Open access Original research Identifying alternative models of … · 2020-03-27 · essupr etfial Open 202010e036112 doi101136bmjopen-2019-036112 1 Open access Identifying alternative

1Jessup R, et al. BMJ Open 2020;10:e036112. doi:10.1136/bmjopen-2019-036112

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Identifying alternative models of healthcare service delivery to inform health system improvement: scoping review of systematic reviews

Rebecca Jessup,1,2 Polina Putrik ,1,2 Rachelle Buchbinder ,1,2 Janet Nezon,1 Kobi Rischin,1,2 Sheila Cyril,1,2 Sasha Shepperd ,3 Denise A O’Connor 1,2

To cite: Jessup R, Putrik P, Buchbinder R, et al. Identifying alternative models of healthcare service delivery to inform health system improvement: scoping review of systematic reviews. BMJ Open 2020;10:e036112. doi:10.1136/bmjopen-2019-036112

► Prepublication history and additional material for this paper are available online. To view these files, please visit the journal online (http:// dx. doi. org/ 10. 1136/ bmjopen- 2019- 036112).

Received 03 December 2019Revised 08 February 2020Accepted 04 March 2020

1Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Victoria, Australia2Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia3Nuffield Department of Population Health, University of Oxford, Oxford, UK

Correspondence toDr Denise A O’Connor; Denise. OConnor@ monash. edu

Original research

© Author(s) (or their employer(s)) 2020. Re- use permitted under CC BY- NC. No commercial re- use. See rights and permissions. Published by BMJ.

Strengths and limitations of this study

► We have followed published methodological guid-ance for conducting this scoping review.

► The search was limited to a 5- year period (2012–2017) to retrieve up- to- date reviews of alternative delivery arrangements relevant to high- income countries.

► As this scoping review sought to map the state of the literature in this area, we did not appraise the quality of the included reviews and did not attempt to synthesise the effects of healthcare delivery ar-rangements in the included systematic reviews.

► Systematic reviews that were awaiting classification in ‘Pretty Darn Quick’-Evidence at the moment of search were not captured in the search.

AbStrACtObjective To describe available evidence from systematic reviews of alternative healthcare delivery arrangements relevant to high- income countries to inform decisions about healthcare system improvement.Design Scoping review of systematic reviews.Data sources Systematic reviews of interventions indexed in Pretty Darn Quick- Evidence.Eligibility criteria All English language systematic reviews evaluating the effects of alternative delivery arrangements relevant to high- income countries, published between 1 January 2012 and 20 September 2017. Eligible reviews had to summarise evidence on at least one of the following outcomes: patient outcomes, quality of care, access and/or use of healthcare services, resource use, impacts on equity and/or social outcomes, healthcare provider outcomes or adverse effects.Data extraction and synthesis Journal, publication year, number and design of primary studies, populations/health conditions represented and types of outcomes were extracted.results Of 829 retrieved records, 531 reviews fulfilled our inclusion criteria. Almost all (93%) reviews reported on patient outcomes, while only about one- third included resource use as an outcome of interest. Just over a third (n=189, 36%) of reviews focused on alternative information and communications technology interventions (including 162 reviews on telehealth). About one- quarter (n=122, 23%) of reviews focused on alternative care coordination interventions. 15% (n=80) of reviews examined interventions involving changes to who provides care and how the healthcare workforce is managed. Few reviews investigated the effects of interventions involving changes to how and when care is delivered (n=47, 9%) or interventions addressing a goal- focused question (n=38, 7%).Conclusion A substantial body of evidence about the effects of a wide range of delivery arrangements is available to inform health system improvements. The lack of economic evaluations in the majority of systematic reviews of delivery arrangements means that the value of many of these models is unknown. This scoping review identifies evidence gaps that would be usefully addressed by future research.

bACkgrOunDThe last century has seen a continuous growth in investment in the health systems of high- income countries.1 This has contrib-uted to significant improvements in popula-tion health and a reduction in demand for medical care of communicable diseases, but a proportional increase in demand for the management of chronic and complex condi-tions.2 3 In addition, advances in medical tech-nology, and more population- based screening and management of disease risk factors have increased the scope of healthcare services.4–8 Taken together, this has fuelled the inflation of healthcare costs.1 The cost of delivering healthcare in most high- income countries is now considered unsustainable and is expected to be unaffordable by the middle of the 21st century without major reforms.1

A challenge for healthcare systems and funders is how to deliver high- value, effec-tive care while slowing (and where possible reversing) the rate of increase in costs. This requires an understanding of the effective-ness and economic impact of current service

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2 Jessup R, et al. BMJ Open 2020;10:e036112. doi:10.1136/bmjopen-2019-036112

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models and a determination of whether there are alter-native models of healthcare delivery that might lead to improved efficiencies without compromising the quality and outcomes of care.

The value of a given model of healthcare service delivery is based on its ratio of benefits and harms rela-tive to its cost.9 10 In an ideal health system, healthcare resources should be allocated across interventions and population groups to generate the highest possible overall level of population health at the lowest cost. In practice, this means reallocating resources away from resource- intensive interventions that have little or no benefit and redistributing to cost- effective and/or resource- wise inter-ventions to enhance the allocative efficiency of health systems. Reconfiguring the way healthcare is delivered may be one method for improving the allocation of finite healthcare resources.

There are a number of different ways that healthcare delivery may be modified, including changing the loca-tion that healthcare is delivered (eg, hospital to home), providing care in a group setting rather than to individ-uals, substituting care provided by one health professional to care provided by an alternative appropriately trained healthcare professional or lay person, or using technology to assist with the provision of care (eg, telehealth). Provi-sion of services in alternative ways such as this may lead to similar, and in some cases better, outcomes for patients. However, they may also modify the costs (or shift them to other stakeholders) or the demand for service due to more liberal access. Therefore, in addition to effective-ness, robust economic evaluations of alternative models of care delivery are required to inform decisions about the allocation of funding based on their relative value. High- cost models that deliver benefits to patients may still be good value, while low- cost models of care that provide little or no benefit may have limited value.9

Numerous systematic reviews summarising the effects of alternative models of care delivery have been published to date. Almost all have focused on changes in the delivery of healthcare for a single condition,11 a change to the scope of practice of a single type of health professional role in a specific setting12 or a single delivery arrangement type, such as chronic disease programmes,13 multidisciplinary care or integrated care interventions.14 A Cochrane over-view of alternative delivery arrangements relevant to low- income countries was recently published.15 Given the differences between low- income and high- income coun-tries in terms of service demands and access to specialist care and technologies, the findings of this overview may have less relevance or applicability to service delivery in high- income countries. No similar study of alternative delivery arrangements relevant to high- income countries has been published to date.

The aim of this scoping review was to describe the extent, range and nature of available systematic reviews of alternative delivery arrangements for health systems relevant to high- income countries published in the last 5 years. A time frame of 5 years was chosen to ensure that

the review contained evidence and data about effects that are most up- to- date, reliable and potentially ready to implement. A secondary aim was to identify gaps in the availability of up- to- date systematic reviews of alternative delivery arrangements needed to inform health system sustainability initiatives and future research directions.

