Costs and outcomes of improving population health through better socialhousing: a cohort study and economic analysis
Bray NJ, Burns P, Jones A, et al International Journal of Public Health, 62, 1039-1050. 2017

Objectives

We sought to determine the impact of warmth-related housing improvements on the health, well-being, and quality of life of families living in social housing.
Methods

An historical cohort study design was used. Households were recruited by Gentoo, a social housing contractor in North East England. Recruited households were asked to complete a quality of life, well-being, and health service use questionnaire before receiving housing improvements (new energy-efficient boiler and double-glazing) and again 12 months afterwards.
Results

Data were collected from 228 households. The average intervention cost was £3725. At 12-month post-intervention, a 16% reduction (−£94.79) in household 6-month health service use was found. Statistically significant positive improvements were observed in main tenant and household health status (p < 0.001; p = 0.009, respectively), main tenant satisfaction with financial situation (p = 0.020), number of rooms left unheated per household (p < 0.001), frequency of household outpatient appointments (p = 0.001), and accident/emergency department attendance (p < 0.012). Conclusions Warmth-related housing improvements may be a cost-effective means of improving the health of social housing tenants and reducing health service expenditure, particularly in older populations.

Dementia care costs and outcomes: a systematic review
Knapp M, Iemmi V, Romeo R International Journal of Geriatric Psychiatry, 28:, 551-556. 2013

Abstract
OBJECTIVE:
We reviewed evidence on the cost-effectiveness of prevention, care and treatment strategies in relation to dementia.

METHODS:
We performed a systematic review of available literature on economic evaluations of dementia care, searching key databases and websites in medicine, social care and economics. Literature reviews were privileged, and other study designs were included only to fill gaps in the evidence base. Narrative analysis was used to synthesise the results.

RESULTS:
We identified 56 literature reviews and 29 single studies offering economic evidence on dementia care. There is more cost-effectiveness evidence on pharmacological therapies than other interventions. Acetylcholinesterase inhibitors for mild-to-moderate disease and memantine for moderate-to-severe disease were found to be cost-effective. Regarding non-pharmacological treatments, cognitive stimulation therapy, tailored activity programme and occupational therapy were found to be more cost-effective than usual care. There was some evidence to suggest that respite care in day settings and psychosocial interventions for carers could be cost-effective. Coordinated care management and personal budgets held by carers have also demonstrated cost-effectiveness in some studies.

CONCLUSION:
Five barriers to achieving better value for money in dementia care were identified: the scarcity and low methodological quality of available studies, the difficulty of generalising from available evidence, the narrowness of cost measures, a reluctance to implement evidence and the poor coordination of health and social care provision and financing.

Framing the evidence for health smart homes and home-based consumer health technologies as a public health intervention for independent aging: A systematic review
Reeder B, Meyer E, Lazar A, et al International Journal of Medical Informatics, 82, 565–579. 2013

Introduction
There is a critical need for public health interventions to support the independence of older adults as the world’s population ages. Health smart homes (HSH) and home-based consumer health (HCH) technologies may play a role in these interventions.

Methods
We conducted a systematic review of HSH and HCH literature from indexed repositories for health care and technology disciplines (e.g., MEDLINE, CINAHL, and IEEE Xplore) and classified included studies according to an evidence-based public health (EBPH) typology.

Results
One thousand, six hundred and thirty nine candidate articles were identified. Thirty-one studies from the years 1998–2011 were included. Twenty-one included studies were classified as emerging, 10 as promising and 3 as effective (first tier).

Conclusion
The majority of included studies were published in the period beginning in the year 2005. All 3 effective (first tier) studies and 9 of 10 of promising studies were published during this period. Almost all studies included an activity sensing component and most of these used passive infrared motion sensors. The three effective (first tier) studies all used a multicomponent technology approach that included activity sensing, reminders and other technologies tailored to individual preferences. Future research should explore the use of technology for self-management of health by older adults, social support and self-reported health measures incorporated into personal health records, electronic medical records, and community health registries.

