Collaborative Emergency Centres

Transcription

Collaborative Emergency
Centres:
Rapid Knowledge Synthesis
February 2012
Jill Hayden, Jessica Babineau, Lara Killian,
Ruth Martin-Misener, Alix Carter, Jan Jensen, Austin Zygmunt
How to cite this project:
Hayden J, Babineau J, Killian L, Martin-Misener R, Carter A, Jensen J, Zygmunt A. Collaborative emergency
centres: Rapid knowledge synthesis. Halifax, Nova Scotia: Nova Scotia Cochrane Resource Centre; 2012.
(1-55) (56-66)
Disclaimer:
This report is a summary of available literature and is intended to provide a starting point in considering current research
evidence. Our research team took care when conducting this project and preparing this report, however the possibility
exists that not all of the best evidence was found during our searches. Thus, the team shall not bear responsibility or
liability for any missing data, incomplete information, or other errors that may be covered in this report. Please consult
other sources to ensure that you have as complete a picture as possible related to any topics of interest covered within this
report.
Collaborative Emergency Centres: Rapid Knowledge Synthesis
Nova Scotia Cochrane Resource Centre
Contents
Executive Summary..…………………………………………………………………………………………………………………………………………….i
Short Report..…………………………………………………………………………………………………………………………………….……………iii-xi
Full Report:
Background .................................................................................................................................................................1
Relevance and Potential Impact .............................................................................................................................1
Collaborative Emergency Centres in Nova Scotia ..................................................................................................1
Using Evidence in Decision Making ............................................................................................................................2
Rapid Knowledge Synthesis Plan and Objectives .......................................................................................................3
Part 1: Scan of CEC-type Models ................................................................................................................................4
Objectives ...............................................................................................................................................................4
Methods .................................................................................................................................................................4
Results ....................................................................................................................................................................6
CEC-type Centres Across Canada........................................................................................................................6
Structures and Processes....................................................................................................................................8
Part 2: Summarizing the Scientific Evidence for CEC-type Models ............................................................................9
Objectives ...............................................................................................................................................................9
Methods .................................................................................................................................................................9
Results ..................................................................................................................................................................15
Prioritized Searches ..........................................................................................................................................15
Non-Prioritized Searches ..................................................................................................................................27
Knowledge Translation .............................................................................................................................................36
Acknowledgments ....................................................................................................................................................37
Contributions of Authors ..........................................................................................................................................37
Declarations of Conflict of Interest ..........................................................................................................................37
How to Cite Full Report Document:.........................................................................................................................37
Sources of Support ...................................................................................................................................................37
Appendices ...............................................................................................................................................................38
Appendix 1: Jurisdictional Review Scoping Searches – Resource List ..................................................................38
Appendix 2: Data Extraction Form for Scan of Jurisdictions Outside of Nova Scotia...........................................40
Appendix 3: Original CEC Evidence Synthesis Review Questions .........................................................................44
Appendix 4: Jurisdiction Review Centre Selection Flowchart ..............................................................................46
Appendix 5: CEC-type Centre Summaries ............................................................................................................47
Appendix 6: Final CEC Evidence Synthesis Review Questions ..............................................................................57
Appendix 7: Search Strategies ..............................................................................................................................59
Appendix 8: Flow Charts of Database Search Results ..........................................................................................68
Appendix 9: Data Extraction Questions from Distiller Form ................................................................................75
Appendix 10: Evidence Tables for Included Reviews ...........................................................................................77
Glossary of Selected Terms from the Report ...........................................................................................................95
References ................................................................................................................................................................98
Collaborative Emergency Centres: Rapid Knowledge Synthesis Executive Summary The Nova Scotia Department of Health and Wellness originally defined a Collaborative Emergency Centre (CEC) as “a model that brings together rural community emergency departments and local family practices to work together to provide seamless access to primary and emergency care to the community”. CECs have three formally linked components: a primary health care team, the capacity to provide urgent care, and protocols in place for emergency care. Report objectives: To inform decision making regarding the development and implementation of effective CECs across Nova Scotia by: 1. Defining CECs through the identification of potential structures, process and implementation strategies of CEC‐type models in other jurisdictions. 2. Identifying scientific evidence that investigates the effectiveness of CEC‐
type models and their structures and processes for improving health outcomes. Results: Twenty‐four potential structures and processes for CECs were identified, including components related to staffing, services, protocols, collaborative practices, governance/funding, research and evaluation. A total of 55 systematic reviews were included in the evidence summary, and 11 records were included in additional scoping searches. These studies provided evidence on the effectiveness of CEC‐type models and relevant components. Overall messages: 
There is some scientific literature on various components of CEC‐type models. 
There is good evidence from systematic reviews to support Nurse Practitioners working in primary care and in the ED with regard to patient satisfaction and compliance, with care at least equivalent to a physician‐in‐training. 
This review captured limited evidence from systematic reviews on the role of paramedics in the ED or primary care. 
There is limited but promising evidence from systematic reviews on the benefit of tele‐consultation. 
Cost‐effectiveness of these novel approaches is unknown. 
A growing number of collaborative models are in operation across Canada and the world; Nova Scotia has the opportunity to share and to lead. 
There is limited scientific literature on the concept of CEC‐type models; there is room in this area for future research studies. Who is this report for? This evidence synthesis is intended for use by local health system stakeholders, policy and decision‐
makers within the Nova Scotia Department of Health and Wellness. Information about this evidence synthesis: This report has been developed into three sub‐reports: an executive summary, a short report, and a full report. The executive and short reports are summaries, while additional and more comprehensive information is available in the full report. Included in this report: Information from a broad collection of literature and evidence sources. Searches were often restricted to systematic reviews. This is supported by information from published reports from other jurisdictions and stakeholder workshops. Not included in this report:  Primary research studies or detailed descriptions of individual study interventions within systematic reviews.  Information not presented in the peer‐reviewed literature except that provided through integrated knowledge translation process.  We do not make recommendations for practice. This knowledge synthesis project was undertaken by the Nova Scotia Cochrane Resource Centre with support from the Nova Scotia Health Research Foundation. i ii Collaborative Emergency Centres: Rapid Knowledge Synthesis Short Report The Nova Scotia Department of Health and Wellness originally defined a CEC as “a model that brings together rural community emergency departments and local family practices to work together to provide seamless access to primary and emergency care to the community”. CECs have three formally linked components: a primary health care team, the capacity to provide urgent care, and protocols in place for emergency care. Who is this report for? This evidence synthesis is intended for use by local health system stakeholders, policy and decision‐makers within the Nova Scotia Department of Health and Wellness. Information about this evidence synthesis: Report Objectives: To inform decision making regarding the development and implementation of effective CECs across Nova Scotia by: 1. Defining CECs through the identification of potential structures, process and implementation strategies of CEC‐type models in other jurisdictions. 2. Identifying scientific evidence that investigates the effectiveness of CEC‐type models and their structures and processes for improving health outcomes. Research Methods: Our approach included two major parts: 1. Scanning of CEC‐type models, 2. Summarizing the scientific evidence for CEC‐type models. We collected information on CEC‐type models relevant to the Nova Scotia context through a scan of other jurisdictions. We summarized information on the structures and processes included in other models and iteratively refined an operational definition of a CEC. We summarized the scientific evidence for CEC‐type models. Comprehensive literature searches of the peer‐reviewed and grey literature studies that provide evidence on the effectiveness of CEC‐
