Evaluating Interventions to Improve the Integration of Care (Among Multiple Providers and Across Multiple Sites)

Typically healthcare improvement programmes have been institution specific examining, for example hospitals, general practices or care homes. While such solipsistic quality improvement initiatives obviously have their place, they also have severe limitations for the patient of today who typically has many complex conditions and whose care is therefore fragmented across many different care providers working in different places. Such patients perceive, and are sometimes the victims of, gaps in the system. Recent attention has therefore turned to approaches to close these gaps, and I am leading an NIHR programme development grant specifically for this purpose (Improving clinical decisions and teamwork for patients with multimorbidity in primary care through multidisciplinary education and facilitation). There are many different approaches to closing these gaps in care and the Nobel Prize winner Elinor Ostrom has featured previously in this News Blog for her seminal work on barriers and facilitators to institution collaboration [1]; while my colleague, CLAHRC WM Deputy Director Graeme Currie, has approached this issue from a management science perspective.

The problem for a researcher is to measure the effectiveness of initiatives to improve care across centres. This is not natural territory for cluster RCTs since it would be necessary to randomise whole ‘health economies’ rather than just organisations such as hospitals or general practices. Furthermore, many of the outcomes that might be observed in such studies, such as standardised mortality rates, are notoriously insensitive to change.[2] The ESTHER Project in Sweden is famous for closing gaps in care across the hospital/community nexus.[3] The evaluation, however, consists of little more than stakeholder interviews where people seem to recite the perceived wisdom of the day as evidence of effectiveness. While I think it is eminently plausible that the intervention was effective, and while the statements made during the qualitative interviews may have a certain verisimilitude, this all seems very weak evidence of effectiveness. It lacks any quantification, such as could be used in a health economic model. Is there a halfway house between a cluster RCT with hard outputs like mortality on the one hand, and ‘how was it for you?’ research on the other?

While it is not easy to come up with a measurement system, there is one person who perceives the entire pathway and that is the patient. The patient is really the only person who can provide an assessment of care quality across multiple providers. There are many patient measures. Some relate to outcome, for instance health and social care related quality of life (EQ-5DL, ASCOT SCT4 and OPOQL-brief [4]). Such measures should be used in service delivery studies, but may be insensitive to change, as stated above. It is therefore important to measure patient perception of the quality of their care. However, such measurements tend to either be non-specific (e.g. LTC-6 [5]) or look at only one aspect of care, such as continuity (PPCMC),[6] treatment burden [7] or person contentedness.[8] We propose a single quality of integrated care tool incorporating dimensions that have been shown to be important to patients and are collaborating with PenCLAHRC who are working on such a tool. Constructs that should be considered include conflicting information from different caregivers; contradicting forms of treatment (such as one clinician countermanding a prescription from another caregiver); duplication or redundancy of advice and information; satisfaction with care overall and with duration of contacts. We suspect that most patients would prefer fewer, more in-depth, contacts to a larger number of rushed contacts.

It might also be possible to design more imaginative qualitative research that goes beyond simply asking questions and uses method to elicit some of their deeper feelings, by prompting their memory. One such method is photo-voice where patients are asked to take photos in various points in their care, and use these as a basis for discussion. We have used such naturalistic settings in our CLAHRC.[9] Such methods could be harnessed in the co-design of services where patients / carers are not just asked how they perceive services, but are actively involved in designing solutions.

Salient quantitative measurements as may be obtained from NHS data systems. Hospital admission and readmission rates should be measured in studies of system-wide change. An effective intervention would result in more satisfied patients with lower rates of hospital admission. What about quantifying physical health? Adverse events in general and mortality in particular have poor sensitivity, such that signal, even after risk adjustment, would only emerge from noise in an extremely large study, or in a very high-risk client group – see ‘More on Integrated Care’ in this News Blog. Adverse events and death can be consolidated into generic health measurements (QALYs/DALYs), but, again, these are insensitive for reasons given above. Evaluating methods to improve the integration of care may be an ‘inconvenient truth scenario’ [10] where it is necessary to rely on process measures and other proxies for clinical / welfare out. Since our CLAHRC is actively exploring the evaluation of service interventions to improve integration of care, we would be very interested to hear from others and explore approaches to evaluating care across care boundaries.

— Richard Lilford, CLAHRC WM Director

References:

  1. Ostrom E. Beyond Markets and States: Polycentric Governance of Complex Economic Systems. Am Econ Rev. 2010; 100(3): 641-72.
  2. Girling AJ, Hofer TP, Wu J, et al. Case-mix adjusted hospital mortality is a poor proxy for preventable mortality: a modelling study. BMJ Qual Saf. 2012; 21(12): 1052-6.
  3. Institute for Healthcare Improvement. Improving Patient Flow: The Esther Project in Sweden. Boston, MA: Institute for Healthcare Improvement, 2011.
  4. Bowling A, Hankins M, Windle G, Bilotta C, Grant R. A short measure of quality of life in older age: the performance of the brief Older People’s Quality of Life questionnaire (OPQOL-brief). Arch Gerontol Geriatr. 2013; 56: 181-7.
  5. Glasgow RE, Wagner EH, Schaefer J, Mahoney LD, Reid RJ, Greene SM. Development and validation of the Patient Assessment of Chronic Illness Care (PACIC). Med Care. 2005; 43(5): 436-44.
  6. Haggerty JL, Robergr D, Freeman GK, Beaulieu C, Breton M. Validation of a generic measure of continuity of care: When patients encounter several clinicians. Ann Fam Med. 2012; 10: 443-51.
  7. Tran VT, Harrington M, Montori VM, Barnes C, Wicks P, Ravaud P. Adaptation and validation of the Treatment Burden Questionnaire (TBQ) in English using an internet platform. BMC Medicine. 2014; 12: 109.
  8. Mercer SW, Scottish Executive. Care Measure. Scottish Executive 2004
  9. Redwood S, Gale N, Greenfield S. ‘You give us rangoli, we give you talk’ – Using an art-based activity to elicit data from a seldom heard group. BMC Medl Res Methodol. 2012; 12: 7.
  10. Lilford RJ. Integrated Care. NIHR CLAHRC West Midlands News Blog. 19 June 2015.
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One thought on “Evaluating Interventions to Improve the Integration of Care (Among Multiple Providers and Across Multiple Sites)”

  1. Dear Richard
    Speaking from the view point of a no longer practising GP, sometime patient and many times patient relative, I do agree that is is the patient who is key to evaluating initiatives to better coordinate care across multiple providers. In addition to the areas you suggest – conflicting info / contradicting treatment decisions / etc (all of which i agree with) – I would suggest measures that focus on navigating the system such as; arranging appointments, cancelled appointments, burden of appointments and travel to them, getting to see the person you want to see (not just about continuity of care as sometimes are told by GP / consultant that you really need to see X about this, but this is easier said than done) and so on. I also think the issue of good use of shared records is important, it seems to me that the NHS can only deliver this for antenatal care. And so patients have to retell their story time and time again!

    In addition to the patient i think the GP, or GP practice in general, could be a source of info on joined up care – I used to spend ages trying to sort out issues arising from hospital appointments – but perhaps this is a bygone role for GPs!!

    cheers
    Mark

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