Integrated care experiences and outcomes in Germany, the Netherlands, and England
Busse R and Stahl J Health Affairs, 33, 1549-1558. 2014

Care for people with chronic conditions is an issue of increasing importance in industrialized countries. This article examines three recent efforts at care coordination that have been evaluated but not yet included in systematic reviews. The first is Germany’s Gesundes Kinzigtal, a population-based approach that organizes care across all health service sectors and indications in a targeted region. The second is a program in the Netherlands that bundles payments for patients with certain chronic conditions. The third is England’s integrated care pilots, which take a variety of approaches to care integration for a range of target populations. Results have been mixed. Some intermediate clinical outcomes, process indicators, and indicators of provider satisfaction improved; patient experience improved in some cases and was unchanged or worse in others. Across the English pilots, emergency hospital admissions increased compared to controls in a difference-in-difference analysis, but planned admissions declined. Using the same methods to study all three programs, we observed savings in Germany and England. However, the disease-oriented Dutch approach resulted in significantly increased costs. The Kinzigtal model, including its shared-savings incentive, may well deserve more attention both in Europe and in the United States because it combines addressing a large population and different conditions with clear but simple financial incentives for providers, the management company, and the insurer.

Integrating funds for health and social care: an evidence review
Mason A, Goddard M, Weatherly H, et al Journal of Health Services Research and Policy, 20, 177-188. 2015

OBJECTIVES:
Integrated funds for health and social care are one possible way of improving care for people with complex care requirements. If integrated funds facilitate coordinated care, this could support improvements in patient experience, and health and social care outcomes, reduce avoidable hospital admissions and delayed discharges, and so reduce costs. In this article, we examine whether this potential has been realized in practice.

METHODS:
We propose a framework based on agency theory for understanding the role that integrated funding can play in promoting coordinated care, and review the evidence to see whether the expected effects are realized in practice. We searched eight electronic databases and relevant websites, and checked reference lists of reviews and empirical studies. We extracted data on the types of funding integration used by schemes, their benefits and costs (including unintended effects), and the barriers to implementation. We interpreted our findings with reference to our framework.

RESULTS:
The review included 38 schemes from eight countries. Most of the randomized evidence came from Australia, with nonrandomized comparative evidence available from Australia, Canada, England, Sweden and the US. None of the comparative evidence isolated the effect of integrated funding; instead, studies assessed the effects of ‘integrated financing plus integrated care’ (i.e. ‘integration’) relative to usual care. Most schemes (24/38) assessed health outcomes, of which over half found no significant impact on health. The impact of integration on secondary care costs or use was assessed in 34 schemes. In 11 schemes, integration had no significant effect on secondary care costs or utilisation. Only three schemes reported significantly lower secondary care use compared with usual care. In the remaining 19 schemes, the evidence was mixed or unclear. Some schemes achieved short-term reductions in delayed discharges, but there was anecdotal evidence of unintended consequences such as premature hospital discharge and heightened risk of readmission. No scheme achieved a sustained reduction in hospital use. The primary barrier was the difficulty of implementing financial integration, despite the existence of statutory and regulatory support. Even where funds were successfully pooled, budget holders’ control over access to services remained limited. Barriers in the form of differences in performance frameworks, priorities and governance were prominent amongst the UK schemes, whereas difficulties in linking different information systems were more widespread. Despite these barriers, many schemes – including those that failed to improve health or reduce costs – reported that access to care had improved. Some of these schemes revealed substantial levels of unmet need and so total costs increased.

CONCLUSIONS:
It is often assumed in policy that integrating funding will promote integrated care, and lead to better health outcomes and lower costs. Both our agency theory-based framework and the evidence indicate that the link is likely to be weak. Integrated care may uncover unmet need. Resolving this can benefit both individuals and society, but total care costs are likely to rise. Provided that integration delivers improvements in quality of life, even with additional costs, it may, nonetheless, offer value for money

Integration of Health and Social Care. A Review of Literature and Models Implications for Scotland
Robertson H Royal College of Nursing Scotland, Glasgow. 2011