type models and their structures and processes were executed. The project included an integrated knowledge translation process, including interactions with important Nova Scotia clinical and policy decision‐makers, such as the Department of Health and Wellness, primary health care practitioners (family physicians, nurses), emergency care practitioners (members of Emergency Health Services, emergency physicians), and members of the Cumberland County Health authority involved in the development and/or functioning of the first implemented CEC, located in Parrsboro, Nova Scotia. iii This report has been developed into three sub‐reports: an executive summary, a short report, and a full report. The executive and short reports are summaries, while additional and more comprehensive information is available in the full report. Included in this report: Information from a broad collection of literature and evidence sources. Searches were often restricted to systematic reviews. This is supported by information from published reports from other jurisdictions and stakeholder workshops. Not included in this report:  Primary research studies or detailed descriptions of individual study interventions within systematic reviews.  Information not presented in the peer‐reviewed literature except that provided through integrated knowledge translation process.  We do not make recommendations for practice. Defining CECs: Our operational definition of a CEC‐type centre, which was finalized at a stakeholder workshop, is: A CEC‐type centre focuses on the delivery of health care services including both primary care and access to emergency care through a seamless collaborative team approach.  Primary care encompasses access to health promotion, wellness, chronic disease management, illness and injury prevention, and diagnosis and treatment of illness and injury.  Access to emergency care includes initial emergency stabilization of life‐threatening conditions, response to (including treatment or referral) the majority of urgent conditions and those conditions of lesser urgency. A health care provider must be available on‐site, and has a formal supportive relationship with other professional(s) or institution(s) elsewhere through telephone or technological means. Jurisdictional scan: We selected 12 locations that represented CEC‐type centres across selected Canadian jurisdictions (see Table 1). Selected centres were from locations across Canada. Two centres were located in Alberta, two in British Columbia, two in Newfoundland and Labrador, two in the North West Territories, one in Nunavut, two in Saskatchewan, and one in the Yukon. Three centres had a health care model with features and demographics similar to those of the CEC model in Nova Scotia, labeled “CEC‐type centres with Nova Scotia context”. The remainder of centres are categorized generally as meeting the final operationalized “CEC‐type centres” model definition. Table 1: CEC‐type centres identified from selected Canadian jurisdictions CEC‐type centres with Nova Scotia context:  Rainbow Lake Health Centre, Rainbow Lake, Alberta  Ladysmith Community Health Centre, Ladysmith, British Columbia  Dr. W. H. Newhook Community Health Centre, Whitbourne, Newfoundland CEC‐type centres:  Northeast Community Health Centre, Edmonton, Alberta  Oceanside Primary & Urgent Centre, Parksville, British Columbia  Hopedale Community Clinic, Hopedale, Newfoundland  Fort Simpson Health Centre, Fort Simpson, North West Territories  Wrigley Health Centre, Wrigley, North West Territories  Igloolik Community Health Centre, Igloolik, Nunavut  Black Lake Health Centre, Black Lake, Saskatchewan  Cumberland House Health Centre, Northern Village of Cumberland House, Saskatchewan  Health Centres (case: Dawson City Community Health Centre), Yukon Introduction to Structures and Processes: Twenty‐four potential structures and processes relevant to CECs were identified. These included components related to health professional staffing, available services, use of treatment protocols, collaborative practices, funding and governance, research and evaluation. These define important considerations for CEC‐type centres and directed our topics for evidence synthesis. Seven structures and processes were prioritized through discussion amongst the research and investigator team and stakeholder workshop participants as of critical importance to the functioning and implementation of a CEC. There were 16 other important structures and processes relevant to CECs, but were not prioritized by Nova Scotia stakeholders. iv Prioritized Structures and Processes: 1. CEC‐type models of health care delivery considered the effects of CEC‐type models according to our operationalized definition. 2. Hours of access to health care services were defined as the operational hours that emergency or primary care services are accessible to members of a community (for example, extended hours, access to on‐call physician only, or daytime only hours). 3. Health care professional staff available (emergency care) included personnel who provide, or assist and support the provision of, care to patients in an organized emergency care facility. This included traditional and allied health professionals and support staff involved in care. 4. Health professional staff available (primary care) included personnel who provide, or assist and support the provision of, care to patients in an organized primary care facility. This included traditional and allied health professionals and support staff involved in care. 5. Collaborative practices (primary or emergency care) were described as multiple health professionals working together to provide care. This was defined broadly according to primary studies as ≥2 professionals involved in care. 6. Telehealth/Tele‐consultation included off‐site consultation and delivery of health services via remote telecommunication. Off‐site consultation meant consultation via remote telecommunications (using various tools) of a health provider on‐site to one at a distance to enhance local scope of practice. This is generally for the purpose of diagnosis or treatment of a patient. Delivery of health services via remote telecommunications included interactive consultative and diagnostic services for a patient communicating with a health care provider at a distance. 7. Comprehensive set of diagnostic services available (primary or emergency care) described having diagnostic services available, organized for the purpose of providing diagnosis to promote and maintain health (for example, x‐ray and other forms of diagnostic imaging, blood work, electrocardiograms, and blood pressure monitoring). Non‐prioritized Structures and Processes: 8. Structure of emergency services represented the different methods of scheduling or prioritizing patient visits or waiting time in emergency departments (e.g., prioritizing care by triage). 9. Structure or primary care services represented the different methods of scheduling or prioritizing patient visits, appointment systems, individual or group appointments, or waiting times (for example, walk‐in appointments). 10. Emergency protocols or use of standing orders in emergency care delivery provide a planned course of medical treatment from providers in the assessment and treatment of patients with acute illness or injuries. The use of standing orders signifies the use of written documents containing rules, policies, procedures, regulations, and orders for the conduct of patient care in various stipulated clinical situations. 11. Destination and transfer plan in emergency health care delivery to manage patients represented the inter‐
facility transfer and transportation methods of patients to obtain specific, definitive or specialist care not available on site. Options for destination plans may include transfer to community hospital, regional hospital, or tertiary care centre, emergency stabilization and transfer to increased care, referral to specialist care, or maximum patient observation time. Transfer mechanism options may include ground ambulance, air ambulance, or Medevac. 12. Levels of service infrastructure in emergency and primary health care delivery referred to the medical or health related services provided in one facility, compared to these services being offered through neighbouring facilities. 13. Ambulatory clinic services available in primary health care delivery are health services provided to patients on an ambulatory basis, rather than by admission to a hospital or other health care facility. Examples of ambulatory services include chemotherapy, intravenous medications, and orthopaedic follow‐up. 14. In‐patient beds available within a community health centre are set up and staffed for use in caring for patients who are deemed to require admission to a hospital. 15. Formal community health needs assessment for organizing health care services in a community represented the systematic identification of a population's needs to determine the proper level of services needed. Formal community health needs assessments could be in the form of an evaluation developed by a strategic planning team linked with representatives of a community advisory committee. v 16. Specific health promotion and prevention services available in primary health care delivery encourages individuals’ behaviour to most likely optimize health potentials (physical and psychosocial) through health information, preventive programs, and access to medical care. 17. Specific governance structure for a community health centre considered the form that a governing body takes. A governing body oversees daily and administrative activities. 18. Formal program evaluations for a community health centre are designed to assess the efficacy of a program. They may include the evaluation of cost‐effectiveness, the extent to which objectives are met, or impact of a program. 19. Program funding structure for a community health centre were the source and means by which programs and services are financed. 20. Funding structure for health professionals at a community health centre were the remuneration paid or benefits granted to an employee. 21. Community awareness campaigns for a community health centre and availability of services represented the use of communications media to interchange, transmit and receive information to increase awareness of services in a community. 22. Recruitment and retention programs for rural health centres were programs and/or plans (financial or otherwise) designed to incentivise and motivate physicians and employees to work in and remain in rural areas to provide health services. 23. Affiliation with an education institution represented a formal relationship with an academic institution to partner with in research and teaching initiatives. 24. Conducting research at a community health centre included basic or applied collaborative research efforts between centre staff and researchers from academic settings. Overall summary of research evidence: A total of 55 systematic reviews were included in the evidence summary of Table 2: Flow chart of overall screening results for prioritized searches Records identified through database searching (n=6545) prioritized structures and processes (see Table 2 for overall screening Records screened after duplicates removed (n=6277) Records excluded at title/abstract stage (n=5931) results for prioritized searches). Eleven records were included from Full text assessed for eligibility (n=259) additional scoping searches for non‐
prioritized structures and Reviews identified and data ex‐
tracted (n=56) processes (see full report for more information). Articles included in synthesis (n=55) vi Full text identified as primary studies (n=203) Summary of the research evidence on CEC‐type models of health care delivery: CEC‐type models We identified 1723 unique records potentially relevant to the effectiveness of CEC‐type models of health care delivery. We selected 45 that we reviewed in full text (32 primary studies and 12 grey literature documents). None of the identified studies met our CEC‐type model definition selection criteria. Key Messages  There is limited scientific literature on the concept of CEC‐type models as a health care delivery model.  This is an area for future research studies. Summary of research evidence on the effectiveness of specific structures and processes relevant to CEC‐type models of healthcare delivery: Hours of access to health care services We identified and screened 835 unique results. We identified two well‐conducted systematic reviews related to the impact of hours of health care service delivery on individual or community health outcomes (1, 2). Key Messages  Lack of evidence is available on the impact of alternative models of after‐hours care.  Telephone triage and advice lines appear to reduce medical workload, have potential to reduce costs, but need to be balanced against reduced patient satisfaction.  While ED overuse is associated with lack of hours of access to primary care, expanding these services does not appear to have a major impact on reducing inappropriate ED use. Health care professional staff available (emergency care) We identified and screened 496 unique results and 46 records were reviewed in full text. We identified eight systematic reviews on the topic of the effect of health care professional staff available in an emergency care delivery environment on health outcomes (3‐10). They included novel medical and non‐medical roles in the emergency care delivery settings. These systematic reviews assessed a small number of RCTs, more frequently including lower levels of study designs. Four systematic reviews investigated the effect of nurse practitioners (NPs) or NPs and other non‐
medical staff in the ED (4,7,8,10). These systematic reviews investigated studies conducted in combined adult and paediatric populations (4,7), or in adult only populations (10). Hoskins (2011) examined the effect of emergency NPs, expanded‐scope physiotherapists and emergency care practitioners in all emergency care settings (7). The other four systematic reviews each investigated one of the following health professional roles/models: triage liaison physicians (9), pharmacists (5), physician assistants (6), and multidisciplinary teams targeted toward frequent ED users (3). Key Messages  Patients accept and are satisfied with the care provided by NPs and physician assistants in the ED.  Additional patient contact time afforded by alternative ED staffing is associated with improved communication and increased health promotion.  Shorter length of stay may be associated with greater patient satisfaction.  The quality of care provided by NPs and physician assistants vs. residents in the ED is comparable.  Case management may reduce ED use for specific groups of vulnerable patients and also for all frequent users of EDs.  Financial implications of staff changes might be significantly different in Canada (current evaluation data is inadequate).  Data from systematic reviews on other health professionals in these roles is lacking. vii Health care professional staff available (primary care) We identified and screened 1052 unique results, 78 records were reviewed in full text. Twelve systematic reviews evaluated the effect of different primary care staff on health outcomes (11‐22). Reviews assessed the effectiveness of including specific staff in the fields of: 1. General primary care, 2. Mental health, and 3. Various other primary care populations. Key Messages  NPs in primary care as substitutes in the same role as GPs has been shown to have no difference in care, and to have improvement in patient compliance, knowledge, or satisfaction.  Evidence is lacking for cost‐effectiveness analyses and examination of long‐term effects of the addition of health care professional staff in primary care; the few cost studies available suggest similar or increased costs with NP compared to extra salaried GPs.  Nurse‐ and pharmacist‐led care for hypertension was found to be effective for hypertension and heart failure. Specialist nurse care in treating diabetes resulted in neutral outcomes.  There is modest evidence to support the addition of pharmacists, paraprofessionals and mental health care workers in primary care settings for mental health.  Characteristics of health care providers, including training and experience, should be reported more consistently in studies. Collaborative practices (primary and emergency care) We identified and screened 1521 unique results, 127 records were reviewed in full text. We identified 18 systematic reviews that assessed the effectiveness of collaborative models of care (23‐40). Nine systematic reviews assessed the team‐based models of collaborative care in: 1. ED, and 2. Primary care (mental health and other chronic diseases). Systematic review definitions of collaborative care ranged from broad (e.g., multiple professionals involved) to more specific (e.g., multifaceted intervention involving combinations of three distinct professionals working collaboratively within the primary care setting: a case manager, a primary care practitioner, and a mental health specialist [to be included in the review, studies had to involve two of these three components of collaborative care]). Collaborative care was most commonly defined by the number of health professional disciplines involved in patient care. Key Messages  Collaborative care (multidisciplinary models) in primary care settings has been shown to consistently improve symptoms and management of chronic disease (depression, hypertension).  Collaborative care has been consistently found to be more expensive than usual care (other than Community Mental Health Teams), although additional high quality economic evaluations are required.  The introduction of multidisciplinary teams to the ED may be successful in improving access, however, more research is needed.  No consistent improvements in health outcomes were observed in many studies examining shared GP