This review forms part of a 5- year Partnership Centre for Health Systems Sustainability, funded by the Austra-lian National Health and Medical Research Council and other partners. The Partnership Centre is a collaborative of investigators, system leaders, expert advisors, system implementation partners and funding partners from around Australia and aims to investigate and create inter-ventions to improve health system performance sustain-ability (https://www. heal thsy stem sust aina bility. com. au/).

MEthODSProtocolThe protocol for this scoping review has been published16 (online supplementary file 1). It was informed by the methodological framework that emphasises transparency of the scoping review process to increase the reliability of the findings.17 18 Scoping reviews such as this are particu-larly useful for systematically mapping research findings across a body of research evidence that is heterogeneous and/or complex in nature. We reported our scoping review according to the Preferred Reporting Items for SystematicReviews and Meta- Analyses (PRISMA) for Scoping Reviews statement.17

Criteria for considering reviews for inclusionAll English language systematic reviews examining the effects of alternative delivery arrangements for health systems relevant to high- income countries published in the last 5 years were included. Alternative delivery arrangements include changes to the method of how and when care is delivered, where care is provided and changes to the healthcare environment, who provides care and how the workforce is managed, coordination of care and management of care processes, and information and communication technology (ICT) systems.18

For inclusion, systematic reviews needed to assess the effects of alternative delivery arrangements of relevance to high- income countries (as classified by the World Bank for the 2017 fiscal year),19 have a methods section with explicit inclusion criteria and report at least one of the following outcomes: patient outcomes (health status and health behaviours), quality of care, access and/or use of healthcare services, resource use, impacts on equity and/or social outcomes, healthcare provider outcomes or adverse effects. As the primary aim of the review was to describe the extent, range and nature of available evidence syntheses published in this area, we included systematic reviews containing trials with or without economic studies, as well as systematic reviews containing trials with or without other study designs (eg, interrupted



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Figure 1 Preferred reporting items for systematic reviews and meta- analyses flow diagram.

time series and controlled before–after studies). This is because trials addressing questions about the effects of health system interventions may be difficult to imple-ment and are often not available. Systematic reviews that included interventions in any setting were included and encompassed hospital (inpatient or outpatient care, acute or subacute), primary care, long- term care facilities/resi-dential care and the community.

Search methods for identifying reviews‘Pretty Darn Quick’ (PDQ)- Evidence was searched to identify systematic reviews of interventions to improve the organisation of healthcare services published between 1 January 2012 and 20 September 2017. PDQ- Evidence is a database of evidence for decisions about health systems derived from the Epistomonikos database of systematic reviews. PDQ- Evidence includes the following databases: Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, MEDLINE via PubMed, Embase, CINAHL, PsycINFO, Latin American and Caribbean Health Sciences Literature, JBI Database of Systematic Reviews and Implementation Reports, Evidence for Policy and Practice Information and Co- or-dinating Centre Evidence Library and the Campbell Collaboration Online Library. The ‘intervention’ publi-cation filter was used to include only systematic reviews that included studies of interventions and excluded

diagnostic (impact and accuracy), prognostic, prediction (diagnostic and prognostic) and qualitative systematic reviews.

Selection of reviewsTwo review authors (RJ and SC) independently screened the titles and abstracts and coded these as ‘retrieve’ (potentially eligible or unclear) or ‘do not retrieve’ (inel-igible). At least two of four review authors (RJ, PP, JN and KR) independently screened the full- text reports for inclusion. The reason for exclusion of ineligible system-atic reviews was recorded. Disagreements were resolved through discussion or involvement of a third review author (DAOC or RB). A PRISMA flow diagram was developed to summarise the search and selection process (figure 1).

Data extraction and managementData were extracted on systematic review characteris-tics (year of publication, authors, number and design of included studies and journal), population, health condi-tions (where reported), types of outcomes of interest (namely, patient outcomes, quality of care, access and/or use of healthcare services, resource use, impacts on equity, social outcomes, healthcare provider outcomes and adverse effects) and whether reviews included economic analyses. Microsoft Excel software (v14) was



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used to manage the data. A data extraction form was piloted and refined.20 Review authors involved in data extraction (RJ, PP, JN and KR) independently extracted data from the first 10 included reviews and discussed their findings to ensure consistency. Consistency of extraction was also performed independently by two review authors (RJ and PP) for a third of included reviews to ensure data collection was robust and to determine the level of agree-ment. As the mean agreement across review authors was 93%, a single- review author independently extracted the data from the remaining included reviews.

Collating and summarising resultsDelivery arrangements were categorised using the Cochrane Effective Practice and Organisation of Care (EPOC) taxonomy of health system interventions,18 which characterises interventions according to concep-tual, functional and/or practical similarities. The delivery arrangement domain of the taxonomy classifies inter-ventions into five categories (and related subcategories) based on changes to the following:1. How and when care is delivered.2. Where care is provided and changes to the healthcare

environment.3. Who provides care and how the healthcare workforce

is managed.4. Coordination of care and management of care pro-

cesses.5. ICT systems.

To this taxonomy we added a category of goal- focused reviews. This was used to categorise systematic reviews that summarised a range of alternative care delivery models across two or more EPOC categories.

As this was a scoping review, rather than an overview of systematic reviews designed to synthesise the results of the included systematic reviews, a critical appraisal of the quality of the included systematic reviews was not conducted.

We summarised our findings quantitatively by presenting a numerical count of reviews in each delivery arrangement category, visually using a bubble chart to display the quantity and range of reviews across categories and also using a narrative synthesis. We reported the number of Cochrane reviews in each category, given that Cochrane reviews are considered to have higher methodological quality compared with non- Cochrane reviews.21 22 We also reported the total number of primary studies (of any design) included in the systematic reviews in each category and separately a number of randomised trials in which the model of care was rigorously tested.

Patient and public involvement

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

rESultSresults of searchThe search yielded 829 citations. After title and abstract screening, 623 full- text reports were retrieved and assessed for eligibility. Ninety- two full- text reports were excluded and 531 systematic reviews were included (figure 1). The citations of included reviews are in online supplementary file 2.

Description of included reviewsOf the 531 systematic reviews, 125 (24%) were Cochrane reviews. A total of 12 230 individual studies were included across all systematic reviews, and these included 6911 randomised controlled trials (RCTs). A total of 106 (20%) reviews focused on common chronic diseases (eg, diabetes, chronic obstructive pulmonary disease, heart failure, chronic kidney failure, asthma and musculoskeletal conditions), and 53 (10%) reviews focused on patients undergoing lifestyle and preven-tion interventions. Over 90% of reviews examined the effects of alternative delivery arrangements on patient outcomes (eg, mortality and morbidity). Approximately one- third of reviews reported access and/or use of healthcare services as outcomes. One- third of reviews included economic evaluation studies. Only 12% of reviews included quality of care measures as outcomes, and only 6% and 3% of reviews reported impacts of alternative delivery arrangements on equity and social outcomes, respectively (table 1).

Figure 2 provides an overview of the 531 systematic reviews, organised according to the Cochrane EPOC taxonomy. The greatest number of reviews focused on changes to ICT systems used by healthcare organisa-tions to manage the delivery of healthcare (n=189). The majority of these focused on telehealth interventions (n=162). The fewest number of reviews (excluding goal- focused) were concerned with changes to how and when healthcare is delivered (n=47). The reviews relating to each category are described further in more detail.

how and when care is deliveredOf the 47 systematic reviews included in this category, 14 (30%) were Cochrane reviews. A total of 1085 primary studies were included in systematic reviews for this cate-gory, including 394 (36%) RCTs.