Summary: This exploration of integrated health and social care reviews the literature on models of integration from six European countries and New Zealand, assessesthe factors which help orhinder integration and considersthe implications for Scotland.An unequivocal message from the literature is that there is no single, agreed definition of integrated care. Integration can take place at a number of levels: team, service or organisation. It can apply to a small number of specialist services or to the full range of health and social care services. The body of information on integration is extensive but contains surprisingly little evidence of improved outcomes for patients. Most measures of the success of integration concentrate on criteriasuch as admissions to hospital, reduced waiting times or service responsiveness and infer benefits to service users.However, robust evidence of the impact on health outcomes is lacking.There are a large number of different models of integration. Some are based on multi-disciplinaryteam working and networks. Others involve structural reform to create single,integrated organisations. Two recent examples ofstructural integration are the TioHundra municipal company in Sweden(Norrtälje)and the Care Trusts Plus in England.Factors helping or hindering integrated working fall into three categories:Organisational issuesVision and cultureUnified budgets or structuresCommunication and ITProfessional issuesStatus and stereotypesPatient focusTraining and educationPolicy and legal issues Policy environment LegislationEmployment contracts, terms and conditions.Scotlandalreadyhas experiencein integrating health and social care services through joint future bodies, community health (and care) partnerships and managed clinical/care networks. A track record of joint working is a marker for success in integration so this previous experience bodes well. However, integration is not a quick or cheap option so if the drivers for integration are a need to reduce costs and ease pressure on secondary care, it may fail.

Interventions for preventing falls in older people in care facilities and hospitals
Cameron ID, Gillespie LD, Robertson MC, et al Cochrane Database Systematic Reviews, 12, CD005465. 2012

Abstract
BACKGROUND:
Falls in care facilities and hospitals are common events that cause considerable morbidity and mortality for older people. This is an update of a review first published in 2010.

OBJECTIVES:
To assess the effectiveness of interventions designed to reduce falls by older people in care facilities and hospitals.

SEARCH METHODS:
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2012); The Cochrane Library 2012, Issue 3; MEDLINE, EMBASE, and CINAHL (all to March 2012); ongoing trial registers (to August 2012), and reference lists of articles.

SELECTION CRITERIA:
Randomised controlled trials of interventions to reduce falls in older people in residential or nursing care facilities or hospitals.

DATA COLLECTION AND ANALYSIS:
Two review authors independently assessed risk of bias and extracted data. We used a rate ratio (RaR) and 95% confidence interval (CI) to compare the rate of falls (e.g. falls per person year) between intervention and control groups. For risk of falling we used a risk ratio (RR) and 95% CI based on the number of people falling (fallers) in each group. We pooled results where appropriate.

MAIN RESULTS:
We included 60 trials (60,345 participants), 43 trials (30,373 participants) in care facilities, and 17 (29,972 participants) in hospitals.Results from 13 trials testing exercise interventions in care facilities were inconsistent. Overall, there was no difference between intervention and control groups in rate of falls (RaR 1.03, 95% CI 0.81 to 1.31; 8 trials, 1844 participants) or risk of falling (RR 1.07, 95% CI 0.94 to 1.23; 8 trials, 1887 participants). Post hoc subgroup analysis by level of care suggested that exercise might reduce falls in people in intermediate level facilities, and increase falls in facilities providing high levels of nursing care.In care facilities, vitamin D supplementation reduced the rate of falls (RaR 0.63, 95% CI 0.46 to 0.86; 5 trials, 4603 participants), but not risk of falling (RR 0.99, 95% CI 0.90 to 1.08; 6 trials, 5186 participants).For multifactorial interventions in care facilities, the rate of falls (RaR 0.78, 95% CI 0.59 to 1.04; 7 trials, 2876 participants) and risk of falling (RR 0.89, 95% CI 0.77 to 1.02; 7 trials, 2632 participants) suggested possible benefits, but this evidence was not conclusive.In subacute wards in hospital, additional physiotherapy (supervised exercises) did not significantly reduce rate of falls (RaR 0.54, 95% CI 0.16 to 1.81; 1 trial, 54 participants) but achieved a significant reduction in risk of falling (RR 0.36, 95% CI 0.14 to 0.93; 2 trials, 83 participants).In one trial in a subacute ward (54 participants), carpet flooring significantly increased the rate of falls compared with vinyl flooring (RaR 14.73, 95% CI 1.88 to 115.35) and potentially increased the risk of falling (RR 8.33, 95% CI 0.95 to 73.37).One trial (1822 participants) testing an educational session by a trained research nurse targeting individual fall risk factors in patients at high risk of falling in acute medical wards achieved a significant reduction in risk of falling (RR 0.29, 95% CI 0.11 to 0.74).Overall, multifactorial interventions in hospitals reduced the rate of falls (RaR 0.69, 95% CI 0.49 to 0.96; 4 trials, 6478 participants) and risk of falling (RR 0.71, 95% CI 0.46 to 1.09; 3 trials, 4824 participants), although the evidence for risk of falling was inconclusive. Of these, one trial in a subacute setting reported the effect was not apparent until after 45 days in hospital. Multidisciplinary care in a geriatric ward after hip fracture surgery compared with usual care in an orthopaedic ward significantly reduced rate of falls (RaR 0.38, 95% CI 0.19 to 0.74; 1 trial, 199 participants) and risk of falling (RR 0.41, 95% CI 0.20 to 0.83). More trials are needed to confirm the effectiveness of multifactorial interventions in acute and subacute hospital settings.