‐specialist consultation in primary care management of chronic health conditions.  Generalizability to the Nova Scotia CEC model is limited as these collaborative models focus largely on physician collaboration with either another physician or an allied health professional, and do not examine the idea of two non‐physicians working collaboratively. viii Tele‐Consultation/Telehealth A good quality review of reviews on the topic of telehealth, published in 2009, was identified (41). We conducted searches to locate reviews published after 2009. We identified 663 unique results. Fifty‐one records were reviewed in full text. Fourteen additional systematic reviews published after 2009 were selected (42‐55). These systematic reviews assessed the effectiveness of telehealth in: 1. Off‐site consultation, 2. Mechanisms for off‐site communication, and 3. Off‐site health care delivery. Key Messages  Studies on telehealth are heterogeneous, making it difficult to draw general conclusions from studies.  Despite a large number of studies and systematic reviews on the effectiveness of telemedicine, high quality evidence is still lacking (mostly observational studies are available).  Reviews demonstrate that telehealth services do not appear to harm patients and are both reliable and feasible in this limited assessment of non‐emergency conditions.  The effect of tele‐consultation on clinical outcomes is not clearly established (finding are mixed and many studies show no difference from usual care).  Studies of telehealth for service provision in chronic/mental health conditions report neutral to positive findings.  Few studies examine the cost effectiveness of tele‐consultation. Acknowledgments: We appreciate the assistance and support of Fred Burge, Alana MacLellan, Jenny Cartwright, and Kristy McGill throughout this rapid evidence synthesis project. We also thank all stakeholder workshops attendees for their support. Declarations of Conflict of Interest: No conflicts of interest have been declared by the authors. This knowledge synthesis project was undertaken by the Nova Scotia Cochrane Resource Centre. For additional and more in depth information on this rapid knowledge synthesis project, please refer to our full report. How to cite this project: Hayden J, Babineau J, Killian L, Martin‐Misener R, Carter A, Jensen J, Zygmunt A. Collaborative emergency centres: Rapid knowledge synthesis. Halifax, Nova Scotia: Nova Scotia Cochrane Resource Centre; 2012. How to cite this document: Hayden J, Babineau J, Killian L, Martin‐Misener R, Carter A, Jensen J, Zygmunt A. Collaborative emergency centres: Rapid knowledge synthesis. Short report. Halifax, Nova Scotia: Nova Scotia Cochrane Resource Centre; 2012. 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(2):181‐200. 52. Verhoeven F, Tanja‐Dijkstra K, Nijland N, Eysenbach G, van Gemert‐Pijnen L. Asynchronous and synchronous teleconsultation for diabetes care: a systematic literature review. J Diabetes Sci Technol. 2010 May;4(3):666‐84. 53. Wade VA, Karnon J, Elshaug AG, Hiller JE. A systematic review of economic analyses of telehealth services using real time video communication. BMC Health Serv Res. 2010;10:233. 54. Warshaw EM, Hillman YJ, Greer NL, Hagel EM, MacDonald R, Rutks IR, et al. Teledermatology for diagnosis and management of skin conditions: a systematic review. J Am Acad Dermatol. 2011 Apr;64(4):759‐72. 55. Young LB, Chan PS, Lu X, Nallamothu BK, Sasson C, Cram PM. Impact of telemedicine intensive care unit coverage on patient outcomes: a systematic review and meta‐analysis. Arch Intern Med. 2011 Mar 28;171(6):498‐506. xi xii
Full Report
Background
Relevance and Potential Impact
Long wait times, lack of access to primary care resources, and inadequate access to emergency departments
(EDs) are noted as the greatest issues plaguing health care in Nova Scotia (67). These issues are not unique to
the province; meeting the needs of health care communities across Canada and around the world is recognized
as a challenge (68, 69).
Collaborative Emergency Centres (CECs) are a unique potential solution to these access issues in Nova Scotia.
CECs are a new model of health care delivery that bring teams of nurses, doctors and other health providers
under one roof to provide improved access to timely primary health care, and appropriate access to 24/7
emergency care (69). CECs have three formally linked components: a primary health care team, the capacity to
provide urgent care, and a protocol in place for emergency care. This collaborative and integrative care model is
different from traditional models of care, in which the delivery of emergency and primary care are typically
distinct (70). Potential solutions to alleviate health care access issues through similar collaborative care models
have been implemented in other Canadian provinces (71, 72) and countries, including Australia (73, 74), New
Zealand (75), and the United Kingdom (73, 76). It is useful to understand the strategies and components that
have been implemented in other jurisdictions, and to assess the strength of evidence supporting these potential
strategies to promote effective implementation of CECs in Nova Scotia.
This rapid knowledge synthesis project aims to inform decision making regarding the development and
implementation of effective CECs across Nova Scotia by:
1. Defining CECs through the identification of potential structures, process and implementation
strategies of CEC-type models in other jurisdictions.
2. Identifying scientific evidence that investigates the effectiveness of CEC-type models and their
structures and processes for improving health outcomes.
Collaborative Emergency Centres in Nova Scotia
CECs seek to fulfill a key commitment of the Better Care, Sooner report by helping to address issues of ED
overcrowding and long wait times to see general practitioners (67). The Nova Scotia Department of Health and
Wellness points out that their objective is to “keep EDs open, reduce patient wait times and provide a teambased approach that offers continuity of care” (77-81). The first CEC was announced in April 2011 and opened in
Parrsboro in July 2011 (82). In October 2011, CECs were announced for Tatamagouche, Pugwash, and Springhill
(77-79). In November 2011, a CEC was announced for Annapolis Royal (80). It is projected that these CECs will be
scheduled to open in the coming months. In December 2011, it was publicized that the province of Nova Scotia
will invest $6.8 million to establish more CECs across the province (81).
1
Using Evidence in Decision Making
The implementation and continued quality improvement of CECs in Nova Scotia, like other policy and clinical
decisions, is best informed by relevant and comprehensive evidence, when available. Evidence-informed
decision making involves the translation of the best available research evidence compiled through a transparent
and systematic process. Knowledge translation is a term used to describe the integration of evidence into
decision making. The Canadian Institutes of Health Research (CIHI) defines knowledge translation as a “dynamic
and iterative process that includes the synthesis, dissemination, exchange and ethically sound application of
knowledge to improve health, provide more effective health services and products, and strengthen the health
care system” (83).
Using research evidence in policy and clinical decision making can enable a transparent and systematic process
to clarify a problem, frame options to address it, and define how an option can be implemented within even the
most dynamic decision making processes, thus helping to protect against error or bias (84). The effective use of
evidence-informed decision making can also lead to the provision of more successful programs and practices,
and subsequently benefit policy and decision making by improving health outcomes (85).
There are many types of evidence syntheses available that may inform decision making (see the Glossary for
descriptions of different types of evidence syntheses, including scoping reviews, jurisdictional reviews and rapid
reviews).
2
Rapid Knowledge Synthesis Plan and Objectives
The overall approach in this rapid knowledge synthesis project followed principles important for knowledge
syntheses: systematic and transparent methods that minimize potential bias. We considered the required time
frame of a rapid knowledge synthesis, the complexity of the topic area and the necessity of producing a
summary of value and relevancy to decision makers in Nova Scotia. To accomplish this, we adapted methods for
rapid reviews (emphasizing expedited systematic review methods) with the methods of a jurisdictional review
(86) and integrated knowledge translation (87).
Our approach included two major parts: 1. Scanning of CEC-type models, and 2. Summarizing the scientific
evidence for CEC-type models. Results from an integrated knowledge translation process, including interactions
with important Nova Scotia CEC stakeholders, are embedded within these major parts of the report.
We first scanned for existing CEC-type models. This part of our project included clearly defining a ‘CEC-type
model’ through scoping the literature and other jurisdictions. Initial scoping searches clarified our review
questions. We collected information on CEC-type models relevant to the Nova Scotia context through a scan of
other jurisdictions and summarized information on the structures and processes that they included.
Summarizing the scientific evidence for CEC-type models was the second major part of our project. The evidence
summary involved searching for relevant peer-reviewed and grey literature. We summarized available evidence
to determine the effectiveness of CEC type-models, and their structures and processes.
We used an integrated knowledge translation approach, engaging clinical and policy decision makers to help
refine our evidence summary questions and interpret findings relevant for CECs in Nova Scotia. This was
executed through two half-day workshops with selected stakeholders, including representatives from groups
relevant to CECs in Nova Scotia, such as the Department of Health and Wellness, primary health care
practitioners (family physicians, nurses), emergency care practitioners (members of Emergency Health Services,
emergency physicians), and members of the Cumberland County Health authority involved in the development
and/or functioning of the first implemented CEC, located in Parrsboro, Nova Scotia (82).
The goals of the first stakeholder workshop were to discuss approaches and methods for evidence synthesis,
discuss the objectives and approach of our project, and refine definitions and priorities within the project. The
goals of the second workshop were to discuss our findings, key messages, and future dissemination plans.
3
Part 1: Scan of CEC-type Models
Objectives
The objectives in the scanning of CEC-type models were to investigate:
1. What CEC-type models have been applied in jurisdictions outside of Nova Scotia
2. What components are included in these health care delivery models
3. How CEC-type models are assessed (e.g., what outcome measures are used?)
Methods
Prior to beginning the scan of jurisdictions outside of Nova Scotia, we conducted a brief scoping search of the
literature. We consulted peer-reviewed literature, grey literature, and documentation on CECs provided by the
Nova Scotia Department of Health and Wellness to determine a preliminary list of structures and processes
essential to CECs, and establish the extent and range of jurisdictions to be selected for the scoping process. We
initially scanned primary government and department of health government websites, and scanned the peer
reviewed literature to support the decision making process regarding search strategy and feasibility.
We conducted a scan of Canadian jurisdictional resources to locate relevant centres and determine their
structures and processes. The jurisdictional scan process included:
a.
b.
c.
d.
e.
f.
g.