Systematic reviews in this category included a number of quality and safety initiatives (eg, use of safety checklists to reduce wrong site surgery), alternative methods for queuing patients (eg, patient- initiated clinics in chronic disease and strategies to reduce waiting times for elective surgery procedures). Many of the reviews in this category were not focused on a specific health condition (n=17, 36%), but they were the greatest number of reviews related to maternal and child health (n=7, 15%) (online supple-mentary file 3). Few systematic reviews examined group versus individual care (n=5, 11%) (eg, group antenatal care for pregnant women) or triage strategies (n=2, 4%) (eg, improving patient flow the emergency department).



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Table 1 Review characteristics

Review characteristics (N=531) Count (%)

Year of publication

2012 50 (9)

2013 79 (15)

2014 67 (12.5)

2015 111 (21)

2016 216 (41)

2017* 8 (1.5)

Cochrane reviews 125 (24)

Included primary studies (all designs) per review, mean (SD) (range)

23 (37) (0–463)

Reviews including randomised controlled trials 245 (46)

Health conditions/ populations

Common chronic diseases (eg, diabetes, chronic obstructive

pulmonary disease, heart failure, chronic kidney failure, asthma, musculoskeletal conditions)

106 (20)

Cancer 21 (4)

Critically or terminally ill 16 (3)

Patients undergoing lifestyle and prevention interventions

53 (10)

Patients undergoing surgical interventions (including preoperative care and safety checklists)

18 (3)

Mental health conditions 67 (12)

Older adults and aged care 17 (3)

Non- communicable diseases (eg, viral hepatitis, HIV, tuberculosis)

17 (3)

Maternal and child health 38 (7)

Outcomes reported

Patient outcomes (health status and/or health behaviours, eg, mortality, morbidity and cure rates)

492 (93)

Quality of care (eg, adherence to recommended practice)

62 (12)

Access and/or use of healthcare services (eg, waiting time to receive care, readmission rates and length of stay in a facility)

178 (34)

Resource use (including healthcare resources, non- healthcare resources, eg, transportation costs, patient and caregiver time)

161 (30)

Impacts on equity 30 (6)

Social outcomes (eg, poverty and unemployment)

15 (3)

Healthcare provider outcomes (eg, well- being, fatigue, stress and satisfaction)

68 (13)

Adverse effects 93 (18)

Reviews incorporating economic evaluation studies

177 (33)

*Incomplete.

There was one Cochrane review focused on walk- in clinics versus physician offices and emergency rooms for urgent care and chronic disease management that did not find any eligible trials.

Where care is provided and changes to the healthcare environmentThere were 55 systematic reviews included in this cate-gory. Of 1002 primary studies in this category, 323 (32%) were RCTs.

Most reviews investigated changes to the site of health-care delivery (n=51, 93%) with the majority of these focused on shifting care away from the hospital setting to the home (n=32). The remaining reviews focused on shifting care from the inpatient to the outpatient or day stay setting (eg, outpatient vs inpatient management for acute pulmonary embolism) (n=6); from the hospital to primary or community care organisations (eg, primary care asthma clinics) (n=4); from hospital to a thera-peutic community (eg, for mental healthcare) (n=2); provision of care in at site (eg, prehospital vs in- hospital thrombolysis) (n=4); or provision of care in schools (eg, for mental health and health equity) (n=3). A small number of reviews in this category looked at changes to other aspects of the healthcare environment, including the physical or sensory environment (n=1) (rooming- in services for pregnant mothers), outreach services (n=1) (mobile screening clinics for maternal and child health) and transportation services (n=1) (helicopter emer-gency medical services for adults with major trauma) and centralisation of services (n=1) (for gynaecological cancer).

Ten reviews (18%) in this category focused on maternal and child health; 5 (9%) focused on mental health; and 5 (9%) focused on cardiovascular disease, while the remainder focused on a range of chronic and complex conditions and lifestyle and preventive care (online supplementary file 3). One Cochrane review on home- based phototherapy for the management of non‐haemolytic jaundice in infants found no eligible trials.

Who provides care and how the healthcare workforce is managedThere were 80 systematic reviews included in this cate-gory, 18 (23%) were Cochrane reviews. Of 1408 primary studies in this category, 802 (57%) were RCTs.

Most reviews in this category explored substituting medical for appropriately trained nursing care (n=27, 34%) or extending the scope of pharmacists’ practice beyond dispensing services to provision of assessments, diagnosis and education (n=23, 29%). A small number of reviews also looked at self- management versus usual care, with a large focus on management of chronic conditions.

Many of the reviews did not focus on a specific health condition (n=17, 21%) but were focused on changes to workforce roles regardless of condition (online supple-mentary file 3). For those that did focus on a specific



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Figure 2 Number of included reviews organised according to the Cochrane Effective Practice and Organisation of Care taxonomy of delivery arrangement interventions. Comm b/w prov, communication between providers; Env, environment; Role exp, role expansion; HIS, Health information systems; ICT, information and communication technology; IT, information technology; Self mgt, self management; Qual & Saf, quality and safety systems; Sha Dec Mak, shared decision making.

health condition, the largest number was concerned with role expansion to care for patients with different types of chronic disease or multimorbidity (n=8, 10%). One Cochrane review on advanced trauma life support training and role expansion of hospital health professionals and ambulance crews on patient mortality and morbidity did not locate any studies that satisfied the eligibility criteria.

Coordination of care and management of care processesThere were 122 systematic reviews included in this cate-gory; 28 (23%) were Cochrane reviews. Of 2554 primary studies in this category, 1619 (63%) were RCTs.

The delivery arrangements in this category included transition care arrangements (eg, hospital to home, from primary to specialist care, or from paediatric to adult services), integrated care models for a range of chronic and complex diseases, early supported discharge to home (eg, for mild to moderate stroke or chronic obstructive pulmonary disease) and multi-disciplinary or interdisciplinary care teams for specific diseases or conditions (eg, geriatric consultation teams in acute hospitals, collaborative care for depression

and anxiety). Other delivery arrangements were care pathways (eg, critical care pathways for head and neck cancer surgery), disease management for a range of conditions (eg, prenatal, dementia and mental illness, and intellectual disability) and case management (eg, intensive case management for heart failure, severe mental health, adults with medical illness and complex care needs) (table 2).

Several reviews in this category did not focus on a particular health condition (n=17, 14%); however, a few focused on coordination of care in cancer (n=9, 7%), diabetes (n=8, 7%), maternal and child health (n=8, 7%), cardiovascular disease (n=6, 5%), mental health (n=6, 5%) and for the terminally ill (n=6, 5%) (online supplementary file 3). We identified two reviews that reported they did not locate any studies that met eligi-bility criteria. One focused on service responses for people with intellectual disabilities and epilepsy, the second focused on specialist teams for neonatal trans-port to neonatal intensive care units.



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and

cha

nges

to

the

heal

thca

re e

nviro

nmen

t (n

=55

)

Env

ironm

ent

Cha

nges

to

the

phy

sica

l or

sens

ory

heal

thca

re e

nviro

nmen

t, b

y ad

din

g or

alte

ring

equi

pm

ent

or la

yout

, p

rovi

din

g m

usic

and

art

1 (1

)1

(1)

0

►

Env

ironm

enta

l int

erve

ntio

ns t

o in

crea

se b

reas

tfee

din

g up

take

whi

le m

othe

rs a

re in

th

e ho

spita

l.