AUTHORS’ CONCLUSIONS:
In care facilities, vitamin D supplementation is effective in reducing the rate of falls. Exercise in subacute hospital settings appears effective but its effectiveness in care facilities remains uncertain due to conflicting results, possibly associated with differences in interventions and levels of dependency. There is evidence that multifactorial interventions reduce falls in hospitals but the evidence for risk of falling was inconclusive. Evidence for multifactorial interventions in care facilities suggests possible benefits, but this was inconclusive.

Interventions for preventing falls in older people living in the community
Gillespie LD, Robertson MC, Gillespie WJ, et al Cochrane Database Systematic Reviews, 9, 1-4. 2012

As people get older, they may fall more often for a variety of reasons including problems with balance, poor vision, and dementia. Up to 30% may fall in a year. Although one in five falls may require medical attention, less than one in 10 results in a fracture.

This review looked at the healthcare literature to establish which fall prevention interventions are effective for older people living in the community, and included 159 randomised controlled trials with 79,193 participants.

Group and home-based exercise programmes, usually containing some balance and strength training exercises, effectively reduced falls, as did Tai Chi. Overall, exercise programmes aimed at reducing falls appear to reduce fractures.

Multifactorial interventions assess an individual’s risk of falling, and then carry out treatment or arrange referrals to reduce the identified risks. Overall, current evidence shows that this type of intervention reduces the number of falls in older people living in the community but not the number of people falling during follow-up. These are complex interventions, and their effectiveness may be dependent on factors yet to be determined.

Interventions to improve home safety appear to be effective, especially in people at higher risk of falling and when carried out by occupational therapists. An anti-slip shoe device worn in icy conditions can also reduce falls.

Taking vitamin D supplements does not appear to reduce falls in most community-dwelling older people, but may do so in those who have lower vitamin D levels in the blood before treatment.

Some medications increase the risk of falling. Three trials in this review failed to reduce the number of falls by reviewing and adjusting medications. A fourth trial involving family physicians and their patients in medication review was effective in reducing falls. Gradual withdrawal of a particular type of drug for improving sleep, reducing anxiety, and treating depression (psychotropic medication) has been shown to reduce falls.

Cataract surgery reduces falls in women having the operation on the first affected eye. Insertion of a pacemaker can reduce falls in people with frequent falls associated with carotid sinus hypersensitivity, a condition which causes sudden changes in heart rate and blood pressure.

In people with disabling foot pain, the addition of footwear assessment, customised insoles, and foot and ankle exercises to regular podiatry reduced the number of falls but not the number of people falling.