Selecting jurisdictions
Identifying resources and developing a search strategy
Searching for relevant CEC-type centres
Selecting relevant CEC-type centres
Data extraction of digital information potentially relevant to CECs
Suitability of CEC-type centres
Telephone follow-up with key CEC-type centres
a. Selecting jurisdictions: We selected Canadian jurisdictions according to their similarities in health care models
and demographics to Nova Scotia for the scoping process. The provinces of Ontario and Quebec were not
included as Ontario’s e-presence contained far too much information to be manageable in a restricted timeline,
and Quebec e-documents were primarily written in French.
b. Identifying resources and developing a search strategy: Relevant digital resources were selected for individual
jurisdictions by a librarian researcher for the jurisdictional scan. Selected resources were:
Government and health department websites
Individual health authority websites
Research citation databases (Canadian Business and Current Affairs Complete, PubMed)
Search engines (Google, Google Scholar, Google news)
We also included any sites related to jurisdictional health care systems discovered through the search process. A
full list of websites searched is available in Appendix 1. The search of digital information was comprehensive,
however, focusing on digital formats limited our jurisdictional scan, as not all information and news becomes
translated to digital format. Furthermore, all documents may not be made publicly available, and thus would not
have been retrieved through this process.
One librarian researcher identified relevant search terms to use in the jurisdictional scan by reviewing the terms
used in located documents. We consistently searched these terms when a search option was available: “primary
and emergency”, “collaborative care”, “collaborative health”, “team model”, “integrated care”, “health centre”,
“community health centre”, “community health centres”, “urgent”, and “urgent and primary”. Inconsistency of
4
language related to CEC-type models across jurisdictions required adding terms to individual search strategies.
Additional search terms included jurisdiction-specific nomenclature for potential CEC-type models, and specific
locations or names of potential CEC-type centres.
c. Searching for relevant CEC-type centres: Each jurisdictional search began with a scan of primary government
and government health websites. In the case of government sites, we scanned reports and publications oriented
towards health services (Canadian government websites consistently link to publications and reports on a
navigation pane). In addition, we scanned government department of health websites for lists of health centres,
lists of services provided, and news releases. All webpages with titles that appeared relevant to alternative
models of care, listing models of care, or listing health centres were also scanned. All websites searched are
listed in Appendix 1. The search strategy was executed on each website.
A single researcher conducted all of these searches to ensure consistency. A maximum of three business days
was used for scoping of each jurisdiction to ensure timely completion of the jurisdiction scoping process. We
consulted co-investigators for additional sites or centres we may have missed through our search process.
d. Selecting relevant CEC-type centres: Our original working definition was provided through preliminary
documentation on CECs in Nova Scotia produced by the Nova Scotia Department of Health and Wellness,
defining CECs as “a model that brings together rural community EDs and local family practices to work together
to provide seamless access to primary and emergency care to the community”. We used this preliminary
definition to determine which centres should be considered CEC-type centres.
We selected any centres that appeared to have:
A mix of primary, urgent and/or emergency care services in one location
Been designed as a primary point of access to care for a community
It was required that these components be present in searched documents for a jurisdiction to be included.
e. Data extraction of digital information potentially relevant to CECs: We developed a data extraction form
(Appendix 2) based on our previously established template of structures and processes, and through
consultation with the research team. We collected the following information about the CEC-type centres, their
structures and processes:
General information on the selected CEC-type centre
Hours of service
Staffing
Health care provider collaboration
Triage
Protocols and standing orders
Destination and transfer plans
Capacity
In-patient beds
Off-site communication and telehealth
Health promotion and prevention services
Governance
Program funding and practitioner funding
A single reviewer completed data extraction for each of the selected centres and added any relevant new
components iteratively. In the event of conflicting information, the most current source of information was
considered, or one researcher contacted the centre to clarify.
5
We used a saturation approach to data collection and extraction: we continued identifying new centres and
extracting information on CEC-type model components when available evidence or new centres were found. Not
only was this process essential to the scoping of other jurisdictions, it also supported the development of a
comprehensive set of 29 structure and process questions and their respective definitions to guide the literature
searches. The original list of these 29 questions is available in Appendix 3.
f. Suitability of CEC-type centres: Selected centres were revisited through different levels of the scanning process
of CEC-type models. Centres were excluded in later stages of the review process based on narrowing of our
definition of CEC-type models, through consultation with investigators and stakeholders. Inclusion and exclusion
of centres was based on CEC-type model criteria and were assessed by two researchers with conflicts resolved
through consultation among the research team.
In the event of lack of clarity regarding the appropriateness of a centre based on our inclusion criteria, one
researcher contacted the centre via telephone (using a telephone number provided on public domain resources)
to confirm whether or not they met inclusion criteria.
Included centres were categorized as “CEC-type centres with Nova Scotia context”, and “CEC-type centres”.
Centres defined as “CEC-type centres with Nova Scotia context” met the criteria of having a health care model
closely related to the CEC model and a similar target population to Nova Scotia. Centres defined as “CEC-type
centres” met the criteria of having a health care model closely related to the CEC model.
To determine the suitability of each centre, two researchers considered the final list of CEC-type centres. Each
researcher individually selected centres with key similarities to the Nova Scotia model based on population and
service models, and centres noted as meeting CEC-type model requirements but having any special conditions.
The results of both researchers were compared. Centres were included in selected categories when there was
consensus; conflicts were resolved through discussion between the two researchers. Any unresolved conflicts
were brought to the attention of the research team for resolution.
g. Telephone follow-up with key CEC-type centres: We contacted selected centres demonstrating particular
relevance to the Nova Scotia context to ensure accurate and thorough understanding of individual jurisdictional
practices as described through web presences.
One researcher called relevant centres at the telephone number provided on public domain resources. The
researcher described the rapid knowledge synthesis project in brief, and requested to speak with a manager or
supervisor at the centre. The researcher followed a semi-structured list of questions on staffing models in
primary and emergency care, collaborative care in primary and emergency health care delivery environments,
off-site consultation and mechanisms for off-site health care delivery, the CEC-type model as a whole, and
formal evaluation methods at the centre. Questions were formulated to clarify and give context to content
available through centres’ online presences.
Information from telephone contact was integrated into the data extraction and summarizing process of the
scan of jurisdictions.
Results
CEC-type Centres Across Canada
We identified 26 CEC-type centres across select Canadian jurisdictions. Twenty-five were identified during the
scan of jurisdictions and one additional centre was recommended through consultation with the investigator
team. Information about the centres, structures and processes were extracted for all 26 centres. Subsequent reassessment and refining of our selection of centres occurred iteratively after further operationalizing our
definition
6
of a CEC-type centre.
Our definition of “CEC-type centres” (supporting the ability to define the scope of the project) was finalized
following group discussions at the first stakeholder workshop:
A CEC-type centre focuses on the delivery of health care services including both primary care and access to
emergency care through a seamless collaborative team approach.
Primary care encompasses access to health promotion, wellness, chronic disease management, illness
and injury prevention, and diagnosis and treatment of illness and injury.
Access to emergency care includes initial emergency stabilization of life-threatening conditions,
response to (including treatment or referral) the majority of urgent conditions and those conditions of
lesser urgency.
A health care provider must be available on-site, and has a formal supportive relationship with other professional(s)
or institution(s) elsewhere through telephone or technological means.
This working definition was used to determine relevancy throughout the rapid knowledge synthesis project.
After final operationalization of the definition of CEC-type centres, 14 centres were excluded. Our final list of
CEC-type centres in jurisdictions across selected Canadian jurisdictions included 12 specific locations, listed in
Table 1. The total number of
centres considered, and the level
Table 1: List of CEC-type centres
of exclusions can be seen in a
CEC-type centres with Nova Scotia context:
flow chart (Appendix 4).
- Rainbow Lake Health Centre, Rainbow Lake, Alberta
-
Ladysmith Community Health Centre, Ladysmith, British Columbia
Dr. W. H. Newhook Community Health Centre, Whitbourne,
Newfoundland
CEC-type centres:
- Northeast Community Health Centre, Edmonton, Alberta*
- Oceanside Primary & Urgent Centre, Parksville, British Columbia†
- Hopedale Community Clinic, Hopedale, Newfoundland
- Fort Simpson Health Centre, Fort Simpson, North West Territories
- Wrigley Health Centre, Wrigley, North West Territories
- Igloolik Community Health Centre, Igloolik, Nunavut
- Black Lake Health Centre, Black Lake, Saskatchewan
- Cumberland House Health Centre, Northern Village of Cumberland
House, Saskatchewan
- Health Centres (case: Dawson City Community Health Centre), Yukon
Selected centres were located
across Canada. Two centres were
located in Alberta, two in British
Columbia, two in Newfoundland
and Labrador, two in the North
West Territories, one in Nunavut,
two in Saskatchewan, and one in
the Yukon.
Three centres had a health care
model with features and
demographics similar to those of
the CEC model in Nova Scotia,
labeled “CEC-type centres with
Nova Scotia context”. The
remainder of centres are categorized generally as meeting the final operationalized “CEC-type centres” model
definition.
*The Northeast Community Health Centre in Edmonton, Alberta is an innovative model of
primary health care delivery that combines community-based services with a 24-hour ED
(88). This large urban ambulatory site opened in 1999. The region it serves contains
vulnerable and high-risk groups with complex medical and social issues who are not well
served by traditional health services.
†The Oceanside Primary and Urgent Centre in Parksville, British Columbia although very
relevant to the CEC-type model of Nova Scotia, is projected to open in late 2012. The
information available on this centre is anticipatory.
7
CEC-type Centres with Nova Scotia Context
The Ladysmith Community Health Centre, in Ladysmith, British Columbia was converted from a hospital into a
community centre in 2008. The previous inpatient space was renovated to accommodate other health care
services that were previously located throughout Ladysmith and in neighbouring communities. The Ladysmith
Community Health Centre serves a population of approximately 7500 people.
The Rainbow Lake Health Centre, in Rainbow Lake, Alberta has a relevant alternative staffing model: the health
centre, dealing with primary and urgent care, has EMS personnel providing primary care services in the clinic.
Rainbow Lake has a population of 1100, and is located 140 kilometers west of High Level, where the regional
hospital is located.
The Dr. W. H. Newhook Community Health Centre, in Whitbourne, Newfoundland provides primary care and
emergency services. Open 24 hours, there is a nurse on staff with an on call GP at night. The population of
Whitbourne, Newfoundland is approximately 855.
CEC-type Centres
Centres listed as “CEC-type centres” have populations below 2000 (with the exception of the Oceanside Primary
and Urgent Centre and the Northeast Community Health Centre), with many being located in the Canadian
territories, or in the more northern regions of Canadian provinces. In the cases from the Yukon, Nunavut and the
North West Territories, the health centres reflect the health care service model which is present throughout
their jurisdiction.