Out

reac

h se

rvic

esV

isits

by

heal

th w

orke

rs t

o d

iffer

ent

loca

tions

, for

exa

mp

le, i

nvol

ving

sp

ecia

lists

, gen

eral

ists

and

mob

ile

units

1 (1

)2

(2)

0

►

Mob

ile c

linic

s fo

r w

omen

’s a

nd c

hild

ren’

s he

alth

.

Con

tinue

d



jopen.bmj.com

/B

MJ O


arch 2020. Dow

nloaded from




Open access

Del

iver

y ar

rang

emen

t b

y E

PO

C t

axo

nom

y ca

teg

ory

and

su

bca

teg

ory

EP

OC

defi

niti

on

Rev

iew

s (n

) (C

och

rane

re

view

s, n

)

Pri

mar

y st

udie

s (n

) (R

CTs

)

Em

pty

re

view

s (n

)Ty

pes

of

inte

rven

tio

ns (s

ee o

nlin

e su

pp

lem

enta

ry fi

le 2

fo

r d

etai

ls)

Site

of s

ervi

ce

del

iver

yC

hang

es in

whe

re c

are

is p

rovi

ded

, fo

r ex

amp

le, h

ome

vers

us h

ealth

care

fa

cilit

y, in

pat

ient

ver

sus

outp

atie

nt,

spec

ialis

ed v

ersu

s no

n- sp

ecia

lised

fa

cilit

y, w

alk-

in c

linic

s, m

edic

al d

ay

hosp

ital a

nd m

obile

uni

ts

51 (2

0)95

6 (3

20)

1

►A

ltern

ativ

es t

o ho

spita

lisat

ions

: out

pat

ient

man

agem

ent,

qui

ck d

iagn

ostic

uni

ts,

hosp

ital a

t ho

me,

ob

serv

atio

n un

its (f

or in

duc

tion

of la

bou

r, in

trav

enou

s an

tibio

tic

ther

apy

for

cyst

ic fi

bro

sis,

car

dia

c ar

rest

, kid

ney

dia

lysi

s, C

OP

D, p

sych

osis

, pae

dia

tric

ca

re).

►

ED

- bas

ed in

terv

entio

ns (f

or m

anag

ing

alco

hol m

isus

e, d

omes

tic v

iole

nce

and

pal

liativ

e ca

re).

►

Hom

e vi

sitin

g (fo

r p

regn

ancy

, chi

ld h

ealth

and

mal

trea

tmen

t, s

ocia

l det

erm

inan

ts o

f he

alth

and

par

tner

vio

lenc

e).

►

Hom

e- b

ased

pre

vent

ion

and

reh

abili

tatio

n.

►Th

e p

atie

nt- c

entr

ed m

edic

al h

ome.

►

Pre

hosp

ital i

nter

vent

ion

for

sep

sis.

►

Rea

chin

g yo

uth

with

out

- of-

faci

lity

serv

ices

(HIV

and

rep

rod

uctiv

e he

alth

).

►S

choo

l- b

ased

hea

lth c

entr

es fo

r m

enta

l hea

lth a

nd s

ocia

l det

erm

inan

ts o

f hea

lth.

►

Ther

apeu

tic c

omm

uniti

es fo

r m

enta

l hea

lth.

►

Wai

ting

room

- bas

ed in

terv

entio

ns t

o p

reve

nt S

TD.

Siz

e of

or

gani

satio

nsIn

crea

sing

or

dec

reas

ing

the

size

of

heal

th s

ervi

ce p

rovi

der

uni

ts1

(1)

5 (0

)0

►

Cen

tral

isat

ion,

sp

ecia

lisat

ion

and

incr

easi

ng v

olum

e of

ser

vice

s to

pro

mot

e q

ualit

y (e

g,

canc

er c

are

and

sur

gery

).

Tran

spor

tatio

n se

rvic

esA

rran

gem

ents

for

tran

spor

ting

pat

ient

s fr

om o

ne s

ite t

o an

othe

r1

(1)

38 (0

)0

►

Hel

icop

ter

emer

genc

y m

edic

al s

ervi

ces

for

adul

ts w

ith m

ajor

tra

uma.

Who

pro

vid

es c

are

and

how

the

wor

kfor

ce is

man

aged

(n=

80)

Rol

e ex

pan

sion

or

task

shi

ftin

gE

xpan

din

g ta

sks

und

erta

ken

by

a ca

dre

of h

ealth

wor

kers

or

shift

ing

task

s fr

om o

ne c

adre

to

anot

her,

to

incl

ude

task

s no

t p

revi

ousl

y p

art

of

thei

r sc

ope

of p

ract

ice

65 (1

2)11

10 (5

86)

1

►

Ad

vanc

ed p

ract

ice

nurs

ing

in o

lder

peo

ple

and

in lo

ng- t

erm

car

e.

►

Ad

vanc

ed t

raum

a lif

e su

pp

ort

trai

ning

for

hosp

ital h

ealth

pro

fess

iona

l and

am

bul

ance

cre

ws.

►

C

arer

invo

lvem

ent

in c

ogni

tion-

bas

ed in

terv

entio

ns fo

r p

eop

le w

ith d

emen

tia.

►

C

omm

unity

- bas

ed h

ealth

wor

ker

inte

rven

tions

.

►

Inte

rven

tions

to

incr

ease

bre

ast

feed

ing.

►

N

urse

–phy

sici

an s

ubst

itutio

n.

►

Pee

r - le

d in

terv

entio

ns (e

g, in

men

tal h

ealth

).

►

Pha

rmac

ist

invo

lvem

ent

in c

are

for

pat

ient

s w

ith c

hron

ic c

ond

ition

s.

►

Prim

ary

care

- led

pro

visi

on o

f car

e (e

g, G

Ps

wor

king

in E

D).

►

R

adio

grap

hers

in a

dva

nced

rol

es.

Sel

f- m

anag

emen

tS

hift

ing

or p

rom

otin

g th

e re

spon

sib

ility

for

heal

thca

re o

r d

isea

se m

anag

emen

t to

pat

ient

s or

th

eir

fam

ilies

15 (6

)29

8 (2

16)

0

►

Pat

ient

nav

igat

ion

(bre

ast

canc

er).

►

P

r om

otin

g se

lf- m

anag

emen

t (in

chr

onic

dis

ease

s, s

pec

ifica

lly H

IV, d

iab

etes

foot

ca

re, C

OP

D, a

sthm

a, c

hild

ren

with

ep

ilep

sy, a

nxie

ty, M

S, I

BS

; sel

f- ad

min

istr

atio

n of

med

icat

ion

in t

he h

osp

ital,

oral

ant

icoa

gula

tion

and

hom

e ut

erin

e m

onito

ring

for

det

ectin

g p

rete

rm la

bou

r).

►

R

educ

ing

med

icat

ion

and

ove

rpre

scrip

tion

(ant

ibio

tic u

se, o

pio

id p

resc

riptio

n,

adm

inis

trat

ion

erro

rs in

chi

ldre

n an

d a

dul

ts, i

nap

pro

pria

te p

resc

ribin

g in

the

eld

erly

).

