improved collection and reporting of how enhanced recovery programmes are implemented, resourced and experienced in NHS settings.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Section: Discussionmentioning

confidence: 99%

Initiatives to reduce length of stay in acute hospital settings: a rapid synthesis of evidence relating to enhanced recovery programmes

Paton

Chambers

Wilson

et al. 2014

Health Services and Delivery Research

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“…Client motivation and readiness to make changes, access to supportive family and social networks, as well as the presence of trauma, substance use issues, child protection concerns, domestic violence and cultural norms where women are devalued, influenced mechanisms and outcomes. These findings suggest the long-term nature of effective service provision may prove resource intensive and reinforces the need for further research into the cost benefits of integrated care initiatives [ 11 , 12 ].…”

Section: Discussionmentioning

confidence: 95%

A critical realist evaluation of an integrated care project for vulnerable families in Sydney, Australia

Tennant

Miller²,

Costantino³

et al. 2020

BMC Health Serv Res

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Background Healthy Homes and Neighbourhoods (HHAN) Integrated Care Initiative was established to improve the care of families with complex health and social needs who reside in Sydney Local Health District. HHAN seeks to provide long-term multi-disciplinary care coordination as well as enhance capacity building and promote integrated care. The critical realist study reported here is part of the longitudinal development and evaluation of complex integrated health and social care interventions in Sydney, Australia. Methods We describe the qualitative component of a critical realist pilot case study aimed at exploring, explaining and refining emerging HHAN programme theories in relation to care coordination. Qualitative interviews were undertaken with HHAN clients (n = 12), staff and other stakeholders (n = 21). Interviews and coding used a context (C), mechanism (M) and outcome (O) framework. Inductive, deductive, retroductive and abductive modes of reasoning were used with the CMO heuristic tool to inform the developing programme theory. Results The mechanisms underpinning effective engagement of clients by care coordinators included: building trust, leveraging other family, social and organisational relationships, meeting clients on their own terms, demonstrating staff effectiveness as quickly as possible, and client empowerment. Mechanisms for enhancing care integration included knowledge transfer activities and shared learning among collaborators, structural and cultural changes, enhancing mutual respect, co-location of multidisciplinary and/or interagency staff and cultivating faith in positive change among staff. Conclusions Use of a critical realism case study approach served to elucidate the varied influences of contexts and mechanisms on programme outcomes, to highlight what works for whom and in what context. Findings supported the initial programme theory that engagement and trust building with clients, alongside enhanced collaboration and integration of services, improved outcomes for vulnerable families with complex needs. Further research is needed to explore the cost-effectiveness of integrated care initiatives, in view of the long term nature of service provision and the risk of staff burnout.

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“…Client motivation and readiness to make changes, access to supportive family and social networks, as well as the presence of trauma, substance use issues, child protection concerns, domestic violence and cultural norms where women are devalued, influenced mechanisms and outcomes. These findings suggest the longterm nature of effective service provision may prove resource intensive and reinforces the need for further research into the cost benefits of integrated care initiatives(10,11).…”

mentioning

confidence: 78%

“…In addition, access to services should promote equity and be cost effective in preventing the consequences of poor physical and mental health, and adverse social outcomes. An emerging evidence base, both internationally and in Australia, supports the adoption of integrated care initiatives to make services, support and care more accessible for vulnerable families with complex needs (10)(11)(12).…”

Section: Introductionmentioning

confidence: 99%

A Critical Realist Evaluation of an Integrated Care Project for Vulnerable Families in Sydney, Australia

Tennant

Miller

Costantino

et al. 2020

Preprint

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Background Healthy Homes and Neighbourhoods (HHAN) Integrated Care Initiative was established to improve the care of families with complex health and social needs who reside in Sydney Local Health District. HHAN seeks to provide long-term multi-disciplinary care coordination as well as enhance capacity building and promotion of integrated care. We describe the qualitative component of a critical realist pilot case study aimed at exploring, explaining and refining emerging HHAN programme theories in relation to care coordination. Methods Semi-structured qualitative interviews with HHAN clients (n=12), HHAN staff and other stakeholders (n=21). Emerging themes informed the development of Context-Mechanism-Outcome configurations aimed at evaluating HHAN’s effectiveness and refining the programme theory. Results HHAN’s effectiveness was based on two process mechanisms: Engagement of vulnerable clients and integration of services. The relational mechanisms underpinning effective engagement of clients by care coordinators included: building trust, leveraging other family, social and organisational relationships, meeting clients on their own terms, demonstrating staff effectiveness as quickly as possible, and client empowerment. Operational mechanisms for enhancing care integration included knowledge transfer activities and shared learning among collaborators, structural and cultural changes, enhancing mutual respect, co-location of multidisciplinary and/or interagency staff and cultivating faith in positive change among staff. Conclusions Use of a critical realism case study approach served to elucidate the varied influences of contexts and mechanisms on programme outcomes, to highlight what works for whom and in what context. Findings supported the initial programme theory that engagement and trust building with clients, alongside enhanced collaboration and integration of services, improved outcomes for vulnerable families with complex needs. Further research is needed to explore the cost-effectiveness of integrated care initiatives, in view of the long term nature of service provision and the risk of staff burnout.

show abstract

The Effectiveness of Integrated Care Pathways for Adults and Children in Health Care Settings: A Systematic Review

Cited by 40 publications

References 14 publications

Initiatives to reduce length of stay in acute hospital settings: a rapid synthesis of evidence relating to enhanced recovery programmes

Initiatives to reduce length of stay in acute hospital settings: a rapid synthesis of evidence relating to enhanced recovery programmes

A critical realist evaluation of an integrated care project for vulnerable families in Sydney, Australia

A Critical Realist Evaluation of an Integrated Care Project for Vulnerable Families in Sydney, Australia

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