Structures and Processes
The scan of jurisdictions supported the development of a comprehensive list of 29 structures and processes
which define the CEC-type model (complete list in Appendix 3). We summarised extracted data for individual
centres in a table, outlining the established components for each jurisdictional CEC-type model (see Appendix 5).
We present descriptive narratives from the results of the scan of jurisdictions within the evidence summary
results in the following part of the report.
Throughout the report, comments from the scan of
jurisdictions will be noted by the icon
, and highlighted
in blue boxes, like this one.
These include:
1. Summaries of all centres, or
2. Anecdotes from specific relevant centres.
8
PLEASE NOTE: The results from the jurisdictional
scan are not based on peer-reviewed evidence;
results from the scan of jurisdictions only
include statements of what is occurring in other
jurisdictions, according to publicly available
resources.
Part 2: Summarizing the Scientific Evidence for CEC-type Models
Objectives
The objectives of the evidence summary were to summarize evidence available in the peer-reviewed literature
about:
1. The effectiveness of CEC-type models compared to traditional health care delivery models, and
2. The effect of specific CEC-type model structures or processes.
Methods
Summarizing the scientific evidence for CEC-type models included identifying evidence about our overall
question, the effectiveness of CEC-type models, and prioritized CEC-type model structures and process identified
as most important by stakeholder workshop participants, as well as scoping literature reviews for additional
structures and processes. This entailed a multi-step process including:
a.
b.
c.
d.
Prioritizing searches
Search strategy development
Citation management and selection
Data extraction
a. Prioritizing searches: A comprehensive set of 29 questions, identified through background scoping and initial
consultation with stakeholders and the investigator team, was presented to stakeholder participants during the
first workshop. These questions addressed variables such as hours of access, staffing models, available services,
and affiliations considered potentially relevant in a CEC-type setting (see Appendix 4). These 29 questions were
remodelled into a final list of 24 questions (see Appendix 6). Seven of these structures and processes were
prioritized through discussion amongst the research and investigator team as of critical importance to the
functioning and implementation of a CEC. At the first stakeholder workshop, stakeholders were asked to also
prioritize structures and processes. The research team received confirmation that the selected prioritized
structures and processes were of the highest importance to stakeholders, as well. Prioritized structures and
processes and their corresponding definitions are listed in Table 2.
b. Search strategy development: We developed comprehensive search strategies for each of the prioritized
structures and processes (Table 2) to assist with electronic searches of the peer-reviewed literature. Sources for
search terms included background literature, consultation with the investigator team, and the jurisdictional
review process. We used Medical Subject Headings (MeSH) for the PubMed database and Emtree terms for the
Embase database in conjunction with key word terms (i.e., text words not in the database thesaurus) to capture
all terminology that might be used to describe a CEC-type model.
Since a CEC by its nature combines primary care with emergency care, a librarian member of the research team
also developed lists of MeSH and key words to describe these settings. Controlled vocabulary is not used
consistently across databases so we adjusted each search strategy accordingly.
Prioritized structures and processes: We searched each prioritized structure or process question in PubMed and
Embase (two of the largest indexes of biomedical and health literature in the world). When appropriate, we also
conducted searches in The Cochrane Library, CINAHL, and the grey literature (see Glossary for definition). We
limited searches to research published in the English language due to insufficient time for translations. Each
search included terms to describe a CEC-type model (e.g., enhanced primary care, wellness centre, polyclinic) as
well as terms to describe a primary care setting (e.g., primary health care, general practice), emergency care
setting (e.g., accident and emergency, rural hospital), or both, depending on the focus of the structure or
process guiding question. Each search then combined the terms describing the setting with terms describing the
structure or process under investigation (e.g., collaborative practices, telehealth).
9
Table 2: Prioritized structures and processes and definitions
#
1
Structure/Process
CEC-type models of
health care delivery
2
Hours of access to health
care services
3
Health care professional
staff available
(emergency care)
4
Health care professional
staff available (primary
care)
5
Collaborative practices
(primary or emergency
care)
6
Telehealth/TeleCollaboration
Definition
A CEC-type model centre focuses on the delivery of health care services including both
primary care and access to emergency care through a seamless collaborative team
approach.
Primary care encompasses access to health promotion, wellness, chronic disease
management, illness and injury prevention, and diagnosis and treatment of
illness and injury.
Access to emergency care includes initial emergency stabilization of lifethreatening conditions, response to (including treatment or referral) the
majority of urgent conditions and those conditions of lesser urgency.
A health care provider must be available on-site, and has a formal supportive relationship
with other professional(s) or institution(s) elsewhere through telephone or technological
means.
Hours of access to primary or emergency care services means the operational hours that
primary care or emergency services are accessible to members of a community. Hours of
access to primary care could be: daytime (regular) hours or extended hours. Examples of
hours of access to emergency services could be: 24 hours/day, extended hours, access to
on-call physician only, or daytime only hours according to health care provider
availability.
Health care professional staff available in emergency care are professional personnel
who provide, or assist and support the provision of, care to patients in an organized
emergency care facility. Specific options include: physician/specialist(s), nurse
practitioner(s), nurse(s) (with or without additional training), physician assistant(s),
paramedic(s) with additional training, allied health professional(s) (regulated or other),
additional support staff.
Health care professional staff available in primary care are professional personnel who
provide, or assist and support the provision of, care to patients in an organized primary
care facility. Specific options include: physician/specialist(s), nurse practitioner(s),
nurse(s) (with or without additional training), physician assistant(s), allied health
professional(s) (regulated or other), additional support staff.
Collaborative practice can be described as multiple health professionals working together
to provide care. Systematic review definitions of collaborative care ranged from broad to
more specific number and types of professionals. Collaborative care was most commonly
defined by the number of health professional disciplines involved in patient care (e.g., ≥2
(39) or ≥3 professionals (29).
Off-site consultation means consultation via remote telecommunications (i.e., the
transmission of information over distances via electronic means) of a health provider onsite to one at a distance to enhance the local scope of practice. This is generally for the
purpose of diagnosis or treatment of a patient.
Mechanisms for off-site communication are the tools by which information is transferred
over distances via technological means.
7
Comprehensive set of
diagnostic services
available (primary or
emergency care)
Delivery of health services via remote telecommunications (i.e., the transmission of
information over distances via electronic means). This includes interactive consultative
and diagnostic services for a patient communicating with a health care provider at a
distance.
Having diagnostic services available means having organized services for the purpose of
providing diagnoses to promote and maintain health. Diagnostic procedures can also be
routinely performed on all individuals or specified categories of individuals in a specified
situation. Examples of diagnostic services are: x-ray and other forms of diagnostic
imaging, blood work, ECGs, and blood pressure monitoring.
10
The primary goal was to identify recent, high quality systematic reviews relevant to each prioritized structure or
process. Therefore we first conducted searches with a filter to specifically identify systematic reviews. If no
relevant reviews were identified, the search was repeated without the review filter, and primary studies were
identified. We categorized primary studies into experimental (e.g., randomized controlled trials [RCTs]),
observational (cohort studies, case control studies, cross-sectional studies), or qualitative. If no primary studies
were identified, a grey literature search was conducted.
Search strategies for each prioritized structure or process were developed (full search strategies for prioritized
questions are provided in Appendix 7) as follows:
1. CEC-type models of health care delivery: In the PubMed and Embase databases, we combined terms
describing emergency care settings, terms to describe primary care setting, and terms to describe CEC settings.
Searches were not combined with a systematic review subset. We used the CADTH’s Grey Matters tool to
identify grey literature sources to conduct grey literature searching (89). We selected 10 sources based on
generalizability and their focus on health contexts most likely to be relevant to Canada and Nova Scotia. During
the searches, we identified two additional grey literature sources and we added these to the original list. A
description of the grey literature search strategy, and list of grey literature sources are included in Appendix 7.
2. Hours of access to health care services: In the PubMed and Embase databases, we combined terms to
describe emergency care settings with terms to describe hours of access (e.g., “after-hours care”, “out of
hours”). Also, in The Cochrane Library, PubMed and Embase databases, we combined terms to describe primary
care settings with terms to describe hours of access. All searches were then combined with a systematic review
subset to isolate reviews from the overall results.
3. Health care professional staff available (emergency care): In The Cochrane Library, PubMed, and Embase
databases, we searched terms describing CEC settings along with terms to describe emergency care settings;
either of these settings would have been acceptable. We combined terms for settings with terms to describe
specific health care professional staff (e.g., “physicians”, “paramedics”). We then combined the searches with a
systematic review subset to isolate reviews from the overall results.
4. Health care professional staff available (primary care): In The Cochrane Library, PubMed, and Embase
databases, we searched terms to describe CEC settings along with terms to describe primary health care
settings; either of these settings would have been acceptable. We combined setting terms with terms to
describe specific health care professional staff (e.g., “physicians”, “paramedics”). We then combined the
searches with a systematic review subset to isolate reviews from the overall results.
5. Collaborative practices (primary or emergency care): In The Cochrane Library, PubMed, and Embase
databases, we searched terms to describe CEC settings along with terms to describe primary health care settings
and terms to describe emergency care settings; any of these settings would have been acceptable. We
combined terms for settings with terms to describe specific collaborative practices in health care settings (e.g.,
“collaborative care”, “patient care team”). We then combined the searches with a systematic review subset to
isolate reviews from the overall results.
6. Telehealth/Tele-consultation: We did not include terms to describe any specific setting in the searches as the
setting for this search was not relevant. In The Cochrane Library, PubMed, and Embase databases, terms to
describe telehealth or tele-consultation were searched (e.g., “remote consultation”, “telehealth”). We then
combined the searches with a systematic review subset to try to isolate reviews from the overall results.
7. Comprehensive set of diagnostic services available (primary or emergency care): Similar to other prioritized
component searches, we conducted scoping searches to identify MeSH and keywords to capture the concept
comprehensively. Although this component question was prioritized by stakeholders during the first workshop,
we did not conduct a comprehensive search for this component question. In addition, we consulted our
investigator team during the scoping process in an attempt to clarify our search process. This approach led to no
manageable search strategy. We completed a scoping literature review on this component.
11
c. Citation management and selection: We imported citations identified in the searches into Endnote reference
management software (90). We removed duplicate citations and uploaded citation lists into Distiller systematic
review software (91). We used three stages of study screening. In the first stage, one reviewer assessed record
titles for potential relevance. Articles relevant (or of unclear relevance) advanced to the next stage of citation
screening.