Coo

rdin

atio

n of

car

e an

d m

anag

emen

t of

car

e p

roce

sses

(n=

122)

Tab

le 2

C

ontin

ued

Con

tinue

d



jopen.bmj.com

/B

MJ O


arch 2020. Dow

nloaded from




Open access

Del

iver

y ar

rang

emen

t b

y E

PO

C t

axo

nom

y ca

teg

ory

and

su

bca

teg

ory

EP

OC

defi

niti

on

Rev

iew

s (n

) (C

och

rane

re

view

s, n

)

Pri

mar

y st

udie

s (n

) (R

CTs

)

Em

pty

re

view

s (n

)Ty

pes

of

inte

rven

tio

ns (s

ee o

nlin

e su

pp

lem

enta

ry fi

le 2

fo

r d

etai

ls)

Inte

grat

ed

heal

thca

re s

yste

ms

Con

solid

atin

g th

e p

rovi

sion

of

diff

eren

t he

alth

care

ser

vice

s to

one

(o

r si

mp

ly fe

wer

) fac

ilitie

s

16 (3

)40

6 (2

58)

0

►

Inte

grat

ed c

are

mod

els

for

vario

us c

ond

ition

s.

Sha

red

dec

isio

n m

akin

gS

harin

g he

alth

care

dec

isio

n- m

akin

g re

spon

sib

ilitie

s am

ong

diff

eren

t in

div

idua

ls, p

oten

tially

incl

udin

g th

e p

atie

nt

14 (5

)48

7 (3

93)

0

►

Ed

ucat

iona

l int

erve

ntio

ns fo

r p

atie

nts

and

car

ers.

►

Im

pro

ving

hea

lthca

re p

rofe

ssio

nals

ski

lls (e

g, c

omm

unic

atio

n in

can

cer,

per

form

ance

in

nur

sing

hom

es, r

ecog

nitio

n an

d m

anag

emen

t of

det

erio

ratin

g p

atie

nts

and

gen

etic

ed

ucat

ion)

.

►

Pro

mot

ing

adop

tion

of s

hare

d d

ecis

ion

mak

ing.

►

R

educ

ing

med

icat

ion

and

ove

rpre

scrip

tion.

►

S

hare

d d

ecis

ion

mak

ing

in p

regn

ancy

and

del

iver

y, t

reat

men

t in

old

er p

eop

le a

nd

canc

er s

cree

ning

.

Pac

kage

s of

car

eIn

trod

uctio

n, m

odifi

catio

n or

rem

oval

of

pac

kage

s of

ser

vice

s d

esig

ned

to

be

imp

lem

ente

d t

oget

her

for

a p

artic

ular

dia

gnos

is/d

isea

se, f

or

exam

ple

, tub

ercu

losi

s m

anag

emen

t gu

idel

ines

and

new

bor

n ca

re

pro

toco

ls

1 (1

)5

(5)

0

►

Car

e d

eliv

ery

mod

els/

dis

ease

man

agem

ent.

Cas

e m

anag

emen

tIn

trod

uctio

n, m

odifi

catio

n or

re

mov

al o

f str

ateg

ies

to im

pro

ve

the

coor

din

atio

n an

d c

ontin

uity

of

del

iver

y of

ser

vice

s, t

hat

is, i

mp

rovi

ng

the

man

agem

ent

of o

ne ’c

ase’

(p

atie

nt)

14 (4

)37

5 (2

60)

0

►

Ad

vanc

e ca

re p

lann

ing

(eg,

hae

mod

ialy

sis

pat

ient

s, p

allia

tive

care

and

end

- of-

life

inte

rven

tions

).

►

Cas

e m

anag

emen

t in

chr

onic

dis

ease

s, s

pec

ifica

lly C

VD

, typ

e 2

dia

bet

es, c

ance

r, ch

ildho

od o

bes

ity, h

aem

ophi

lia, m

enta

l hea

lth, m

ultim

orb

iditi

es a

nd c

hron

ic v

iral

hep

atiti

s.

►

Out

pat

ient

cas

e m

anag

emen

t.

Dis

ease

m

anag

emen

tP

rogr

amm

es d

esig

ned

to

man

age

or p

reve

nt a

chr

onic

con

diti

on u

sing

a

syst

emat

ic a

pp

roac

h to

car

e an

d

pot

entia

lly e

mp

loyi

ng m

ultip

le w

ays

of in

fluen

cing

pat

ient

s, p

rovi

der

s or

th

e p

roce

ss o

f car

e

16 (3

)29

8 (1

69)

1

►

Ad

oles

cent

- sp

ecifi

c p

rena

tal i

nter

vent

ions

on

imp

rovi

ng a

tten

dan

ce a

nd r

educ

ing

harm

dur

ing

and

aft

er b

irth.

►

C

are

del

iver

y m

odel

s/d

isea

se m

anag

emen

t.

►

Chr

onic

dis

ease

man

agem

ent—

asth

ma.

►

Im

pro

ving

hea

lthca

re p

rofe

ssio

nals

ski

lls.

►

O

utp

atie

nt m

anag

emen

t of

car

dio

met

abol

ic r

isk

fact

or c

ontr

ol in

peo

ple

with

d

iab

etes

.

Car

e p

athw

ays

Aim

to

link

evid

ence

to

pra

ctic

e fo

r sp

ecifi

c he

alth

con

diti

ons

and

loca

l ar

rang

emen

ts fo

r d

eliv

erin

g ca

re

8 (2

)99

(24)

0

►

Ad

vanc

ed c

are

pla

nnin

g.

►

Car

e d

eliv

ery

mod

els/

dis

ease

man

agem

ent.

►

C

ritic

al c

are.

►

In

terv

entio

ns t

o im

pro

ve li

nkag

e w

ith o

r re

tent

ion

in H

IV s

ervi

ces.

►

R

apid

res

pon

se s

yste

ms

to r

educ

e ho

spita

l mor

talit

y.

Tab

le 2

C

ontin

ued

Con

tinue

d



jopen.bmj.com

/B

MJ O


arch 2020. Dow

nloaded from




Open access

Del

iver

y ar

rang

emen

t b

y E

PO

C t

axo

nom

y ca

teg

ory

and

su

bca

teg

ory

EP

OC

defi

niti

on

Rev

iew

s (n

) (C

och

rane

re

view

s, n

)

Pri

mar

y st

udie

s (n

) (R

CTs

)

Em

pty

re

view

s (n

)Ty

pes

of

inte

rven

tio

ns (s

ee o

nlin

e su

pp

lem

enta

ry fi

le 2

fo

r d

etai

ls)

Team

sC

reat

ing

and

del

iver

ing

care

thr

ough

a

mul

tidis

cip

linar

y te

am o

f hea

lthca

re

wor

kers

22 (4

)39

8 (2

29)

1

►

Mul

tidis

cip

linar

y te

am c

are

for

dem

entia

and

oth

er m

enta

l hea

lth c

ond

ition

s, o

lder

ad

ults

, ep

ilep

sy, a

sthm

a, H

IV, h

eart

h fa

ilure

, chr

onic

cou

gh in

chi

ldre

n, a

nten

atal

car

e,

chro

nic

dis

ease

man

agem

ent,

sp

ecifi

cally

CV

D, t

ype

2 d

iab

etes

, can

cer,

child

hood

ob

esity

, hae

mop

hilia

, mul

timor

bid

ities

and

chr

onic

vira

l hep

atiti

s.

