BACKGROUND: Delivery arrangements include changes in who receives care and when, who provides care, the working conditions of those who provide care, coordination of care amongst different providers, where care is provided, the use of information and communication technology to deliver care, and quality and safety systems. How services are delivered can have impacts on the effectiveness, efficiency and equity of health systems. This broad overview of the findings of systematic reviews can help policymakers and other stakeholders identify strategies for addressing problems and improve the delivery of services.
OBJECTIVES: To provide an overview of the available evidence from up-to-date systematic reviews about the effects of delivery arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on delivery arrangements and informing refinements of the framework for delivery arrangements outlined in the review.
METHODS: We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of delivery arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use, healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty or employment) and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the findings. Two overview authors independently screened reviews, extracted data, and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence), and assessments of the relevance of findings to low-income countries.
MAIN RESULTS: We identified 7272 systematic reviews and included 51 of them in this overview. We judged 6 of the 51 reviews to have important methodological limitations and the other 45 to have only minor limitations. We grouped delivery arrangements into eight categories. Some reviews provided more than one comparison and were in more than one category. Across these categories, the following intervention were effective; that is, they have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects. Who receives care and when: queuing strategies and antenatal care to groups of mothers. Who provides care: lay health workers for caring for people with hypertension, lay health workers to deliver care for mothers and children or infectious diseases, lay health workers to deliver community-based neonatal care packages, midlevel health professionals for abortion care, social support to pregnant women at risk, midwife-led care for childbearing women, non-specialist providers in mental health and neurology, and physician-nurse substitution. Coordination of care: hospital clinical pathways, case management for people living with HIV and AIDS, interactive communication between primary care doctors and specialists, hospital discharge planning, adding a service to an existing service and integrating delivery models, referral from primary to secondary care, physician-led versus nurse-led triage in emergency departments, and team midwifery. Where care is provided: high-volume institutions, home-based care (with or without multidisciplinary team) for people living with HIV and AIDS, home-based management of malaria, home care for children with acute physical conditions, community-based interventions for childhood diarrhoea and pneumonia, out-of-facility HIV and reproductive health services for youth, and decentralised HIV care. Information and communication technology: mobile phone messaging for patients with long-term illnesses, mobile phone messaging reminders for attendance at healthcare appointments, mobile phone messaging to promote adherence to antiretroviral therapy, women carrying their own case notes in pregnancy, interventions to improve childhood vaccination. Quality and safety systems: decision support with clinical information systems for people living with HIV/AIDS. Complex interventions (cutting across delivery categories and other health system arrangements): emergency obstetric referral interventions.
AUTHORS' CONCLUSIONS: A wide range of strategies have been evaluated for improving delivery arrangements in low-income countries, using sound systematic review methods in both Cochrane and non-Cochrane reviews. These reviews have assessed a range of outcomes. Most of the available evidence focuses on who provides care, where care is provided and coordination of care. For all the main categories of delivery arrangements, we identified gaps in primary research related to uncertainty about the applicability of the evidence to low-income countries, low- or very low-certainty evidence or a lack of studies.
BACKGROUND: Supported self-management has been recommended by asthma guidelines for three decades; improving current suboptimal implementation will require commitment from professionals, patients and healthcare organisations. The Practical Systematic Review of Self-Management Support (PRISMS) meta-review and Reducing Care Utilisation through Self-management Interventions (RECURSIVE) health economic review were commissioned to provide a systematic overview of supported self-management to inform implementation. We sought to investigate if supported asthma self-management reduces use of healthcare resources and improves asthma control; for which target groups it works; and which components and contextual factors contribute to effectiveness. Finally, we investigated the costs to healthcare services of providing supported self-management.
METHODS: We undertook a meta-review (systematic overview) of systematic reviews updated with randomised controlled trials (RCTs) published since the review search dates, and health economic meta-analysis of RCTs. Twelve electronic databases were searched in 2012 (updated in 2015; pre-publication update January 2017) for systematic reviews reporting RCTs (and update RCTs) evaluating supported asthma self-management. We assessed the quality of included studies and undertook a meta-analysis and narrative synthesis.
RESULTS: A total of 27 systematic reviews (n = 244 RCTs) and 13 update RCTs revealed that supported self-management can reduce hospitalisations, accident and emergency attendances and unscheduled consultations, and improve markers of control and quality of life for people with asthma across a range of cultural, demographic and healthcare settings. Core components are patient education, provision of an action plan and regular professional review. Self-management is most effective when delivered in the context of proactive long-term condition management. The total cost (n = 24 RCTs) of providing self-management support is offset by a reduction in hospitalisations and accident and emergency visits (standard mean difference 0.13, 95% confidence interval -0.09 to 0.34).
