Table 1
Study inclusion and exclusion criteria.
| Population | Older adults |
|---|---|
| Intervention | Inclusion: Organisational or systemic level of integration; Exclusion: interventions not consisting of pooled resources, interventions for hospitalised patients, interventions focusing on a single medical disease |
| Comparisons of interest | Comparison of no intervention i.e. usual care or comparison with baseline measures of the intervention group; Exclusion: Studies with no comparison |
| Outcomes | Any objective measure of hospital admission, length of hospital stay, hospital readmission, mortality, and subjective measure of patient satisfaction |
| Type of study | Inclusion: studies of any designs published between January 1995 to October 2018 written in English; Exclusion: Studies with no original data e.g. reviews, studies without an abstract |
Figure 1
Study selection flowchart.
Table 2
Characteristics of studies included in this systematic review.
| Author, year | Country | Study design | Study subjects | Length of follow-up | Integrated care programme | Outcomes reported |
|---|---|---|---|---|---|---|
| Atherly et al. 2004 | USA | survey | n = 402 community-dwellers; n = 235 enrolled to the Program for All-Inclusive Care of the Elderly (PACE) and n = 167 non-PACE community-dwellers | 18 months | PACE (The Program for All-Inclusive Care of the Elderly) involves comprehensive integration of medical and social services and care including care planning with family members. | Patient satisfaction |
| Beland et al. 2006 | Canada | RCT | n = 1297 community-dwellers aged >64 years with moderate or severe functional problems (assessed using the Functional Autonomy Measurement System) of which n = 606 assigned to SIPA and n = 624 assigned to the usual services available | 22 months | SIPA (System of Integrated Care for Older Persons) a publicly managed and funded system of community-based multidisciplinary teams with full clinical responsibility for delivering integrated care through the provision of community health and social services and the coordination of hospital and nursing home care. | Hospital admission, patient satisfaction, mortality |
| Bernabei et al. 1998 | Italy | RCT | n = 200 community-dwellers aged ≥65 years with frailty based on their physical, mental and cognitive health identified through existing home health services or home assistance programmes; n = 100 intervention and n = 100 controls who received care as usual | 12 months | Intervention involving case management and care planning by the community geriatric evaluation unit consisting of 2 case managers (performing assessments, monitoring the provision of services), 1 social worker, 1 geriatrician, nurses and general practitioners. | Hospital admission, length of stay, mortality |
| Brown et al. 2003 | UK | mixed-methods | n = 393 community-dwellers aged >64 years; n = 195 integrated care, n = 198 care as usual | 18 months | Joint working primary and social care consisting of two co-located integrated teams, one based in a general practice and the other in a health centre attached to a general practice. | Patient satisfaction |
| Ham et al. 2003 | USA, England | comparative study | Data from medical records presented in numbers per 100 000 population consisting of people aged ≥65 years | n/a | Kaiser-Permanente: a medical care program that involves voluntary enrolment, prepayment for services, comprehensive benefits, preventive medical care, integrated hospital-based health care facilities, and provision of physician services through group medical practice vs NHS (National Health Service): the universal and free healthcare programme in England. | Hospital admission, length of stay |
| Hebert et al. 2010 | Canada | quasi-experimental | n = 920 community-dwellers aged ≥75 years at risk of functional decline (assessed using the Functional Autonomy Measurement System); n = 501 assigned to PRISMA and n = 419 controls receiving care as usual | 4 years | PRISMA (Program of Research to Integrate Services for the Maintenance of Autonomy) an embedded model with a single entry point using all the public, private, or voluntary health and social service organisations involved in caring for older people in a given area where every organisation keeps its own structure but agrees to participate under an umbrella system and to adapt its operations and resources to the agreed requirements and processes. Case manager included in PRISMA could be any clinical healthcare professional and is responsible for conducting a thorough assessment of the patient’s needs, planning the required services, arranging patient admission to these services, etc. | Hospital admission, patient satisfaction, length of stay, readmission, mortality |