►

Team

inte

rven

tions

to

pro

mot

e w

ork

par

ticip

atio

n in

peo

ple

with

reg

iona

l m

uscu

losk

elet

al p

ain.

►

M

ultid

isci

plin

ary

team

car

e in

chr

onic

dis

ease

.

►

Mul

tidis

cip

linar

y te

am in

neo

nata

l car

e.

Com

mun

icat

ion

bet

wee

n p

rovi

der

sS

yste

ms

or s

trat

egie

s fo

r im

pro

ving

th

e co

mm

unic

atio

n b

etw

een

heal

thca

re p

rovi

der

s

6 (2

)10

5 (4

4)0

►

Im

pr o

ving

clin

ical

com

mun

icat

ion

in h

osp

itals

, bet

wee

n p

rimar

y an

d s

econ

dar

y ca

re; i

mp

rovi

ng p

atie

nt h

and

over

s fr

om h

osp

ital t

o p

rimar

y ca

re a

nd v

ice

vers

a.

Tran

sitio

n of

car

eIn

terv

entio

ns t

o im

pro

ve t

rans

ition

fr

om o

ne c

are

pro

vid

er t

o an

othe

r7

(0)

138

(26)

0

►

Tran

sitio

n fr

om p

aed

iatr

ic t

o ad

ult

care

set

tings

or

serv

ices

.

Dis

char

ge p

lann

ing

An

ind

ivid

ualis

ed p

lan

of d

isch

arge

to

faci

litat

e th

e tr

ansf

er o

f a p

atie

nt fr

om

hosp

ital t

o a

pos

tdis

char

ge s

ettin

g

18 (4

)24

3 (2

11)

0

►

Ear

ly s

upp

orte

d d

isch

arge

pla

nnin

g (a

cute

str

oke,

CO

PD

, old

er a

dul

ts, c

hild

ren

with

ca

ncer

and

feb

rile

neut

rop

aeni

a).

►

Fa

st- t

rack

sur

gery

pro

gram

mes

(liv

er s

urge

ry).

►

P

rovi

din

g w

ritte

n in

form

atio

n to

red

uce

read

mis

sion

s in

hea

rt fa

ilure

.

►

Tran

sitio

nal c

are

man

agem

ent

afte

r ho

spita

l dis

char

ge t

o re

duc

e 30

- day

re

adm

issi

on r

ates

.

ICT

syst

ems

(n=

189)

Hea

lth in

form

atio

n sy

stem

sH

ealth

rec

ord

and

hea

lth

man

agem

ent

syst

ems

to s

tore

and

m

anag

e p

atie

nt h

ealth

info

rmat

ion,

fo

r ex

amp

le, e

lect

roni

c p

atie

nt

reco

rds,

or

syst

ems

for

reca

lling

p

atie

nts

for

follo

w- u

p o

r p

reve

ntio

n

13 (4

)71

8 (1

18)

0

►H

ealth

not

es v

ersu

s E

MR

in p

regn

ancy

.

►In

terv

entio

ns t

o im

pro

ve a

tten

dan

ce o

f ap

poi

ntm

ents

.

►P

aed

iatr

ic t

rack

and

trig

ger

syst

ems

for

hosp

italis

ed c

hild

ren.

►

Pat

ient

saf

ety

inte

rven

tions

tha

t us

e te

chno

logy

.

►R

ecal

l int

erva

ls (f

or d

enta

l vis

its, w

omen

with

his

tory

of g

esta

tiona

l dia

bet

es, T

B

app

oint

men

ts.

►

Rem

ind

er in

terv

entio

ns t

o im

pro

ve t

reat

men

t ad

here

nce.

►

The

use

of m

edic

al s

crib

es in

hea

lthca

re s

ettin

gs.

The

use

of IC

TTe

chno

logy

- bas

ed m

etho

ds

to

tran

sfer

hea

lthca

re in

form

atio

n an

d

sup

por

t th

e d

eliv

ery

of c

are

13 (1

)62

7 (2

50)

0

►C

omp

uter

ised

clin

ical

dec

isio

n su

pp

ort

to e

nab

le p

atie

nt- c

entr

ed c

are

(nut

ritio

n in

form

atic

s an

d a

dvi

ce o

n d

rug

dos

age)

.

►M

edic

atio

n or

gani

satio

n d

evic

es.

►

Med

icat

ion

reco

ncili

atio

n in

terv

entio

ns in

the

hos

pita

l.

►M

ultim

edia

ed

ucat

iona

l int

erve

ntio

ns fo

r co

nsum

ers

abou

t p

resc

ribed

and

ove

r‐th

e‐co

unte

r m

edic

atio

ns.

►

Pat

ient

por

tals

.

►IT

inte

rven

tions

for

red

ucin

g in

app

rop

riate

imag

ing

and

tes

ting

(eg,

car

dia

c, lo

w- b

ack

pai

n im

agin

g an

d la

b t

ests

ord

erin

g b

y G

Ps)

.

►IT

inte

rven

tions

for

red

ucin

g m

edic

atio

n us

e an

d o

verp

resc

riptio

n.

►S

erio

us g

ames

for

pro

fess

iona

l tra

inin

g an

d p

atie

nt e

duc

atio

n (e

g, c

hron

ic d

isea

ses

and

men

tal h

ealth

).

Tab

le 2

C

ontin

ued

Con

tinue

d



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Del

iver

y ar

rang

emen

t b

y E

PO

C t

axo

nom

y ca

teg

ory

and

su

bca

teg

ory

EP

OC

defi

niti

on

Rev

iew

s (n

) (C

och

rane

re

view

s, n

)

Pri

mar

y st

udie

s (n

) (R

CTs

)

Em

pty

re

view

s (n

)Ty

pes

of

inte

rven

tio

ns (s

ee o

nlin

e su

pp

lem

enta

ry fi

le 2

fo

r d

etai

ls)

Sm

art

hom

e te

chno

logi

esE

lect

roni

c as

sist

ive

tech

nolo

gies

1 (0

)48

(9)

0

►R

emot

e m

onito

ring

(eg,

aft

er r

ecen

t ho

spita

l dis

char

ge w

ith h

eart

failu

re, i

n ol

der

ad

ults

, ast

hma)

.

Tele

heal

thE

xcha

nge

of h

ealth

care

info

rmat

ion

from

one

site

to

anot

her

via

elec

tron

ic

com

mun

icat

ion

162

(29)

3533

(252

7)2

►

Sel

f- ca

re a

pp

licat

ions

.

►S

ocia

l net

wor

ks a

nd s

ocia

l med

ia.

►

Tele

coac

hing

(tel

epho

ne c

ouns

ellin

g; p

eer

sup

por

t p

rogr

amm

es; a

utom

ated

tel

epho

ne

mes

sagi

ng; w

eb- b

ased

pro

gram

mes

, for

exa

mp

le, c

ogni

tive–

beh

avio

ural

the

rap

y fo

r m

enta

l hea

lth c

ond

ition

s, c

oach

ing

for

chro

nic

dis

ease

).

