A systematic review and meta-analysis of chronic and integrated care models to improve child health

Introduction: New models of healthcare have largely focussed on adults, with increasing policy and practice interest in integrated care across many high-income countries. Integrated care models have been identified as a promising solution by children and young people (CYP), and by policy-makers, to target the gaps in healthcare delivery for CYP with on-going conditions. However, there has been limited work on developing and evaluating integrated models of child healthcare, so there is an evidence gap in this important area of policy. This systematic review and meta-analysis assessed the effects of integrated care interventions on child health, health service use, and healthcare quality for CYP with on-going conditions. Methods: Articles were eligible for the review if they 1) reported randomised controlled trials (RCTs), published between 1996 and September 2018; 2) evaluated an integrated healthcare intervention designed to improve child health; 3) included CYP (0-18 years) with an on-going health condition; 4) included at least one health-related outcome. Descriptive data on a range of outcomes was synthesised for all included papers, and data homogeneity allowed further meta-analyses to explore the effects of integrated care interventions compared with usual care, on health-related quality of life (QOL) and number of emergency department visits. Results: Twenty-three randomised controlled trials were identified, describing 18 interventions. Studies had medium risk of bias, as assessed by the Cochrane Risk of Bias tool. Improvements were found for quality of care (87% of interventions found a positive effect for intervention) and child health (39% found a positive effect for intervention). The meta-analyses found that integrated care interventions have a positive effect in improving QOL over usual care (n=5 trials; SMD = 0.24; 95% CI = 0.03, 0.44; P=0.02), but no significant difference across groups for emergency department contacts (n=5 trials; OR=0.82; 95% CI = 0.53, 1.26; p=0.37). Conclusion and Discussion: Integrated care interventions for CYP with on-going conditions may deliver improved quality of life for children, health, and quality of care. However, no conclusions can be made about the direction or magnitude of the effect for integrated care interventions on emergency department contacts in CYP with on-going conditions. However, only 23 RCTs were included in this review, which were of moderate quality, highlighting the need for more robust trials to inform current health service delivery in this area and fully establish the effectiveness of integrated healthcare interventions on CYP outcomes. In collaboration with NHS Trusts, local councils, CYP and families, the findings from this review have been used to inform a fully integrated healthcare model for CYP that will be implemented at scale, and rigorously evaluated using an RCT design.