The evidence relating to the provision of educational materials alone for preventing falls is inconclusive

Loneliness and Social Isolation Among Older People in North Yorkshire
Bernard SM Research Report. SPRU Working Paper, WP 256 . Social Policy Research Unit, York. 2013

This report was commissioned by the Loneliness Task Group of the North Yorkshire
Older People‟s Partnership Board (NYOPPB). Its purpose was to build on the
findings from the „Voice of Ripon‟ loneliness survey carried out in 2009 on behalf of
NYOPPB(1) . The report aims to provide a review of current literature that brings
together knowledge about the extent and nature of loneliness among older people.
This will help to clarify current thinking about what a „good practice‟ or service looks
like and start to identify likely models of good practice in North Yorkshire.
The report looks at how loneliness and social isolation are understood in the
literature, why they should be important concerns of local strategic organisations,
such as health and wellbeing boards, and what might be done. This evidence is set
in the context of the geography and demography of North Yorkshire and suggestions
for future work are made.

Meta-review of International Evidence on Interventions to Support Carers
Parker G, Arksey H, Harden M Social Policy Research Unit, York. 2010

Given the increasingly valuable and essential role that carers play in society, it is timely to undertake a comprehensive review of the research literature on interventions for carers. The present overview of the evidence base relating to the outcomes and cost-effectiveness of support was intended to inform thinking by the Department of Health and the Standing Commission on Carers about how best to improve outcomes for carers, as well as identifying future research areas.

Older People and Social Isolation: A Review of the Evidence
Kinsella S Wirral Council Business & Public Health Intelligence Team, Wirral. 2015

Reducing social isolation is likely to have positive effects on health and mortality:
Greater benefits were observed (in reducing mortality) from improving levels of social
isolation, compared to reducing loneliness.
Targeting has the greatest impact: Focussing public health intervention efforts on
those most at risk, e.g those who live alone, are on low incomes, have poorer health,
been recently bereaved or are carers – rather than all older people – is more effective.
There is still considerable stigma attached to being lonely: and initiatives should
bear this in mind. For example, their marketing materials, should not use the ‘L’ word (as
Age UK call loneliness), particularly if they wish to attract more men
Initiatives based on evidence were more effective than those that were not: 87% of
interventions based on evidence reported beneficial effects compared to 59% of
interventions which were not. Studies aiming to achieve and maintain characteristics
essential for positive mental health (e.g people realising their own abilities, having a
purpose in life, a sense of belonging and support) appeared to be most effective.
Group activities achieve good outcomes: 79% of group based interventions reported
at least one improved outcome, compared to 55% of one-to-one interventions.
Group activities which have an arts, educational learning or social focus are
particularly beneficial: A systematic review supported this finding that group
interventions involving some form of educational, training, arts or social activity that
target specific groups of people are the most effective.
Participatory initiatives are most beneficial: Positive effects are reported in 80% of
initiatives which were participatory, compared to 44% of non-participatory initiatives.
One-to-one initiatives (e.g befriending) only appears to be effective in certain
circumstances: Namely, when the befriender and recipient have enough in common to
build a genuine relationship. They do not appear to reduce use of health services, but
can result in reductions in depression and improvements in quality of life. One-to-one
interventions targeted at specific groups of older people (e.g the recently bereaved, or
recently discharged from hospital), may offer more benefit than trying to reach to all
older people. Currently, there is little evidence of benefit for mentoring support.
The impact of new technologies is inconclusive: The evidence is often contradictory
on the subject of new technologies, but there is some evidence of benefit for training on
the use of computers, the internet, Skype (particularly for specific groups such as carers)
Real and practical barriers to reducing isolation should be the focus of joint
efforts by all agencies concerned with the wellbeing of older people: particularly
those relating to transport, toilets, continence issues and long term health conditions

Personal Budgets and Health: A Review of the Evidence
Wirrmann Gadsby E Policy Research Unit in Commissioning and the Healthcare System, Centre for Health Services Studies, Kent. 2013