In the second stage of study screening, we assessed abstracts using an accelerated screening approach. We
advanced articles to full text consideration (third stage) if one reviewer judged the abstract to be relevant to the
specific component question under consideration. Two reviewers were required to reject an abstract, a
mechanism to ensure that potentially relevant abstracts were not rejected. Records were excluded when either
the structure or process being considered or study setting was not relevant to the research question.
Operationalization for structures and processes (“exposures”) are included in Table 2. A restriction on
methodology was also implemented: only reviews were advanced to the data extraction level (with the
exception of the first prioritized question on CEC-type models). The inclusion/exclusion criteria used to screen
abstracts, in brief, is described in Table 3. For example, for a study to be included in our evidence synthesis for
health care staff in emergency care, the study had to be a systematic review evaluating the use of specific health
professional staff (as defined in Table 2) in an emergency care setting.
In the third stage of screening, we retrieved full text articles if available through Dalhousie University Libraries.
Studies flagged as not relevant in full article review were checked by a second reviewer before exclusion. Flow
charts detailing the article selection process are found in Appendix 8.
d. Data extraction: We extracted the
following data from included studies:
Author objectives
Descriptions of the participants,
interventions, and outcomes
(related to health, process,
and/or costs)
Author conclusions
Review quality (type of
evidence, potential bias,
generalizability)
Quality of evidence included
Table 3: Screenshot of Inclusion/exclusion criteria for screening
citations
The form developed to extract data is
shown in Appendix 9. Author
conclusions were listed as positive,
negative or neutral. Positive results
suggested an intervention leading to
improved outcomes. Neutral results
concluded that the intervention had no
impact on outcomes or had similar outcomes to the comparison. Negative results concluded that the
intervention led to inferior outcomes to the comparison.
One researcher extracted data from full text articles. At least one additional researcher checked data extraction.
We exported collected data from Distiller into Microsoft Excel, to be formatted, condensed and summarized. We
distributed data tables to the content expert members of the investigator team along with worksheets
developed to extract the key messages of review articles for each specific prioritized structure or process search.
12
As part of extracting key messages from the data extracted for included studies for each prioritized structure or
process search, we asked our investigator team to flag any records that they felt were not fully relevant to the
specific structure or process, or which were not generalizable to the Nova Scotia context. Of the studies that
remained, the investigators extracted key messages and synthesized overall messages. A template of the
worksheet is available in Table 4. A minimum of two investigators looked at each data set and extracted
messages. The research team compared results and assessed them for consistency. These key messages and the
data tables were discussed at the second stakeholder workshop held in December 2011.
Non-prioritized structures and processes: For
Table 4: Evaluation of available evidence
component questions not prioritized by the
What population, exposure, and outcomes does the evidence
research team or stakeholders, we conducted
represent?
scoping literature searches in PubMed. A list of
Population(s):
Exposure(s):
these non-prioritized components of CEC-type
Outcome(s):
models and their operationalized definitions are
What are the results/key messages (Narrative points)?
available in Table 5. Where available, we
What key population, exposure, outcomes are not represented
selected the most recent, highest quality
by the reviews available?
systematic review as representative of the
Population(s):
evidence related to a specific component, and
Exposure(s):
the research team summarized these. This
Outcome(s):
approach is limited in that without a full
What are the limitations/caveats in the messages?
comprehensive search strategy in multiple major
Additional notes:
databases, we may have missed relevant
systematic reviews on a particular topic.
However, the research team felt that conducting these scoping searches would help round out the available
evidence on specific components of CECs, and it was therefore worthwhile to provide brief summaries. Key
messages were not created based on scoping searches, due to the limitations of this evidence.
Table 5: Non-prioritized structures and processes
#
8
Structure/Process
Structure of
emergency services
9
Structure of
primary care
services
10
Emergency
protocols or use of
standing orders in
emergency care
delivery
11
Destination and
transfer plan in
emergency health
care delivery to
manage patients
Definition
Structure of emergency care services represents the different methods of scheduling or
prioritizing patient visits, waiting times, waiting lists, etc. For emergency care, examples of
service structure include prioritizing care by triage (Canadian Triage Acuity Scale/other),
prioritizing care by walk-in, and priority care for seniors.
Structure of primary care services represents the different methods of scheduling or
prioritizing patient visits, appointment systems, individual or group appointments, waiting
times, waiting lists, etc. For primary care, examples of service structure include walk-in
appointments, same day appointments, advanced booking only, HCP referral only, and
priority for patients without a family physician.
Emergency protocols provide a planned course of medical treatment from emergency care
providers in the assessment and treatment of patients with acute illness or injuries.
The use of standing orders signifies the use of written documents containing rules, policies,
procedures, regulations, and orders for the conduct of patient care in various stipulated
clinical situations. The standing orders are usually formulated collectively by the professional
members of a department in a hospital, or other health care facility or organization.
Destination and transfer plans represent the inter-facility transfer and transportation
methods of patients to obtain specific, definitive or specialist care not available on site.
Options for destination plans may include: transfer to community hospital, transfer to
regional hospital, transfer to tertiary care centre, emergency stabilization and transfer to
increased care, referral to specialist care, and maximum patient observation time (e.g., six
hours). Transfer mechanism options may include: ground ambulance, air ambulance, or
Medevac.
13
12
13
14
15
16
17
18
19
20
21
22
23
Levels of service
infrastructure in
emergency and
primary health care
delivery
Specific ambulatory
clinic services
available in primary
In-patient beds
available within a
community health
centre
Formal community
health needs
assessment for
organizing health
care services in a
community
Specific health
promotion and
prevention services
available in primary
Specific governance
structure for a
community health
centre
Formal program
evaluation for a
community health
centre
Program funding
structure for a
community health
centre
Funding structure
for health
professionals at a
community health
centre
Community
awareness
campaigns for a
community health
centre and
availability of
services
Recruitment and
retention programs
for rural health
centres
Affiliation with an
educational
Service infrastructure refers to the medical or health related services provided in one facility,
compared to these services being offered through neighbouring facilities.
Ambulatory clinic services are seen as health care services provided to patients on an
ambulatory basis, rather than by admission to a hospital or other health care facility.
Examples of ambulatory services include: chemotherapy, intravenous medications, and
orthopaedic follow-up.
In-patient beds (beds defined as equipment on which one may lie and sleep) are set up and
staffed for use in caring for patients that are deemed to require admission to a hospital.
Patients can be admitted to a variety of different beds, examples include: surgery beds,
medicine beds, telemetry beds, ICU beds, long term care beds.
A community health needs assessment represents the systematic identification of a
population's needs to determine the proper level of services needed. Formal community
health needs assessments could be in the form of an evaluation developed by a strategic
planning team linked with representatives of a community advisory committee.
Health promotion and prevention services are means of encouraging individuals’ behaviour
to most likely optimize health potentials (physical and psychosocial) through health
information, preventive programs, and access to medical care. Specific examples are: Health
Education, Public Health, Nutrition, Recreation, Specialist Services, Chronic Disease, Infection
Control, Mental Health & Addictions, Home Care, and Health Clinics (specific groups).
Governance structure represents the form that a governing body takes. A governing body
oversees daily and administrative activities. Specific examples of a governance structure for a
community health centre include: the department of health, regional health authorities,
contracts with for-profit providers, contracts with non-profit providers, directly owned
facilities, or mixed-governance models.
Formal program evaluations are designed to assess the efficacy of a program. They may
include the evaluation of cost-effectiveness, the extent to which objectives are met, or
impact of a program.
Funding structure is the source and means by which programs and services are financed.
Examples for funding structure sources include: public funding, provincial government
funding, Health Canada funding, performance-based contracts, lump sum, hospital
foundation donations, health foundation (volunteer organization), public-private partnership.
The remuneration paid or benefits granted to an employee. Specific examples of funding
structures for health professionals include: salary, fee-for-service, on-call pay.
Community awareness campaigns represent the use of communications media to
interchange, transmit, and receive information to increase awareness of services in a
community. Specific examples of community awareness campaign mechanisms are: news
releases, and mass media.
Programs and/or plans (financial or otherwise) designed to incentivise and motivate
physicians and employees to work in and remain in rural areas to provide health services.
For a community health centre to be affiliated with an education institution means the
centre has a formal relationship with an academic institution to partner with in research and
14
24
institution
Conducting
research at a
community health
centre
teaching initiatives.
Research at a community health centre may include basic or applied collaborative research
efforts between staff and researchers from academic settings.
Results
Prioritized Searches
Overall, 15 databases searches and 12 grey literature searches were conducted for prioritized structures and
processes, and we identified 6545 citations. Once we omitted duplicate records, we screened 6277 citations at
the title and abstract level, with 5931 of these ultimately excluded. We screened 259 results at the full-text level,
and excluded 203 of these records. We report on 55 records. Below we describe the results and key messages
for each of the prioritized component searches. Flowcharts for each component search are provided in Appendix
8. Evidence tables for included reviews are listed in Appendix 10.
1. CEC-type models
In the database searches, we retrieved 1758 citations, in addition to 12 citations obtained through the grey
literature search. Of these, 1723 were unique records. We excluded 1678 records through title and abstract
screening, leaving 45 records to review in full text. Of these, 32 citations were primary studies and 12 were grey
literature documents. All results did not meet the criteria of the appropriate exposure (being relevant to CECtype models). Data were extracted for one review; no records were suitable for inclusion in the data synthesis.
Key Messages
There is limited scientific literature on the concept of CEC-type models as a health care delivery model.
This is an area for future research studies.
2. Hours of access to health care services
In the database searches for hours of access to emergency services (full search strategy in Appendix 7), there
were 780 unique results, and 779 were excluded through title and abstract screening, leaving one record to
review in full text. This final record was excluded at the full text screen as it did not meet inclusion criteria. In the
database searches for hours of access to primary care (full search strategy in Appendix 7), there were 55 unique
results, and 45 were excluded through title and abstract screening due to not meeting inclusion criteria, leaving
10 records to review in full text.
Summary of reviews identified in the search: We identified two well-conducted systematic reviews related to
the impact of hours of health care service delivery on individual or community health outcomes (1, 2). Leibowitz
(2003) investigated evidence on the effect of different models of after-hours primary medical services on health
related (clinical outcomes, patient satisfaction) and health care process outcomes (medical workload) (2). This
systematic review included 19 studies of varying methodology (including four RCTs and two pseudo RCTS, and
comparative or case studies representing adult patients seeking care after primary care hours).