CONCLUSIONS: Evidence from a total of 270 RCTs confirms that supported self-management for asthma can reduce unscheduled care and improve asthma control, can be delivered effectively for diverse demographic and cultural groups, is applicable in a broad range of clinical settings, and does not significantly increase total healthcare costs. Informed by this comprehensive synthesis of the literature, clinicians, patient-interest groups, policy-makers and providers of healthcare services should prioritise provision of supported self-management for people with asthma as a core component of routine care.
SYSTEMATIC REVIEW REGISTRATION: RECURSIVE: PROSPERO CRD42012002694 ; PRISMS: PROSPERO does not register meta-reviews.
Síntesis amplia/ Revisión panorámica de revisiones sistemáticas
BACKGROUND: Diabetes is a common chronic disease that places an unprecedented strain on health care systems worldwide. Mobile health technologies such as smartphones, mobile applications, and wearable devices, known as mHealth, offer significant and innovative opportunities for improving patient to provider communication and self-management of diabetes.
OBJECTIVE: The purpose of this overview is to critically appraise and consolidate evidence from multiple systematic reviews on the effectiveness of mHealth interventions for patients with diabetes to inform policy makers, practitioners, and researchers.
METHODS: A comprehensive search on multiple databases was performed to identify relevant systematic reviews published between January 1996 and December 2015. Two authors independently selected reviews, extracted data, and assessed the methodological quality of included reviews using AMSTAR.
RESULTS: Fifteen systematic reviews published between 2008 and 2014 were eligible for inclusion. The quality of the reviews varied considerably and most of them had important methodological limitations. Focusing on systematic reviews that offered the most direct evidence, this overview demonstrates that on average, mHealth interventions improve glycemic control (HbA1c) compared to standard care or other non-mHealth approaches by as much as 0.8% for patients with type 2 diabetes and 0.3% for patients with type 1 diabetes, at least in the short-term (≤12 months). However, limitations in the overall quality of evidence suggest that further research will likely have an important impact in these estimates of effect.
CONCLUSIONS: Findings are consistent with clinically relevant improvements, particularly with respect to patients with type 2 diabetes. Similar to home telemonitoring, mHealth interventions represent a promising approach for self-management of diabetes.
Síntesis amplia/ Revisión panorámica de revisiones sistemáticas
Servicio de mensajes cortos (SMS) Los mensajes pueden presentar un método conveniente y rentable para apoyar las intervenciones de salud. Este trabajo evalúa los efectos del servicio de mensajes cortos en diversas intervenciones de salud que se encuentran en las revisiones sistemáticas. La estrategia de búsqueda se basa en dos conceptos clave: el servicio de mensajes cortos y prestación de asistencia sanitaria. La búsqueda inicial se realizó en diciembre de 2012 y fue actualizado en junio de 2013. De las 550 referencias identificadas, 13 revisiones sistemáticas cumplieron los criterios de inclusión, de los cuales 8 fueron publicados en revistas revisadas por pares y 5 fueron recuperados de la biblioteca Cochrane. Análisis de los datos muestra que baja a moderada evidencia de investigación existe sobre los beneficios de las intervenciones de servicios de mensajes cortos para recordatorios de citas, la promoción de la salud en los países en desarrollo y de salud preventiva. En muchas de las intervenciones, sin embargo, hubo algunos estudios que eran de alta calidad, y la mayoría de los estudios se calificaron de calidad baja a moderada o tenido sin valoraciones en absoluto. Las organizaciones de salud, responsables políticos, o los médicos que utilizan los mensajes de servicio de mensajes cortos para apoyar las intervenciones de salud deben (1) implementar intervenciones que se han encontrado para trabajar en establecimientos de salud, (2) continuar la evaluación de intervenciones de los servicios de mensajería corta que no han sido evaluados adecuadamente, y (3) mejorar la colaboración entre las distintas entidades de salud para desarrollar estudios dirigidos a poblaciones específicas para evaluar el impacto a largo plazo del servicio de mensajes cortos en los resultados de salud.