The UK Government has committed to expanding the use of personal health budgets for health service users following the evaluation of the pilot programme which ran from 2009-2012. This is part of a wider ‘personalisation’ agenda, which has become a central theme in the reform of health and social care in England, and also features increasingly prominently in the policies of other UK governments, in addition to governments of many other developed countries around the world. A number of other countries around the world have experimented with various forms of personal budgets, although predominantly for the purchasing of care that, in the UK, would be described as social rather than health care. Programmes – and their contexts – vary enormously. There is no programme elsewhere that is directly comparable to personal health budgets in England. There is therefore no directly relevant evidence from which we might extrapolate. However, this review collates evidence on those various programmes in order to examine the case for investing further in personal health budgets. It incorporates the findings of the recently published final report of the evaluation of the personal health budget pilot in England

Personalization in the health care system: Do personal health budgets impact on outcomes and cost?
Jones K, Forder J, Caiels J et al Journal of Health Services Research and Policy, 18, 59-67. 2013

Objectives: In England’s National Health Service, personal health budgets are part of a growing trend to give patients more choice and control over how health care services are managed and delivered. The personal health budget programme was launched by the Department of Health in 2009, and a three-year independent evaluation was commissioned with the aim of identifying whether the initiative ensured better health- and care-related outcomes and at what cost when compared to conventional service delivery. Methods: The evaluation used a pragmatic controlled trial design to compare the outcomes and costs of patients selected to receive a personal health budget with those continuing with conventional support arrangements (control group). Just over 1000 individuals were recruited into the personal health budget group and 1000 into the control group in order to ensure sufficient statistical power, and followed for 12 months. Results: The use of personal health budgets was associated with significant improvement in patients’ care-related quality of life and psychological wellbeing at 12 months. Personal health budgets did not appear to have an impact on health status, mortality rates, health-related quality of life or costs over the same period. With net benefits measured in terms of care-related quality of life on the adult social care outcome toolkit measure, personal health budgets were cost-effective: that is, budget holders experienced greater benefits than people receiving conventional services, and the budgets were worth the cost. Conclusion: The evaluation provides support for the planned wider roll-out of personal health budgets in the English NHS after 2014 in so far as the localities in the pilot sample are representative of the whole country.

Telemedicine and telecare for older patients - a systematic review
van den Berg N, Schumann M, Kraft K, et al Maturitas, 3, 94–114. 2012

Telemedicine is increasingly becoming a reality in medical care for the elderly. We performed a systematic literature review on telemedicine healthcare concepts for older patients. We included controlled studies in an ambulant setting that analyzed telemedicine interventions involving patients aged ≥60 years. 1585 articles matched the specified search criteria, thereof, 68 could be included in the review. Applications address an array of mostly frequent diseases, e.g. cardiovascular disease (N=37) or diabetes (N=18). The majority of patients is still living at home and is able to handle the telemedicine devices by themselves. In 59 of 68 articles (87%), the intervention can be categorized as monitoring. The largest proportion of telemedicine interventions consisted of measurements of vital signs combined with personal interaction between healthcare provider and patient (N=24), and concepts with only personal interaction (telephone or videoconferencing, N=14). The studies show predominantly positive results with a clear trend towards better results for “behavioral” endpoints, e.g. adherence to medication or diet, and self-efficacy compared to results for medical outcomes (e.g. blood pressure, or mortality), quality of life, and economic outcomes (e.g. costs or hospitalization). However, in 26 of 68 included studies, patients with characteristic limitations for older patients (e.g. cognitive and visual impairment, communication barriers, hearing problems) were excluded. A considerable number of projects use rather sophisticated technology (e.g. videoconferencing), limiting ready translation into routine care. Future research should focus on how to adapt systems to the individual needs and resources of elderly patients within the specific frameworks of the respective national healthcare systems.

Updated meta-review of evidence on support for carers
Thomas S, Dalton J, Harden M, et al Health Services and Delivery Research, 5, 12. 2016

BACKGROUND:
Policy and research interest in carers continues to grow. A previous meta-review, published in 2010, by Parker et al. (Parker G, Arksey H, Harden M. Meta-review of International Evidence on Interventions to Support Carers. York: Social Policy Research Unit, University of York; 2010) found little compelling evidence of effectiveness about specific interventions and costs.