Carret and Domingues (2009) assessed factors, including hours of primary care services available, associated
with inappropriate ED resource use (1). This systematic review from 2009 included one cohort, two case-control,
and 19 cross-sectional studies that addressed this issue.
Summary of the research evidence: Overall these reviews reported neutral findings with respect to the impact
of hours of services on health (Leibowitz 2003) and resource (Carret 2009) outcomes. There has been little
benefit found from adding alternative models of after-hours care.
15
Leibowitz (2003) reported that there is very little evidence about
All 12 Canadian CEC-type centres
the advantages of one service model compared with another in
consulted reported having standard
relation to clinical outcomes. The only area where there is some
daytime hours for primary care (usually
limited evidence is about differences in prescribing habits. The
9-5). The hours in which urgent and
evidence suggests that deputizing doctors (see Glossary) may
emergent care are provided varies
prescribe less appropriately than doctors from practice-based or
considerably between all centres: 24/7
co-operative services, and that GPs prescribe more
on-call service, 24 hour care, extended
appropriately than junior emergency medical staff. Telephone
hours and standard daytime hours.
triage and advice services appear to reduce medical workload
through the substitution of telephone consultations for inperson consultations and have the potential to reduce costs.
This should be balanced with the finding of reduced patient satisfaction when in-person consultations are
replaced by telephone consultations (2).
Carret (2009) reported that two out of 22 studies included in their review found an association between difficult
access to primary health care and inappropriate ED use; the remaining studies did not assess this intervention.
An included cohort study conducted in the United States found that difficulty in scheduling a primary care
appointment, difficult telephone contact for primary care, and longer waiting time for a primary care
appointment were associated with inappropriate ED use (1).
Limitations of the evidence available: No evidence from systematic reviews was found regarding the impact of
(more or less) emergency service hours on health outcomes. Relevant populations not represented in the
identified reviews include rural emergency settings and children; Leibowitz (2003) focused on a United Kingdom
health delivery model, in addition to considering types of organizational modes of delivery rather than the effect
of more or less hours of access to care (2). Limited information is available on hours of service, particularly as
relevant to CEC-type model of care delivery, and important clinical, safety, and resource use (e.g.,
workload/patient volumes, wait times, cost, and impact of ED service variables on primary care) outcomes are
not reported.
Key Messages
A lack of evidence is available on the impact of alternative models of after-hours care.
Telephone triage and advice lines appear to reduce medical workload, and have potential to reduce
costs, but need to be balanced against reduced patient satisfaction.
While ED overuse is associated with lack of hours of access to primary care, expanding these services
does not appear to have a major impact on reducing inappropriate ED use.
3. Health care professional staff available (emergency care)
In the database searches on health professional staff in emergency care (full search strategy in Appendix 7),
there were 495 unique results, and 449 were excluded through title and abstract screening due to inappropriate
setting or exposure. Forty-six records were reviewed in full text.
Summary of reviews identified in the search: We identified eight systematic reviews related to the topic of the
effect of health care professional staff available in an emergency care delivery environment on health outcomes
(3-10). They included novel medical and non-medical roles in the emergency care delivery settings. These
systematic reviews assessed a small number of RCTs, but mostly including lower levels of study designs. Four
systematic reviews investigated the effect of nurse practitioners (NPs) or NPs and other staff in the ED (Hoskins
2011; Wilson 2009; Kleinpell 2008; Carter 2007). These systematic reviews investigated studies conducted in
combined adult and paediatric populations (Hoskins 2011; Carter 2007), or in adult only (Wilson 2009)
populations (Kleinpell 2008 also included ICU, however we have focused on evidence from ED settings). Hoskins
(2011) examined the effect of Emergency Nurse Practitioners (ENPs), expanded-scope physiotherapists, and
16
emergency care practitioners in all emergency care settings. The other four systematic reviews each investigated
one of the following health professional roles/models: triage liaison physicians (Rowe 2011), pharmacists (Cohen
2009), physician assistants (Doan 2011), and multidisciplinary teams targeted toward frequent ED users (Althaus
2011).
Overall these systematic reviews reported (cautiously due to the low quality of included studies) positive effects
of alternative health professional staff in emergency settings based on patient satisfaction (Doan 2011; Hoskins
2011; Wilson 2009; Carter 2007) and competency with adequate training (Doan 2011; Kleinpell 2008; Carter
2007). There are, however, few well-conducted controlled studies available. It should be noted that many of the
studies compare to house staff and the UK model in which there is no attending physician in the ED; this is not
the same as the Canadian (or US) model or standard of care.
Summary of the research evidence:
NPs in the ED: Hoskins (2011) reported that 22 out of 23 studies found high levels of patient satisfaction with
non-medical roles in the ED. Patients seen by ENPs were more likely to seek follow up in primary care following
their initial visit to the ED (7).
Wilson (2009) reported that reducing the amount of medical officer time spent on specified presentations
improves patient access to interventions, reducing issues of ED overcrowding and improving patient satisfaction
with health service. Two studies reported that care provided by ENPs was effective in reducing waiting times for
treatment and overall length of stay (LOS) in the ED. Nine studies found no significant difference between the
effectiveness of ENP and junior doctors (10).
Carter (2007) reported that overall, NPs appear to be more expensive than residents, on a per patient basis. The
included studies factored in more than salary, although it is unknown whether training costs of residents were
included. The addition of an NP, whether in a minor injury unit in the ED or in a free standing unit, was shown to
reduce wait times. The included studies do not compare the addition of an NP with the addition of any other
staff (e.g., more residents, another attending physician or a physician assistant) (4).
Other non-medical staff/models: Rowe (2011) included two RCTs that found a significant 37 minute reduction in
mean ED LOS when comparing triage liaison physician (TLP) (See Glossary) intervention to nurse-led triage. Most
non-RCT studies reported statistically significant reductions in their individual estimates of ED LOS. One RCT
showed a significant 30 minute reduction in the mean time to
physician initial assessment associated with TLP presence when
Many of the consulted centres
compared
to nurse-led triage. Most non-RCTs also showed a
have emergency staff on call during
significant reduction in the indicator of patients leaving the ED
evening hours. In one Canadian CECwithout being seen; this was not significantly different in the
type centre consulted, there is a nurse
included RCT. Individual study results on 'leaving against medical
on site overnight with one
advice' were inconsistent (9).
administrative support staff, with a
physician and second nurse on call.
Cohen (2009) found one observational study reporting that a
Three Canadian CEC-type centres
pharmacist in the ED reduces medication errors, provides complete
consulted have only on-call staff – one
medication and immunization histories, and potentially avoids
has a nurse practitioner on call, while
costs. Services provided by pharmacists in the ED in this study
the other two have nurses on call.
included traditional clinical pharmacy services, medical emergency
response, and providing consultations on medication issues (5).
Limitations of the evidence available: Many reviews that we identified were based on studies of low level
design. Relevant populations not represented in the identified reviews include rural emergency settings and
patients with emergency/life-threatening illness. Some important health professional groups, such as
paramedics, were not included in the systematic reviews. Provider satisfaction was not measured by included
studies and cost/resource use was not adequately assessed. The studies that were included in the reviews were
17
heterogeneous because of differing triage scoring systems, diagnostic categories used in EDs, and scope of
interventions; most studies focused on minor injuries. When a comparison was provided, care was often
compared to that provided by medical trainees (house officers or residents), not to attending staff physicians.
Key Messages
Patients accept and are satisfied with the care provided by NPs and physician assistants in the ED.
Additional patient contact time afforded by the alternative ED staffing is associated with improved
communication and increased health promotion.
Shorter length of stay may be associated with greater patient satisfaction.
The quality of care provided by NPs and physician assistants vs. residents in the ED is comparable.
Case management may reduce ED use for specific groups of vulnerable patients and also for all frequent
users of EDs.
Financial implications of staff changes might be significantly different in Canada (evaluation data is
inadequate).
Data from systematic reviews on other health professionals in these roles is lacking.
4. Health care professional staff available (primary care)
In the database searches for health professional staff available in primary care (full search strategy in Appendix
7), there were 1052 unique results, and 974 were excluded through title and abstract screening due to
inappropriate setting or exposure, leaving 78 records to review in full text. Of these 78, 48 were systematic
reviews.
Summary of reviews identified in the search: Twelve systematic reviews evaluated the effect of different
primary care staff on health outcomes (11-22). Reviews assessed the effectiveness of including specific staff in
the fields of: 1. General primary care, 2. Mental health, and 3. Various other primary care populations (diabetes,
midwifery, heart failure patients, hypertension).
Five reviews assessed models of primary care where nurses substituted or led care on health, process, and cost
outcomes. These reviews mainly considered the use of NPs in doctor substitute roles in three overlapping
reviews (overlapping reviews include some of the same studies, and the more recent review includes previous
ones within its synthesis) (Hollinghurst 2006; Horrocks 2002; Brown 1995); while two overlapping reviews (one
Cochrane Review [Laurant 2005] and one systematic review [Keleher 2009]) broadened their scope to include
nurses in general, considering varying levels of training and experience.
Four reviews considered the addition of mental health care staff to primary care on health, process, and cost
outcomes. Two reviews (one Cochrane Review [Harkness 2009] and one systematic review [Bower 2000])
considered the addition of mental health care professional delivery of care on-site in a primary care
environment. One Cochrane Review considered the addition of paraprofessionals (den Boer 2005) while one
review assessed the evidence on the addition of pharmacists providing prescription information and patient
education for the management of depression in a primary care setting (Gilbody 2003).
Finally, three systematic reviews were identified that explored the addition of specific staff to narrower
populations. One Cochrane Review looked at the evidence on the effect of diabetes specialist nurses compared
with usual care in hospital clinics or primary care for children and adults with diabetes (Loveman 2003). One
review considered the addition of pharmacists (Koshman 2008) in the management of heart failure patients on
health outcomes. The last systematic review evaluated the effect of nurse- or pharmacist-led care for patients
with essential hypertension in a primary care, outpatient, or community care setting (Fahey 2005).
