OBJECTIVE: To provide an overview of the currently available risk prediction models (RPMs) for cardiovascular diseases (CVDs), diabetes and hypertension, and to compare their effectiveness in proper recognition of patients at risk of developing these diseases.
DESIGN: Umbrella systematic review.
DATA SOURCES: PubMed, Scopus, Cochrane Library.
ELIGIBILITY CRITERIA: Systematic reviews or meta-analysis examining and comparing performances of RPMs for CVDs, hypertension or diabetes in healthy adult (18-65 years old) population, published in English language.
DATA EXTRACTION AND SYNTHESIS: Data were extracted according to the following parameters: number of studies included, intervention (RPMs applied/assessed), comparison, performance, validation and outcomes. A narrative synthesis was performed. Data were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
STUDY SELECTION: 3612 studies were identified. After title/abstract screening and removal of duplicate articles, 37 studies met the eligibility criteria. After reading the full text, 13 were deemed relevant for inclusion. Three further papers from the reference lists of these articles were then added.
STUDY APPRAISAL: The methodological quality of the included studies was assessed using the AMSTAR tool.
RISK OF BIAS IN INDIVIDUAL STUDIES: Risk of Bias evaluation was carried out using the ROBIS tool.
RESULTS: Sixteen studies met the inclusion criteria: six focused on diabetes, two on hypertension and eight on CVDs. Globally, prediction models for diabetes and hypertension showed no significant difference in effectiveness. Conversely, some promising differences among prediction tools were highlighted for CVDs. The Ankle-Brachial Index, in association with the Framingham tool, and QRISK scores provided some evidence of a certain superiority compared with Framingham alone.
LIMITATIONS: Due to the significant heterogeneity of the studies, it was not possible to perform a meta-analysis. The electronic search was limited to studies in English and to three major international databases (MEDLINE/PubMed, Scopus and Cochrane Library), with additional works derived from the reference list of other studies; grey literature with unpublished documents was not included in the search. Furthermore, no assessment of potential adverse effects of RPMs was carried out.
CONCLUSIONS: Consistent evidence is available only for CVD prediction: the Framingham score, alone or in combination with the Ankle-Brachial Index, and the QRISK score can be confirmed as the gold standard. Further efforts should not be concentrated on creating new scores, but rather on performing external validation of the existing ones, in particular on high-risk groups. Benefits could be further improved by supplementing existing models with information on lifestyle, personal habits, family and employment history, social network relationships, income and education.
PROSPERO REGISTRATION NUMBER: CRD42018088012.
AIM: Integrated care commonly involves provision of comprehensive community-based care for people with chronic conditions. It is anticipated that implementation of integrated care, with a proactive approach to management of chronic conditions, will reduce reliance on hospital and emergency department (ED) services. The aim of this rapid review was to summarize the best available evidence on the impact of integrated care for patients with chronic conditions on hospital and ED utilization and investigate trends in outcomes over time.
METHODS: Given the large body of literature available on this topic, this rapid review considered existing systematic reviews and meta-analyses that included adults with chronic conditions. Any model of integrated care that involved management of patients across the continuum of care, with the aim to provide more care in community settings, was considered for inclusion. A search of PubMed, CINAHL, Google Advanced, and websites of international healthcare provider organizations was conducted to locate relevant published and gray literature.
RESULTS: A total of 13 systematic reviews were included. Overall, evidence suggests that integrated care may reduce the risk of hospitalization, with reviews including patients with diverse chronic conditions showing a 19% reduction. Integrated care appears effective in reducing readmissions for patients with heart failure, with an absolute risk reduction of 8% for first and 19% for subsequent rehospitalization. For ED presentations, evidence indicates that integrated care has no effect overall but may reduce ED visits for patients aged 65 years or more. For patients with chronic obstructive pulmonary disease, integrated care was associated with reductions in length of stay ranging from 2.5 to 4 days. Studies with shorter follow-up, from 3 to 12 months, in general appeared to show a greater impact of integrated care than studies with longer follow-up of 18 months or more.
CONCLUSION: The evidence identified suggests integrated care generally reduces utilization of hospital services. In some instances, there were no differences observed between integrated care and usual care, but no included reviews reported increased utilization of these services. The impact of integrated care may be greater in the short-term, given the ultimate deterioration associated with advanced chronic disease which may negate any long-term benefits.
There is controversy about the role of statins in chronic heart failure. Even though it is clear they decrease inflammatory markers and probably improve some echocardiographic parameters, it is not clear if they impact clinically important outcomes. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified six systematic reviews including 21 randomized trials. We combined the evidence using meta-analysis and generated a summary of findings table following the GRADE approach. We concluded statins in chronic heart failure do not decrease mortality, and might lead to little or no decrease in hospitalizations for heart failure or other clinical outcomes.