OBJECTIVE:
To update what is known about effective interventions to support carers of ill, disabled or older adults.

DESIGN:
Rapid meta-review.

SETTING:
Any relevant to the UK health and social care system.

PARTICIPANTS:
Carers (who provide support on an unpaid basis) of adults who are ill, disabled or older.

INTERVENTIONS:
Any intervention primarily aimed at carers.

MAIN OUTCOME MEASURES:
Any direct outcome for carers.

DATA SOURCES:
Database searches (including Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, MEDLINE, Applied Social Sciences Index and Abstracts and Social Care Online) for systematic reviews published from January 2009 to 2016.

REVIEW METHODS:
We used EndNote X7.4 (Thomson Reuters, CA, USA) to screen titles and abstracts. Final decisions on the inclusion of papers were made by two reviewers independently, using a Microsoft Excel® 2013 spreadsheet (Microsoft Corporation, Redmond, WA, USA). We carried out a narrative synthesis structured by patient condition and by seven outcomes of interest. We assessed the quality of the included systematic reviews using established criteria. We invited a user group of carers to give their views on the overall findings of our review.

RESULTS:
Sixty-one systematic reviews were included (27 of high quality, 25 of medium quality and nine of low quality). Patterns in the literature were similar to those in earlier work. The quality of reviews had improved, but primary studies remained limited in quality and quantity. Of the high-quality reviews, 14 focused on carers of people with dementia, four focused on carers of those with cancer, four focused on carers of people with stroke, three focused on carers of those at the end of life with various conditions and two focused on carers of people with mental health problems. Multicomponent interventions featured prominently, emphasising psychosocial or psychoeducational content, education and training. Multiple outcomes were explored, primarily in mental health, burden and stress, and well-being or quality of life. Negative effects following respite care were unsupported by our user group. As with earlier work, we found little evidence on intervention cost-effectiveness. No differences in review topics were found across high-, medium- and low-quality reviews.

LIMITATIONS:
The nature of meta-reviews precludes definitive conclusions about intervention effectiveness, for whom and why. Many of the included reviews were small in size and authors generally relied on small numbers of studies to underpin their conclusions. The meta-review was restricted to English-language publications. Short timescales prevented any investigation of the overlap of primary studies, and growth in the evidence base since the original meta-review meant that post-protocol decisions were necessary.

CONCLUSIONS:
There is no ‘one size fits all’ intervention to support carers. Potential exists for effective support in specific groups of carers. This includes shared learning, cognitive reframing, meditation and computer-delivered psychosocial support for carers of people with dementia, and psychosocial interventions, art therapy and counselling for carers of people with cancer. Counselling may also help carers of people with stroke. The effectiveness of respite care remains a paradox, given the apparent conflict between the empirical evidence and the views of carers.

FUTURE WORK:
More good-quality, theory-based, primary research is warranted. Evidence is needed on the differential impact of interventions for various types of carers (including young carers and carers from minority groups), and on the effectiveness of constituent parts in multicomponent programmes. Further research triangulating qualitative and quantitative evidence on respite care is urgently required. The overlap of primary studies was not formally investigated in our review, and this warrants future evaluation.

STUDY REGISTRATION:
This study is registered as PROSPERO CRD42016033367.

What is the Evidence on the Economic Impacts of Integrated Care? Technical Report
Nolte E and Pitchforth E World Health Organization, Geneva. 2014

This new policy summary reviews the existing evidence on the economic impact of integrated care approaches. Whereas it is generally accepted that integrated care models have a positive effect on the quality of care, health outcomes and patient satisfaction, it is less clear how cost effective they are. As the evidence-base in this field is rather weak, the authors suggest that we may have to revisit our understanding of the concept and our expectations in terms of its assessment. Integrated care should rather be seen as a complex strategy to innovate and implement long-lasting change in the way services in the health and social-care sectors are delivered. This policy summary (number 11) is based on a report for the European Commission to inform the discussions of the EU’s Reflection process on modern, responsive and sustainable health systems on the objective of integrated care models and better hospital management. Both authors are affiliated to RAND Europe.