►T e

lehe

alth

(em

ail c

omm

unic

atio

n, m

obile

pho

ne m

essa

ging

, mob

ile p

hone

tec

hnol

ogy,

m

obile

tec

hnol

ogy

or r

ange

of i

nter

vent

ion

typ

es).

►

Tele

med

icin

e (s

cree

ning

, tel

ereh

abili

tatio

n an

d t

elem

onito

ring)

.

Goa

l- fo

cuse

d r

evie

ws

(n=

38)

Inte

rven

tions

to

add

ress

soc

ial d

eter

min

ants

of h

ealth

14 (2

)31

9 (1

23)

0

►C

ultu

rally

ap

pro

pria

te p

reve

ntio

n an

d c

are

(ind

igen

ous

pop

ulat

ions

, rac

ial–

ethn

ic

min

oriti

es, l

ow s

ocio

econ

omic

pop

ulat

ions

).

►E

limin

atin

g re

pea

t un

inte

nded

pre

gnan

cy in

tee

nage

rs.

►

Imp

r ovi

ng a

cces

s to

hea

lthca

re fo

r ho

mel

ess

peo

ple

.

►In

terv

entio

ns t

o ad

dre

ss s

ocia

l det

erm

inan

ts o

f hea

lth fo

r m

inor

ity p

opul

atio

ns (e

thni

c an

d r

acia

l dis

par

ities

).

Imp

rovi

ng m

edic

atio

n ad

here

nce

11 (2

)65

4 (5

51)

0

►In

terv

entio

ns a

imed

at

imp

rovi

ng m

edic

atio

n ad

here

nce

(eg,

chr

onic

dis

ease

s,

spec

ifica

lly d

iab

etes

, HIV

and

CV

D in

eth

nic

min

oriti

es).

Ad

dre

ssin

g m

ultim

orb

idity

in p

rimar

y ca

re1

(1)

18 (1

8)0

►

Inte

rven

tions

ad

dre

ssin

g m

ultim

orb

idity

in p

rimar

y ca

re.

Pre

vent

ing

read

mis

sion

s1

42 (4

2)0

►

Inte

rven

tions

for

pre

vent

ing

unp

lann

ed 3

0- d

ay h

osp

ital r

ead

mis

sion

s.

Red

ucin

g in

app

rop

riate

imag

ing

and

tes

ting

324

(6)

0

►In

terv

entio

ns fo

r re

duc

ing

inap

pro

pria

te im

agin

g an

d t

estin

g.

Mee

ting

fam

ily n

eed

s of

the

crit

ical

ly il

l1

14 (1

)0

►

Mee

ting

fam

ily n

eed

s of

crit

ical

ly il

l pat

ient

s in

an

ICU

.

Com

mun

icat

ing

cont

race

ptiv

e ef

fect

iven

ess

1 (1

)7

(7)

0

►C

omm

unic

atin

g co

ntra

cep

tive

effe

ctiv

enes

s.

Imp

rovi

ng a

dhe

renc

e to

tre

atm

ent

238

(35)

0

►Im

pro

ving

ad

here

nce

to t

reat

men

t in

chi

ldre

n w

ith c

hron

ic d

isea

ses

and

ad

ult

hear

t tr

ansp

lant

pat

ient

s.

Inte

rven

tions

to

incr

ease

ret

entio

n in

hea

lthca

re s

ervi

ces

1 (1

)11

(9)

0

►In

terv

entio

ns t

o in

crea

se r

eten

tion

in m

enta

l hea

lth s

ervi

ces.

Inte

rven

tions

to

incr

ease

vac

cine

up

take

312

8 (7

7)0

►

Inte

rven

tions

to

incr

ease

vac

cine

up

take

in c

hild

ren

and

the

eld

erly

.

Tota

l53

112

230

(691

1)7

CO

PD

, chr

onic

ob

stru

ctiv

e p

ulm

onar

y d

isea

se; C

VD

, car

dio

vasc

ular

dis

ease

; ED

, em

erge

ncy

dep

artm

ent;

EM

R, e

lect

roni

c m

edic

al r

ecor

d; E

PO

C, E

ffect

ive

Pra

ctic

e an

d O

rgan

isat

ion

of C

are;

ER

, em

erge

ncy

room

; GP,

gen

eral

pra

ctiti

oner

; IB

S, i

rrita

ble

bow

el s

ynd

rom

e; IC

T, in

form

atio

n an

d c

omm

unic

atio

n te

chno

logy

; IC

U, i

nten

sive

car

e un

it; IT

, inf

orm

atio

n te

chno

logy

; MS

, mul

tiple

scl

eros

is;

RC

T, r

and

omis

ed c

ontr

olle

d t

rial;

STD

, sex

ually

tra

nsm

itted

dis

ease

; TB

, tub

ercu

losi

s.

Tab

le 2

C

ontin

ued



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Figure 3 Summary of included reviews by year of publication (2012–2016) and incorporating economic analyses.

ICt systemsThere were 189 systematic reviews included in this cate-gory; 34 (18%) were Cochrane reviews. Of 4926 primary studies in this category, 2904 (59%) were RCTs.

The largest number of reviews focused on telehealth (n=162, 86%) and included a range of interventions such as telephone counselling, telemonitoring, mobile texting or applications, and internet- based programmes (eg, cognitive–behavioural therapy) (table 2). A smaller number of reviews investigated health information systems (n=13, 7%) (eg, paediatric track and trigger systems for hospitalised children), the use of ICT (n=13, 7%) (eg, ICT interventions for reducing inappropriate imaging and testing) and smart home technology (n=1, 0.5%) (eg, remote monitoring of patients discharged from hospital with heart failure).

The majority of reviews in this category focused on changes to ICT systems for delivering mental health-care (n=44, 23%), while 39 (21%) focused on delivery of lifestyle changes and preventative strategies for health (n=39, 21%) (online supplementary file 3). There were two empty Cochrane reviews in this category. The first focused on the use of email for communicating results of diagnostic medical investigations to patients; the second focused on telerehabilitation for people with low vision.

goal-focused reviewsThere were 38 systematic reviews included in this cate-gory, including 7 (18%) Cochrane reviews. Of 1255 primary studies in this category, 869 (6%) were RCTs. A number of these reviews investigated interventions designed to address health disparities and social determi-nants of health (14 reviews). These covered a wide range of interventions, some targeting particular populations (eg, for improving access for the homeless to primary

care), while others focused on any intervention to reduce health disparities among racial and ethnic minority populations (eg, community coalition- driven interven-tions and cultural adaptations of interventions to change behaviour). A further 13 reviews investigated strategies to improve medication or treatment adherence, some targeting particular conditions (eg, pharmacy care and brief messaging to improve medication adherence in type 2 diabetes), others targeting particular medications (eg, lipid- lowering medications).

resource use outcomes and inclusion of economic evaluation studiesFigure 3 provides a summary of included reviews published by year (excluding 2017 as the search of the available liter-ature was not conducted for the full 2017 calendar year), including (1) number of reviews which specified cost as an outcome of interest or aimed to include economic eval-uations, and (2) number of reviews that included at least one primary study reporting on costs or economic evalu-ation. A total of 177 (32%) reviews included costs and/or economic analysis as an outcome of interest, with only 124 reporting at least one primary study including one of these economic outcomes. Resource use (including healthcare resources, eg, length of stay or number of visits to provider; non- healthcare resources, eg, transpor-tation costs, patient and caregiver time) were collected in 161 (30%) of the reviews (table 1).