| Landi et al. 1999 | Italy | quasi-experimental | n = 115 community-dwellers, mean age 77.5 years (+/– 11.7) assessed pre/post intervention | 6 months | Case managers and the geriatric evaluation unit designed and implemented individualised care plans in agreement with general practitioners, and determined the services for which patients were eligible. The approved services were then provided by multidisciplinary teams, with the case manager coordinating the delivery and facilitating the integration process between social and healthcare professionals. | Hospital admission, length of stay |
| Landi et al. 2001 | Italy | quasi-experimental | n = 1204 community-dwellers, mean age 77.4 years (+/– 9.7) assessed pre/post intervention | 12 months | National model that integrates all the community-based services provided either by the health agency or by the municipality into one “single enter” centre. | Hospital admission, length of stay |
| Looman et al. 2014 | The Netherlands | quasi-experimental | n = 417 community-dwellers aged ≥75 years who were frail (assessed with the Groningen Frailty Indicator); n = 205 assigned to WICM and n = 212 received care as usual | 3 months | WICM (Walcheren Integrated Care Model) includes a single entry point system through the general practice known for patient data being shared across teams and focus on prevention. Case managers organise admittance to the required services, the planning and co-ordination of care delivery and periodical evaluation and monitoring of the treatment plan in cooperation with multidisciplinary teams. | Patient satisfaction |
| Schiotz et al. 2011 | USA, Denmark | comparison study | Data from medical records of people aged ≥65 years with one or more of the following 5 chronic conditions: angina, heart failure, COPD, hypertension and diabetes. | n/a | Kaiser-Permanente: a medical care programme that involves voluntary enrolment, prepayment for services, comprehensive benefits, preventive medical care, integrated hospital-based health care facilities, and provision of physician services through group medical practice vs Danish Healthcare system (DHS): the universal and free healthcare programme in Denmark. | Hospital admission, length of stay, readmission, mortality |
| de Stampa et al. 2014 | France | quasi-experimental | n = 428 community-dwellers aged >64 years classified as very frail (assessed using Katz ADL, Lawton IADL, the cognitive performance scale, the depression rating scale, etc.); n = 105 assigned to COPA intervention and n = 323 received care as usual | 12 months | COPA (Coordination of care for the elderly) single entry point system connecting primary care and hospital care, home-based geriatric assessment, individualised care plan, interdisciplinary protocols, case manager organises planned hospital visits. | Hospital admission |
| Tourigny et al. 2004 | Canada | quasi-experimental | n = 482 people aged ≥75 years (2/3 living in own home, 1/3 in private seniors’ residence) reporting functional decline (based on Katz ADL, Lawton IADL, etc.); n = 272 in geographical area where ISD is provided and n = 210 in different geographical area where there was no ISD network | 5 years | ISD (Integrated service delivery) network of health and social services is a single entry service designed to manage both home and institutional care that involves exchange of clinical information across institutions. The service is run by case managers who develop individual service plans for enrolled patients. | Hospital admission, length of stay, readmission, mortality |
Table 3
Summary of findings on patient-related outcomes of integrated care comprising older adults.
| Author, year | Level of integration | Patient satisfaction | Hospital admission | Length of stay | Readmission | Mortality |
|---|---|---|---|---|---|---|
| Atherly et al. 2004 | Systemic | Significantly greater satisfaction in level of concern and attentiveness displayed by staff (p < 0.01) and patient’s decisions about their care (p < 0.01) but not access to medical specialists (p = 0.54) among PACE-enrolled participants compared to non-participants completing the 23-item PACE satisfaction survey. | n/a | n/a | n/a | n/a |
| Beland et al. 2006 | Systemic | No significant difference between intervention and control groups using the 8-item Client Satisfaction Questionnaire. No effect size reported. | No significant difference between intervention and control groups. No effect size reported. | n/a | n/a | No significant difference between intervention and control groups. No effect size reported. |
| Bernabei et al. 1998 | Organisational | n/a | Significantly reduced risk in the intervention group. HR: 0.74 95% CI 0.56–0.97, p < 0.05 | n/a | n/a | No significant difference between intervention and control group. HR 0.99 95% CI 0.89–1.09 |