The use of perioperative statins has been proposed as a measure to reduce morbidity and mortality in cardiac surgery. However, their clinical role is controversial. Searching in Epistemonikos database, which is maintained by screening multiple databases, we identified 36 systematic reviews comprising 92 primary studies addressing the question of this article, including 22 randomized trials. We extracted data, combined the evidence using meta-analysis and generated a summary of findings following the GRADE approach. We concluded perioperative statins probably do not decrease mortality in cardiac surgery and it is unclear if they have any benefit because the certainty of the evidence is very low.; Se ha propuesto el uso de estatinas perioperatorias como una medida para disminuir la morbimortalidad en cirugía cardíaca. No obstante, su impacto clínico es controvertido. Utilizando la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en múltiples bases de datos, identificamos 36 revisiones sistemáticas que en conjunto incluyen 92 estudios primarios de los cuales 22 son estudios aleatorizados. Realizamos un metanálisis y tablas de resumen de los resultados utilizando el método GRADE. Concluimos que las estatinas perioperatorias probablemente no disminuyen la mortalidad en cirugía cardíaca y no está claro si tienen algún beneficio porque la certeza de la evidencia es muy baja.
OBJECTIVE: To summarise the evidence regarding the effectiveness of integrated care interventions in reducing hospital activity.
DESIGN: Umbrella review of systematic reviews and meta-analyses.
SETTING: Interventions must have delivered care crossing the boundary between at least two health and/or social care settings.
PARTICIPANTS: Adult patients with one or more chronic diseases.
DATA SOURCES: MEDLINE, Embase, ASSIA, PsycINFO, HMIC, CINAHL, Cochrane Library (HTA database, DARE, Cochrane Database of Systematic Reviews), EPPI-Centre, TRIP, HEED, manual screening of references.
OUTCOME MEASURES: Any measure of hospital admission or readmission, length of stay (LoS), accident and emergency use, healthcare costs.
RESULTS: 50 reviews were included. Interventions focused on case management (n=8), chronic care model (CCM) (n=9), discharge management (n=15), complex interventions (n=3), multidisciplinary teams (MDT) (n=10) and self-management (n=5). 29 reviews reported statistically significant improvements in at least one outcome. 11/21 reviews reported significantly reduced emergency admissions (15-50%); 11/24 showed significant reductions in all-cause (10-30%) or condition-specific (15-50%) readmissions; 9/16 reported LoS reductions of 1-7 days and 4/9 showed significantly lower A&E use (30-40%). 10/25 reviews reported significant cost reductions but provided little robust evidence. Effective interventions included discharge management with postdischarge support, MDT care with teams that include condition-specific expertise, specialist nurses and/or pharmacists and self-management as an adjunct to broader interventions. Interventions were most effective when targeting single conditions such as heart failure, and when care was provided in patients' homes.
CONCLUSIONS: Although all outcomes showed some significant reductions, and a number of potentially effective interventions were found, interventions rarely demonstrated unequivocally positive effects. Despite the centrality of integrated care to current policy, questions remain about whether the magnitude of potentially achievable gains is enough to satisfy national targets for reductions in hospital activity.
TRIAL REGISTRATION NUMBER: CRD42015016458.
Background: The economic impact and ease of measurement of all-cause hospital readmission rates (HRR) have led to the current debate as to whether they are reducible, and whether they should be used as a publicly reported quality indicators of medical care. Objective: To assess the efficacy of broad clinical interventions in preventing HRR of patients with chronic diseases. Method: A meta-review of published systematic reviews of randomized controlled trials (RCTs) of clinical interventions that have included HRR among the patients' outcomes of interest. Main findings: Meta-analyses of RCTs have consistently found that, in the community, disease management programs significantly reduced HRR in patients with heart failure, coronary heart disease and bronchial asthma, but not in patients with stroke and in unselected patients with chronic disorders. Inhospital interventions, such as discharge planning, pharmacological consultations and multidisciplinary care, and community interventions in patients with chronic obstructive pulmonary diseases had an inconsistent effect on HRR. Main study limitation: Despite their economic impact and ease of measurement, HRR are not the most important outcome of patient care, and efforts aimed at their reduction may compromise patients' health by reducing also justified re-admissions. Conclusions: The efficacy of inhospital interventions in reducing HRR is in need of further study. In patients with heart diseases and bronchial asthma, HRR may be considered as a publicly reported quality indicator of community care, provided that future research confirms that efforts to reduce HRR do not adversely affect other patients' outcomes, such as mortality, functional capacity and quality of life. Future research should also focus on the reasons for the higher efficacy of community interventions in patients with heart diseases and bronchial asthma than in those with other chronic diseases.
BACKGROUND: Despite favourable results from past meta-analyses, some recent large trials have not found heart failure (HF) disease management programs to be beneficial. To explore reasons for this, we evaluated evidence from existing meta-analyses.