Síntesis amplia/ Revisión panorámica de revisiones sistemáticas
El objetivo de esta revisión sistemática de las revisiones es identificar intervenciones de mensajes de texto móviles diseñados para mejorar la salud y el cambio de comportamiento y para derivar recomendaciones para la práctica. Hemos compilado y revisado comentarios sistemáticos de investigación existentes y meta-análisis para organizar y resumir la evidencia de intervención de mensajes de texto, identificar recomendaciones de mejores prácticas basadas en los hallazgos de múltiples opiniones y explorar las implicaciones para la investigación futura. Nuestra revisión encontró que la mayoría de las intervenciones de mensajes de texto publicados fueron eficaces al abordar el autocontrol de la diabetes, la pérdida de peso, la actividad física, dejar de fumar, y la adherencia a la medicación para la terapia antirretroviral. Sin embargo, encontramos evidencia limitada en toda la población de los estudios y las revisiones de informar a las características de intervención recomendadas. Aunque una fuerte evidencia apoya el valor de la integración de las intervenciones de mensajes de texto a la práctica de la salud pública, se necesita investigación adicional para establecer los efectos de intervención a más largo plazo, identificar las características de intervención recomendadas, y explorar cuestiones de costo-efectividad.
Síntesis amplia/ Revisión panorámica de revisiones sistemáticas
BackgroundStrong compromiso internacional y el uso generalizado de la terapia antirretroviral han llevado a una mayor longevidad de las personas que viven con el virus de inmunodeficiencia humana (VIH). Intervenciones de mensajería de texto se han demostrado mejorar los resultados de salud en las personas que viven con el VIH. Los objetivos de esta revisión fueron: Mapa del estado de la evidencia de las intervenciones de mensajería de texto, identificar las brechas de conocimiento, y desarrollar un marco para la transferencia de datos a otras enfermedades crónicas.MethodsWe realizó una revisión sistemática de las revisiones sistemáticas sobre las intervenciones de mensajería de texto para mejorar la salud o los resultados de salud relacionados. Se realizó una búsqueda exhaustiva en PubMed, EMBASE (Exerpta Medica base de datos), CINAHL (Cumulative Index de Enfermería y Salud Aliada Literatura), PsycINFO, Web of Science (WoS) y la Biblioteca Cochrane en el 17 de abril 2014. Proyección, extracción y evaluación de la calidad metodológica de datos se realizaron por duplicado. Nuestros resultados se utilizaron para desarrollar un marco conceptual para la transferencia.ResultsOur búsqueda identificó 135 posibles revisiones sistemáticas de los cuales nueve fueron incluidos, al informar sobre 37 estudios de origen, llevados a cabo en 19 países diferentes. Siete de nueve (77,7%) de estas críticas eran de alta calidad. Hubo algunas pruebas para la mensajería de texto como una herramienta para mejorar la adherencia a la terapia antirretroviral. Los mensajes de texto también mejoraron asistencia a las citas y los resultados de cambio de comportamiento. Los resultados no fueron concluyentes para la autogestión de la enfermedad, el tratamiento de la tuberculosis y la comunicación de los resultados de las investigaciones médicas. La distribución geográfica de la investigación de mensajes de texto se limita a regiones específicas del mundo. Lagunas de conocimiento más destacados cabe mencionar la falta de datos sobre los resultados a largo plazo, la satisfacción del paciente, y evaluaciones económicas. Los comentarios incluidos también identificaron limitaciones metodológicas en muchos de los estudios primarios.Pruebas ConclusionsGlobal apoya el uso de la mensajería de texto como una herramienta para mejorar la adherencia a la medicación y la asistencia a las citas programadas. Dadas las similitudes entre el VIH y otras enfermedades crónicas (medicamentos a largo plazo, la atención de toda la vida, una fuerte vinculación con el comportamiento y la necesidad de apoyo en el hogar) pruebas de VIH pueden ser transferidos a estas enfermedades usando nuestro marco propuesto por la integración del VIH y servicios de enfermedades crónicas o la transferencia directa.
Síntesis amplia/ Revisión panorámica de revisiones sistemáticas
ANTECEDENTES: La carga mundial de enfermedades crónicas es generalizado y creciente. Este cambio de aguda a la atención crónica requiere un replanteamiento de cómo se invierten los recursos en la gestión de estas condiciones. Una respuesta ha sido la creación de programas e intervenciones que tienen el objetivo de ayudar a los pacientes a manejar mejor sus propias condiciones. Con el tiempo, estas intervenciones y estrategias de autogestión han recurrido cada vez más diversas tecnologías para su aplicación, con la más nueva tecnología de ser teléfonos móviles y servicio de mensajes cortos (SMS).
OBJETIVO: El objetivo de este meta-revisión fue evaluar la evidencia actual sobre el uso de teléfonos móviles y SMS para realizar intervenciones de autogestión de las enfermedades crónicas.
