Search

Additional file 3. Table describing the included studies.

Additional file 1. Search 1: Interventions to reduce mental ill health.

Additional file 2. Table describing the stakeholder group meetings.

Additional file 4. Examples of the citations that provide evidence for each CMOc.

Background:\ud The NHS policy of constructing multispecialty community providers (MCPs) rests on a complex set of assumptions about how health systems can replace hospital use with enhanced primary care for people with complex, chronic or multiple health problems, while contributing savings to health-care budgets.\ud \ud Objectives:\ud To use policy-makers’ assumptions to elicit an initial programme theory (IPT) of how MCPs can achieve their outcomes and to compare this with published secondary evidence and revise the programme theory accordingly.\ud \ud Design:\ud Realist synthesis with a three-stage method: (1) for policy documents, elicit the IPT underlying the MCP policy, (2) review and synthesise secondary evidence relevant to those assumptions and (3) compare the programme theory with the secondary evidence and, when necessary, reformulate the programme theory in a more evidence-based way.\ud \ud Data sources:\ud Systematic searches and data extraction using (1) the Health Management Information Consortium (HMIC) database for policy statements and (2) topically appropriate databases, including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Applied Social Sciences Index and Abstracts (ASSIA). A total of 1319 titles and abstracts were reviewed in two rounds and 116 were selected for full-text data extraction. We extracted data using a formal data extraction tool and synthesised them using a framework reflecting the main policy assumptions.\ud \ud Results:\ud The IPT of MCPs contained 28 interconnected context–mechanism–outcome relationships. Few policy statements specified what contexts the policy mechanisms required. We found strong evidence supporting the IPT assumptions concerning organisational culture, interorganisational network management, multidisciplinary teams (MDTs), the uses and effects of health information technology (HIT) in MCP-like settings, planned referral networks, care planning for individual patients and the diversion of patients from inpatient to primary care. The evidence was weaker, or mixed (supporting some of the constituent assumptions but not others), concerning voluntary sector involvement, the effects of preventative care on hospital admissions and patient experience, planned referral networks and demand management systems. The evidence about the effects of referral reductions on costs was equivocal. We found no studies confirming that the development of preventative care would reduce demands on inpatient services. The IPT had overlooked certain mechanisms relevant to MCPs, mostly concerning MDTs and the uses of HITs.\ud \ud Limitations:\ud The studies reviewed were limited to Organisation for Economic Co-operation and Development countries and, because of the large amount of published material, the period 2014–16, assuming that later studies, especially systematic reviews, already include important earlier findings. No empirical studies of MCPs yet existed.\ud \ud Conclusions:\ud Multidisciplinary teams are a central mechanism by which MCPs (and equivalent networks and organisations) work, provided that the teams include the relevant professions (hence, organisations) and, for care planning, individual patients. Further primary research would be required to test elements of the revised logic model, in particular about (1) how MDTs and enhanced general practice compare and interact, or can be combined, in managing referral networks and (2) under what circumstances diverting patients from in-patient to primary care reduces NHS costs and improves the quality of patient experience.

Introduction: Current National Health Service (NHS) policy towards care coordination in England, involving the introduction of Multi-Specialty Community Providers (MCPs), assumes that repeated unplanned admissions of older people with multiple morbidity make disproportionately heavy use of hospital bed-days, that a substantial number of these admissions are preventable, and that reducing these admissions would substantially reduce cost and access pressures on hospital services. 'Integrated' (better-coordinated) care, delivered by MCPs, is intended to reduce these admissions by partly replacing hospital care with non-hospital care, hence raising the quality and reducing the cost of care. Our study synthesised existing evidence about how to integrate care at the system-level, including management of complexity and whole system patient flow. Theory/Methods: Stage 1. From grey literature, MCPs’ published logic models, and a think tank (policy makers, health-workers, patients/public), we elicited policy-assumptions ('programme theory') about what structures, working practices and services ('mechanisms') the MCPs will contain, and how these mechanisms are expected to produce the outcomes above. Stage 2. Realist review: Evidence from other ‘integrated’ care projects which related to the programme theory identified in stage 1 was synthesised to produce a revised, more strongly evidence-based explanation of how complex, MCP-like ‘integrated’ care systems function in different contexts. 3. 'Critical Analysis': The policy-makers' initial programme theory (from stage 1) was compared with the evidence from stage 2. In that way the policy-makers’ initial programme theory was elaborated, qualified and revised, better to inform the development of health and social care co-ordination in England. Results: We present 1) the initial programme theory, built from NHS England policy-makers' assumptions as to what outcomes the MCP models of care integration will produce in England, and by what means, and 2) some main findingsof how different models of care co-ordination might contribute to achieving these outcomes and under what conditions. Discussions: We discuss 1) how realist review methods were used to elaborate, qualify or challenge policy-makers' assumptions about how care co-ordination by means of MCPs would achieve the desired outcomes, and 2) how these findings can inform better care co-ordination. Conclusions: We describe the main empirical strengths and weaknesses in the assumptions underlying the models of care and care coordination which inform current NHS policy, and indicate where existing evidence is weak or lacking. Lessons learned: We discuss how we met the challenge of focusing the scope of a project that encompasses complex system-level issues across health and social care, and how far the findings and lessons might apply to other, differently-structured health systems. Limitations: Policy-makers assumptions were complex and incompletely articulated, making our findings depend, at points, upon our interpretation of what policy makers specifically intended. The complexity constrained us to focus our review on the policy makers’ most central assumptions. Future research: 1) Understanding how the logic models informed practice by evaluating the usefulness, and any future policy application, of our findings by policy makers in England. 2) Testing our findings empirically through primary research (Realist evaluation) of MCPs in practice.