METHODS: Systematic review incorporating meta-review was used. We selected meta-analyses of randomized controlled trials published after 1995 in English that examined the effects of HF disease management programs on key outcomes. Databases searched: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews (CDSR), DARE, NHS EED, NHS HTA, Ageline, AMED, Scopus, Web of Science and CINAHL; cited references, experts and existing reviews were also searched.
RESULTS: 15 meta-analyses were identified containing a mean of 18.5 randomized trials of HF interventions +/- 10.1 (range: 6 to 36). Overall quality of the meta-analyses was very mixed (Mean AMSTAR Score = 6.4 +/- 1.9; range 2-9). Reporting inadequacies were widespread around populations, intervention components, settings and characteristics, comparison, and comparator groups. Heterogeneity (statistical, clinical, and methodological) was not taken into account sufficiently when drawing conclusions from pooled analyses.
CONCLUSIONS: Meta-analyses of heart failure disease management programs have promising findings but often fail to report key characteristics of populations, interventions, and comparisons. Existing reviews are of mixed quality and do not adequately take account of program complexity and heterogeneity.
OBJECTIVE: To assess the evidence for the effect of disease management on quality of care, disease control, and cost, with a focus on population-based programs.
STUDY DESIGN: Literature review.
METHODS: We conducted a literature search for and a structured review of studies on population-based disease management programs, as well as for reviews and meta-analyses of disease management interventions. We identified 3 evaluations of large-scale population-based programs, as well as 10 meta-analyses and 16 systematic reviews, covering 317 unique studies.
RESULTS: We found consistent evidence that disease management improves processes of care and disease control but no conclusive support for its effect on health outcomes. Overall, disease management does not seem to affect utilization except for a reduction in hospitalization rates among patients with congestive heart failure and an increase in outpatient care and prescription drug use among patients with depression. When the costs of the intervention were appropriately accounted for and subtracted from any savings, there was no conclusive evidence that disease management leads to a net reduction of direct medical costs.
CONCLUSIONS: Although disease management seems to improve quality of care, its effect on cost is uncertain. Most of the evidence to date addresses small-scale programs targeting high-risk individuals, while only 3 studies evaluate large population-based interventions, implying that little is known about their effect. Payers and policy makers should remain skeptical about vendor claims and should demand supporting evidence based on transparent and scientifically sound methods.
To provide an overview of the currently available risk prediction models (RPMs) for cardiovascular diseases (CVDs), diabetes and hypertension, and to compare their effectiveness in proper recognition of patients at risk of developing these diseases.
DESIGN:
Umbrella systematic review.
DATA SOURCES:
PubMed, Scopus, Cochrane Library.
ELIGIBILITY CRITERIA:
Systematic reviews or meta-analysis examining and comparing performances of RPMs for CVDs, hypertension or diabetes in healthy adult (18-65 years old) population, published in English language.
DATA EXTRACTION AND SYNTHESIS:
Data were extracted according to the following parameters: number of studies included, intervention (RPMs applied/assessed), comparison, performance, validation and outcomes. A narrative synthesis was performed. Data were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
STUDY SELECTION:
3612 studies were identified. After title/abstract screening and removal of duplicate articles, 37 studies met the eligibility criteria. After reading the full text, 13 were deemed relevant for inclusion. Three further papers from the reference lists of these articles were then added.
STUDY APPRAISAL:
The methodological quality of the included studies was assessed using the AMSTAR tool.
RISK OF BIAS IN INDIVIDUAL STUDIES:
Risk of Bias evaluation was carried out using the ROBIS tool.
RESULTS:
Sixteen studies met the inclusion criteria: six focused on diabetes, two on hypertension and eight on CVDs. Globally, prediction models for diabetes and hypertension showed no significant difference in effectiveness. Conversely, some promising differences among prediction tools were highlighted for CVDs. The Ankle-Brachial Index, in association with the Framingham tool, and QRISK scores provided some evidence of a certain superiority compared with Framingham alone.
LIMITATIONS:
Due to the significant heterogeneity of the studies, it was not possible to perform a meta-analysis. The electronic search was limited to studies in English and to three major international databases (MEDLINE/PubMed, Scopus and Cochrane Library), with additional works derived from the reference list of other studies; grey literature with unpublished documents was not included in the search. Furthermore, no assessment of potential adverse effects of RPMs was carried out.
CONCLUSIONS:
Consistent evidence is available only for CVD prediction: the Framingham score, alone or in combination with the Ankle-Brachial Index, and the QRISK score can be confirmed as the gold standard. Further efforts should not be concentrated on creating new scores, but rather on performing external validation of the existing ones, in particular on high-risk groups. Benefits could be further improved by supplementing existing models with information on lifestyle, personal habits, family and employment history, social network relationships, income and education.