MÉTODOS: Una revisión meta se llevó a cabo de las 11 revisiones sistemáticas (SR) que fueron identificados y recuperados después de una extensa búsqueda en bases de datos electrónicas para los años 2000-2012. La información pertinente se abstrae de cada revisión sistemática y una evaluación de la calidad lleva a cabo utilizando el ("Una herramienta de medición para evaluar Revisiones Sistemáticas") AMSTAR criterios.
RESULTADOS: El número y tipos de estudios incluidos y el número total de sujetos variaron significativamente entre las revisiones sistemáticas. Móvil mensajes de texto de teléfono se informó a mejorar significativamente la adherencia a las citas y la terapia antirretroviral, el fumar a corto plazo las tasas de abandono, y seleccionó los resultados clínicos y de comportamiento. Puntajes AMSTAR oscila entre un 11 a 3, lo que refleja una variación sustancial en la calidad de SR.
VINCULACIÓN DE LAS PRUEBAS A LA ACCIÓN: Los teléfonos móviles y el espectáculo SMS promesa como una tecnología para realizar intervenciones de autogestión para mejorar los resultados de la gestión de la atención crónica. Sin embargo, la calidad de los futuros estudios y revisiones sistemáticas necesita ser mejorado. También hay cuestiones sin resolver acerca de la tecnología en sí.
Delivery arrangements include changes in who receives care and when, who provides care, the working conditions of those who provide care, coordination of care amongst different providers, where care is provided, the use of information and communication technology to deliver care, and quality and safety systems. How services are delivered can have impacts on the effectiveness, efficiency and equity of health systems. This broad overview of the findings of systematic reviews can help policymakers and other stakeholders identify strategies for addressing problems and improve the delivery of services.
OBJECTIVES:
To provide an overview of the available evidence from up-to-date systematic reviews about the effects of delivery arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on delivery arrangements and informing refinements of the framework for delivery arrangements outlined in the review.
METHODS:
We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of delivery arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use, healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty or employment) and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the findings. Two overview authors independently screened reviews, extracted data, and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence), and assessments of the relevance of findings to low-income countries.
MAIN RESULTS:
We identified 7272 systematic reviews and included 51 of them in this overview. We judged 6 of the 51 reviews to have important methodological limitations and the other 45 to have only minor limitations. We grouped delivery arrangements into eight categories. Some reviews provided more than one comparison and were in more than one category. Across these categories, the following intervention were effective; that is, they have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects. Who receives care and when: queuing strategies and antenatal care to groups of mothers. Who provides care: lay health workers for caring for people with hypertension, lay health workers to deliver care for mothers and children or infectious diseases, lay health workers to deliver community-based neonatal care packages, midlevel health professionals for abortion care, social support to pregnant women at risk, midwife-led care for childbearing women, non-specialist providers in mental health and neurology, and physician-nurse substitution. Coordination of care: hospital clinical pathways, case management for people living with HIV and AIDS, interactive communication between primary care doctors and specialists, hospital discharge planning, adding a service to an existing service and integrating delivery models, referral from primary to secondary care, physician-led versus nurse-led triage in emergency departments, and team midwifery. Where care is provided: high-volume institutions, home-based care (with or without multidisciplinary team) for people living with HIV and AIDS, home-based management of malaria, home care for children with acute physical conditions, community-based interventions for childhood diarrhoea and pneumonia, out-of-facility HIV and reproductive health services for youth, and decentralised HIV care. Information and communication technology: mobile phone messaging for patients with long-term illnesses, mobile phone messaging reminders for attendance at healthcare appointments, mobile phone messaging to promote adherence to antiretroviral therapy, women carrying their own case notes in pregnancy, interventions to improve childhood vaccination. Quality and safety systems: decision support with clinical information systems for people living with HIV/AIDS. Complex interventions (cutting across delivery categories and other health system arrangements): emergency obstetric referral interventions.
AUTHORS' CONCLUSIONS:
A wide range of strategies have been evaluated for improving delivery arrangements in low-income countries, using sound systematic review methods in both Cochrane and non-Cochrane reviews. These reviews have assessed a range of outcomes. Most of the available evidence focuses on who provides care, where care is provided and coordination of care. For all the main categories of delivery arrangements, we identified gaps in primary research related to uncertainty about the applicability of the evidence to low-income countries, low- or very low-certainty evidence or a lack of studies.
Síntesis amplia»Revisión panorámica de revisiones sistemáticas