| Brown et al. 2003 | Organisational | No major differences between intervention and control group regarding their satisfaction with the services received – question asked in qualitative interview. No effect size reported. | n/a | n/a | n/a | n/a |
| Ham et al. 2003 | Systemic | n/a | Lower admission rates in KP compared to NHS in 6 of 11 common causes. No effect size reported. | Shorter stay for patients in KP compared to NHS no matter reason for admission. No effect size reported. | n/a | n/a |
| Hebert et al. 2010 | Organisational | Significant improvements in satisfaction with services, delivery of care, and organisation of care and services (all p < 0.001) in intervention group and no changes in control group using the 26-item Health Care Satisfaction Questionnaire | No significant differences in admissions rates in intervention group (rates remained the same) and control group (rates increased) p = 0.578 | No difference observed between intervention and control group. No effect size reported. | No difference observed between intervention and control group. No effect size reported. | No difference observed between intervention and control group p > 0.05 |
| Landi et al. 1999 | Organisational | n/a | Significant decrease in admission rates post intervention compared to pre intervention p < 0.001 | Significantly shorter stays post intervention compared to pre intervention p < 0.01 | n/a | n/a |
| Landi et al. 2001 | Organisational | n/a | Significant decrease in admission rates post intervention compared to pre intervention p < 0.001 | Significantly shorter stays post intervention compared to pre intervention p = 0.01 | n/a | n/a |
| Looman et al. 2014 | Organisational | No significant difference between intervention and control group using study-specific consumer quality index with questions on client-orientation, knowledge of care needs, joint decision making, attention to social-emotional aspects, information, and approach | n/a | n/a | n/a | n/a |
| Schiotz et al. 2011 | Systemic | n/a | Significantly higher admission rates in DHS compared to KP: 5.21 hospitalisations/100 persons 95% CI 5.17–5.26 in DHS and 2.02 hospitalisations/100 persons 95% CI 1.98–2.06 in KP | No significant difference between DHS and KP (4.08 days in DHS, 3.91 days in KP) | Significantly higher readmission rates in DHS compared to KP (OR 1.10 95% CI 1.03–1.16) | No significant difference between DHS and KP (effect size reported for each condition, no effect size on overall findings) |
| de Stampa et al. 2014 | Organisational | n/a | Significantly reduced risk of having at least one unplanned hospitalisation in the intervention group. OR: 0.39 95% CI 0.16–0.98 | n/a | n/a | n/a |
| Tourigny et al. 2004 | Organisational | n/a | No significant difference between intervention and control group p = 0.11 | No significant difference in average hospitalisation duration between intervention and control group p = 0.28 | No significant difference between intervention and control group p = 0.17 | No significant difference between intervention and control group p = 0.37 |
Figure 2
Summary of studies related to each of the patient-related outcomes assessed.
| Author (year) | Study design | Selection bias | Risk of performance bias | Risk of detection bias | Risk of attrition bias | Risk of reporting bias | Risk of conflict of interest | Interweaved risk of bias |
|---|---|---|---|---|---|---|---|---|
| Atherly et al. (2004) | Quasi-experimental | Moderate | Low | Moderate | Moderate | Low | Moderate | Moderate |
| Beland et al. (2006) | RCT | Low | Low | Low | Moderate | Low | Low | Low |
| Bernabei et al. (1998) | RCT | Low | Low | Low | Low | Low | Low | Low |
| Ham et al. (2003) | Retrospective cohort | Moderate | Moderate | Low | Low | Low | Low | Low |
| Hebert et al. (2009) | Quasi-experimental Study | Moderate | Moderate | Moderate | Low | Moderate | Low | Moderate |
| Landi et al. (1999) | Quasi-experimental study | Low | Low | Low | Low | Moderate | Moderate | Low |
| Landi et al. (2001) | Quasi-experimental study | Low | Low | Low | Moderate | Low | Moderate | Low |
| Looman et al. (2014) | Quasi-experimental Study | Low | Low | Moderate | Low | Low | Moderate | Low |
| Schiotz et al. (2011) | Retrospective cohort | Moderate | Moderate | Moderate | Low | Low | Low | Moderate |
| de Stampa et al. (2014) | Quasi-experimental Study | Low | Low | Low | Moderate | Low | Low | Low |
| Tourigny et al. (2004) | Quasi-experimental | Low | Low | Low | Low | Low | Moderate | Low |
| Author (year) | Study design | Well defined aim | Risk of Selection bias | Risk of data collection bias | Risk of analysis bias | Risk of reporting bias | Interweaved risk of bias | |
|---|---|---|---|---|---|---|---|---|
| Brown et al. (2003) | Non-randomised comparative study | Yes | Low | Low | Low | Low | Low |