DISCuSSIOnThis scoping review describes the extent, range and nature of synthesised evidence of alternative models of healthcare delivery relevant to high- income countries published in the past 5 years. It identified 531 reviews



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of interventions that involved changes to how and when care is delivered (47 reviews), where care is provided and changes to the healthcare environment (55 reviews), who provides care and how the healthcare workforce is managed (80 reviews), coordination of care and manage-ment of care processes (122 reviews), ICT systems (189 reviews) and reviews of interventions addressing a goal- focused question (38 reviews).

We identified variability in the distribution of system-atic reviews across the categories of the Cochrane EPOC taxonomy for delivery arrangement interventions; some interventions, such as telehealth and role expansion or substitution, received substantially more attention than others. There were a number of delivery arrangement categories with few published systematic reviews, such as provision of care in a group instead of as an individual, use of triage systems for managing healthcare delivery, changes to the size of healthcare organisations or length of consultations, use of packages of care or smart home technologies. Since the aim of this scoping review was not to examine the extent, range and nature of primary research in this area, it is unclear whether the limited number of reviews on these topics is due to few primary studies or other factors.

Technological advances over the past decade have seen a rapidly changing healthcare landscape that likely explains the large number of reviews we found in the tele-health subcategory. The intense interest in technology belies the barriers associated with their uptake and use, including the upfront and ongoing financial invest-ment in equipment, licensing and software required,23 real or perceived privacy risks, and funding systems that do not always support the delivery of healthcare in this way.24 They are advocated as having potential to enhance care delivery, with the promise of improved capacity for patients to be cared for at home, and improved access for those living rurally or remotely.

Over the past 10 years, there has also been a prolif-eration of policy decisions both in Australia and else-where that have encouraged the development of new or expanded workforce roles to address human resource shortages.25–28 The large number of systematic reviews in this subcategory likely reflects the extensive investment in this area over this time. In addition, there may be other drivers of role expansion for specific health workers; for example, with changes to legislation around supply of pharmaceuticals and a growth in ‘supermarket pharma-cies’, there is greater potential for pharmacists to take on additional non- dispensing roles.

While almost all included reviews reported on patient outcomes, only a third of reviews included resource use as an outcome and/or searched for an incorpo-rated economic evaluation studies. Evidence about the economic impact of changes to the way in which health-care services are organised and delivered is likely to become increasingly important to those making decisions about system redesign and improvement. The lack of economic evaluations in the majority of systematic reviews

of delivery arrangements means that the value of many of these models is unknown. Therefore, it is important that the impact of alternative delivery arrangement interven-tions on these outcomes be considered in future reviews.

There are a number of strengths and limitations to this scoping review. Two authors independently screened and selected reviews, thus minimising the likelihood of omit-ting eligible reviews. While independent data extraction by two review authors was not feasible due to the large number of included reviews (and is not recommended in methods guidance for scoping reviews20), we did take steps to optimise consistency in data extraction.16 As this scoping review sought to map the state of the literature in this area, we did not appraise the quality of the included reviews and did not attempt to synthesise the results of the included systematic reviews. The search was limited to the last 5 years and only abstracts published on PDQ- Evidence and filtered by the ‘intervention’ category were included. We used the Cochrane EPOC taxonomy for delivery arrangement interventions to map the extent, range and nature of systematic review evidence about alternative models of care delivery but categorisation was not always straightforward. This was because interventions could sometimes be categorised to more than one category (eg, information technology used to improve coordination of care). In these instances, the review team discussed and reached consensus on the categorisation of reviews (see online supplementary file 2). Due to the nature of delays between publication, indexing by databases and capture allocation to the intervention category by PDQ- Evidence, there may be eligible systematic reviews published during our search period but not captured in our search. Since the date of our last search, we have identified 31 system-atic reviews indexed in PDQ- Evidence that are potentially eligible for this scoping review. Given this modest volume (5% of current total), addition of this evidence is unlikely to substantially alter the conclusions.

Finally, this review focused on changes in how, when and where healthcare is organised and delivered, and who delivers care and thus excluded consideration of alternatives focused on changes to financial arrange-ments (eg, changes to how funds are collected, insurance schemes, purchasing of services and use of incentives/disincentives), governance arrangements (changes in rules or processes that determine authority and account-ability) and implementation strategies (aimed at bringing about changes in behaviour of healthcare professionals or organisations). Mapping the synthesised evidence focused on these interventions relevant to high- income countries could be described in future scoping reviews.

The findings of this review raise questions that could be investigated in future research. These include exploring to what extent have identified systematic reviews informed policy decisions in Australia and elsewhere? To what extent have decisions to undertake systematic reviews of delivery arrangements been driven by the needs of decision makers versus other motivations? And how can the alignment between review production and the



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needs of decision- makers be improved? Priority setting approaches that engage both health policy makers and researchers/producers of reviews are likely to increase the availability of reviews relevant to policy and reduce unnecessary duplication of effort. Exploring the need for, and addressing the gaps in, reviews of alternative delivery arrangements highlighted by our review could also be the focus of future work.

The results of the scoping review have informed a Delphi survey to prioritise the most promising alterna-tives for further investigation. The survey was delivered in two rounds to an Australian panel of policy, clinician, manager, consumer and academic representatives. The next steps include conducting (or updating where relevant) systematic reviews of delivery arrangements ranked as important to the panel and undertaking pilot evaluations (including economic) of high priority, promising alternative delivery arrangements in collabo-ration with healthcare system partners.

COnCluSIOnA substantial body of evidence about the effects of a wide range of delivery arrangements is available to inform health system improvements. Most of the avail-able evidence focuses on alternative ICT systems and care coordination models. This scoping review provides a map of the extent, range and nature of available synthesised evidence and identifies gaps where research efforts could be directed, that is, in updating out- of- date reviews or conducting reviews where no reviews currently exist.

Contributors The study conception and overall design were conceived by RB and DAOC. RJ, DAOC and PP designed the data extraction tool and RJ, PP, KR and JN assisted in piloting. RJ wrote the first draft of the protocol and DAOC, RB, PP, KR, JN, SC and SS critically reviewed the manuscript, contributed improvements and approved the final version.

Funding This work was supported by a National Health and Medical Research Council (NHMRC) Partnership Centre for Health System Sustainability (grant ID: 9100002). Along with the NHMRC, the funding partners in this research collaboration are BUPA Health Foundation, NSW Health, Department of Health, Western Australia and The University of Notre Dame Australia. RB is funded by an NHMRC Senior Principal Research Fellowship (#APP1082138). DAOC is supported by a NHMRC Translating Research into Practice Fellowship (APP1168749).

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

Data availability statement Data sharing not applicable as no datasets generated and/or analysed for this study. All data is presented in the manuscript and supplementary material.

Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non- commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non- commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.

OrCID iDsPolina Putrik http:// orcid. org/ 0000- 0002- 9342- 1861Rachelle Buchbinder http:// orcid. org/ 0000- 0002- 0597- 0933Sasha Shepperd http:// orcid. org/ 0000- 0001- 6384- 8322

Denise A O’Connor http:// orcid. org/ 0000- 0002- 6836- 122X

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