Search strategy. Ovid SP MEDLINE search strategy. (DOCX 13Â kb)

Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols (PRISMA-P) 2015 checklist: recommended items to address in a systematic review protocol. (DOCX 36Â kb)

Identifying literature for a systematic review requires searching a variety of sources. The main sources are typically bibliographic databases. Web searching using search engines and websites may be used to identify grey literature. Searches should be reported in order to ensure transparency and reproducibility. This study assesses the reporting of web searching for systematic reviews carried out by the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme (UK). The study also makes recommendations about reporting web searching for systematic reviews in order to achieve a reasonable level of transparency and reproducibility.Systematic reviews were identified by searching the HTA database via the Centre for Reviews and Dissemination (CRD) website. Systematic reviews were included in the study if they made reference to searching the web using either search engines or websites. A data-extraction checklist was designed to record how web searching was reported. The checklist recorded whether a systematic review reported: the names of search engines or websites; the dates they were searched; the search terms; the results of the searches; and, in the case of websites, whether a URL was reported.554 HTA reports published between January 2004 and December 2013 were identified. 300 of these reports are systematic reviews, of which 108 report web searching using either a search engine or a website. Overall, the systematic reviews assessed in the study exhibit a low standard of web search reporting. In the majority of cases, the only details reported are the names of websites (n = 54) or search engines (n = 33). A small minority (n = 6) exhibit the highest standard of web search reporting.Most web search reporting in systematic reviews carried out on the UK HTA programme is not detailed enough to ensure transparency and reproducibility. Transparency of reporting could be improved by adhering to a reporting standard such as the standard detailed in the CRD systematic reviews methods guidance. Reproducibility is harder to achieve due to the frequency of changes to websites and search engines.

Supplementary Information. (DOCX 39Â kb)

Purpose: Upper limb disability following stroke may have multiple effects on the individual. Existing assessment instruments tend to focus on impairment and function and may miss other changes that are personally important. This study aimed to identify personally significant impacts of upper limb disability following stroke. Methods: Accounts by stroke survivors, in the form of web-based diaries (blogs) and stories, were sought using a blog search engine and in stroke-related web-sites. Thematic analysis using the World Health Organisation’s International Classification of Functioning Disability and Health (ICF) was used to identify personal impacts of upper limb disability following stroke. Results: Ninety-nine sources from at least four countries were analysed. Many impacts were classifiable using the ICF, but a number of additional themes emerged, including emotional, cognitive and behavioural changes. Blogs and other web-based accounts were easily accessible and rich sources of data, although using them raised several methodological issues, including potential sample bias. Conclusions: A range of impacts was identified, some of which (such as use of information technology and alienation from the upper limb) are not addressed in current assessment instruments. They should be considered in post-stroke assessments. Blogs may help in the development of more comprehensive assessments.Implications for RehabilitationA comprehensive assessment of the upper limb following stroke should include the impact of upper limb problems on social participation, as well as associated emotional, cognitive and behavioural changes.Using personalised assessment instruments alongside standardised measures may help ensure that these broader domains are considered in discussions between clinicians and patients.Rehabilitation researchers should investigate whether and how these domains could be addressed and operationalised in standard upper limb assessment instruments. A comprehensive assessment of the upper limb following stroke should include the impact of upper limb problems on social participation, as well as associated emotional, cognitive and behavioural changes. Using personalised assessment instruments alongside standardised measures may help ensure that these broader domains are considered in discussions between clinicians and patients. Rehabilitation researchers should investigate whether and how these domains could be addressed and operationalised in standard upper limb assessment instruments.