18
NPs as doctor substitute: Two overlapping reviews, Horrocks (2002) and Brown (1995), the former including 11
RCTs and 23 observational studies with a prospective experimental design (22), and the latter with 38 studies
(12 RCTs) (13), evaluated NPs as substitutes for physician-led care. Both reviews reported neutral and positive
health outcomes. NPs ordered slightly more laboratory tests than did physicians. NPs received higher patient
satisfaction scores. There was no difference on quality of care, prescription drugs, functional status, number of
visits per patients, or use of emergency departments. NPs made more complete records, scored better on
communication than doctors and offered more advice on self-care and management (13, 22). Hollinghurst
(2006), in a meta-analysis, considered the addition of an extra salaried GP or NP to deal with excess patient
demand in primary care, and included two RCTs (based on the results and an updated search of the systematic
review strategy by Horrocks 2002), reporting negative results, concluding that employing NPs to provide firstline care and deal with excess patient demand in UK general practice is likely to cost the same or slightly more
than employing GPs (21).
Nurses as doctor substitutes: Keleher (2009) evaluated two systematic reviews (including the Cochrane Review
by Laurant [2005]), six RCTs, and one randomized controlled crossover trial. Compared to doctor-led care, nurseled care resulted in neutral results for patient mortality and quality of life (QOL), but positive outcomes for
compliance with medication or care, patient knowledge and patient satisfaction (17).
Mental health care professionals in primary care on-site setting: Harkness (2009), a Cochrane Review, in addition
to a previous systematic review (Bower 2000), considered the impact of the addition of on-site mental health
workers (MHWs) delivering psychological therapy and psychosocial interventions in primary care on process
outcomes. The evidence provides support for MHWs providing psychological therapy and psychosocial
interventions on-site in primary care that modestly but significantly reduces consultation rates, psychotropic
prescribing, prescribing costs, and rates of mental health referrals. There is evidence that on-site MHWs do not
impact prescribing behaviour with regard to the wider practice population. However, evidence does not support
the addition of MHWs to primary care teams with the aim of reducing demand on primary care providers (PCPs)
or achieving enduring changes in their clinical behaviour which will generalise to the wider practice population
(12, 16).
Paraprofessionals in primary care: One Cochrane Review (den Boer 2005) considered the addition of
paraprofessionals on health outcomes. This review included five RCTs involving the use of paraprofessionalperformed psychological treatment of anxiety and depressive disorders for adults compared to psychological
treatment by professionals, or no treatment. No conclusions about the effect of paraprofessionals compared to
professionals could be made. Three studies in female-only populations indicated a significant effect for
paraprofessionals compared to no treatment (11).
One novel health care provider
Pharmacists and depression management: Gilbody (2003)
discussed in one Canadian CEC-type
considered 36 studies (29 randomized and non-randomized
centre consulted is that of a
controlled trials, five controlled before and after studies and two
paramedic working in the primary care
interrupted time series studies) assessing the impact of the addition
setting. Paramedics in primary care
of pharmacists providing prescribing information and patient
conduct patient assessments, drawing
education for the management of depression in a primary care
blood for lab tests, and suturing. At
setting on health outcomes. Clinician education on medication
other times, the centre would be
provided by expert pharmacists resulted in significantly improved
staffed with an NP or nurse (92).
prescribing of antidepressants among patients older than 60 years
(15).
Diabetes specialist nurses: Loveman (2003) a Cochrane Review, considered evidence from six RCTs and
controlled clinical trials, assessing the impact of diabetes specialist nurses compared with usual primary care in
hospital clinics or primary care with no specialist nursing input for both children and adults with diabetes. The
19
evidence was neutral, finding no significant results on the effects of a diabetes specialist nurse/nurse casemanager on patient health outcomes (20).
Heart failure care: Koshman (2008) considered four RCTs examining the effect of adding pharmacists in
managing heart failure patients on health outcomes. Pharmacist care was shown to reduce the rates of both allcause hospitalization and heart failure hospitalization by almost one-third. There was no significant reduction in
mortality with the addition of pharmacist care (18).
Hypertension care: Fahey (2005) included seven RCTs assessing the impact of nurse- or pharmacist-led care for
patients with essential hypertension in a primary care, outpatient or community care setting on health
outcomes. These RCTs were significantly heterogeneous and did not allow for a pooled estimate to be
calculated; individually most RCTs found favourable results showing improved control of blood pressure through
nurse- or pharmacist-led care (14).
Limitations: Reviews did not distinguish between training and roles
held by NPs compared to nurses. The characteristics of nurses and
doctors (numbers, training, experience) are often not consistently
reported in studies.
In general, the current evidence is limited by the quality of the
included studies, in particular, poor methodological rigor,
heterogeneous findings among studies, and limited generalizability
to the Nova Scotia setting. In addition, there is a lack of evidence
considering the addition of health care staff other than mental
health specialists, pharmacists, nurses, or NPs in alternative
primary care staffing models. Evidence is also lacking in costeffectiveness analyses and examination of long-term effects of
these alternative staffing models.
There is a high level of variety in
terms of the staffing models in both
primary and emergency care in CEC-type
centres based on available evidence for
all 12 Canadian CEC-type centres
consulted. Specific roles of each staff
member within the model of care were
rarely discussed. Similar to peer-reviewed
evidence, there is inconsistency in the
language used to describe nursing staff
roles.
Key Messages
NPs in primary care as substitutes in the same role as GPs have been shown to have no difference in care
and improvement in patient compliance, knowledge, or satisfaction.
Evidence is lacking for cost-effectiveness analyses and examination of long-term effects of the addition of
health care professional staff in primary care; the few cost studies available suggest similar or increased
costs with NP compared to extra salaried GPs.
Nurse- and pharmacist-led care for hypertension was found to be effective for hypertension and heart
failure. Specialist nurse care in treating diabetes resulted in neutral outcomes.
There is modest evidence to support the addition of pharmacists, paraprofessionals and mental health
care workers in primary care settings for mental health.
Characteristics of health care providers, including training and experience, should be reported more
consistently in studies.
5. Collaborative practices (primary or emergency care)
In the database searches for collaborative practices (full search strategy in Appendix 7), there were 1521 unique
results, and 1394 were excluded through title and abstract screening, leaving 127 records to review in full text.
Of these 127, 69 were reviews. Fifty-one of these were excluded due to inappropriate exposure or setting.
Summary of reviews identified in the search: A large amount of literature is available on collaborative practices,
although limited in scope. We identified a total of 18 systematic reviews that assessed the effectiveness of
collaborative models of care (23-40). Nine systematic reviews assessed the team-based models of collaborative
care in: 1. ED, and 2. Primary care (mental health and other chronic diseases). Systematic review definitions of
20
collaborative care ranged from broad (e.g., multiple professionals involved) to more specific (e.g., multifaceted
intervention involving combinations of three distinct professionals working collaboratively within the primary
care setting: a case manager, a primary care practitioner, and a mental health specialist [to be included in the
review, studies had to involve two of these three
components of collaborative care]). Collaborative care
While the value of collaborative
was most commonly defined by the number of health
practice is often voiced, the scope of
professional disciplines involved in patient care (e.g., ≥2
collaboration used in most of the Canadian
[van Steenbergen-Weijenburg 2010] or ≥3 professionals
CEC-type centres consulted was not clearly
[Gilbody 2006]).
discussed in literature resources.
One systematic review assessed the evidence of
collaborative care in the ED (Kilner 2010). Five systematic
reviews assessed the effect of collaborative care in managing mental health conditions in primary care or
community settings (e.g., major depressive disorder [van Steenbergen-Weijenburg 2010; Gilbody 2006], or other
serious mental health diagnoses [Malone 2007 (Cochrane Review); Simmonds 2001; Tyrer 2000]). Three reviews
addressed treatment of other chronic conditions: hypertension (Carter 2009), heart failure (Holland 2005), and
the elderly (Johansson 2010) in the primary care or community setting.
An additional six systematic reviews assessed the effect of specialist-GP collaborative consultation on health
related outcomes. These reviews focused on the effect of specialist consultation in primary care management of
the following chronic health conditions: depression (Cape 2010; Chang-Quan 2009), stroke care (Mitchell 2008),
and broad chronic disease management (Foy 2010; Smith 2007/Smith 2008 [a Cochrane Review]; Mitchell 2002).
Collaborative care in these systematic reviews included simple (single interaction or intervention with health
professionals) or multifaceted (multiple features) interventions.
Three systematic reviews were identified that explored specific components of collaborative care models that
were likely to be effective (Butler 2011; Bower 2006), and evidence on intervention strategies to improve
collaboration (Zwarenstein 2009 [Cochrane Review]).
Collaborative team-based care (ED): Kilner (2009) included 14 observational studies (five controlled before and
after studies, five descriptive case studies, four descriptive cross-sectional studies), focused specifically on
physiotherapy practice. There is low quality evidence that the introduction of multidisciplinary teams to the ED
may be successful in reducing access block, and physiotherapists
Three of the Canadian CEC-type
may play a role in this; teamwork and communication are
centres consulted reported great
paramount but remain difficult to quantify. There is very limited
value in collaboration between staff,
evidence regarding teamwork and communication in the ED. The
administration and support systems
evidence available is limited by the lack of experimental studies
outside the physical health centre.
(32).
One of the consulted centres voiced
Collaborative team-based care (primary care, mental health):
the importance of providing
Gilbody (2006) included 37 RCTs that assessed the effect of
integrated and collaborative team
multifaceted collaborative care on health outcomes for those with
care to patients by the appropriate
depression (29), and van Steenbergen-Weijenburg (2010) assessed
provider in the appropriate setting in
the cost-effectiveness for management of depression (39). Study
an appropriate time and at an
results
provide evidence that collaborative care is effective in
appropriate type and format of
improving short-term depression outcomes and demonstrate
intervention for their needs (93).
emerging evidence of longer-term benefit (health outcomes
maintained at 12 months). Economic information, however, is
insufficient for policy decisions. Studies found that the overall cost of collaborative care is often more expensive
than usual care but these studies did not conduct cost-effectiveness analyses (29, 39).
21
Three overlapping reviews, a Cochrane Review by Malone (2007), one by Simmonds (2001) and a Cochrane
Review by Tyrer (2000), each including RCTs, assessed Community Mental Health Teams (CMHT) in the
management of adults with severe mental illness (most commonly schizophrenia). These reviews found that
CMHT management was associated with no significant differences in death from any cause including suicide and
suspicious circumstances. CMHT management was significantly associated with treatment acceptance,
satisfaction with care, and avoidance of hospital admission. There was suggestion that CMHT management leads
to a reduction in direct medical costs but further synthesis was not possible (33, 36, 38).
Collaborative team-based care (primary care, other chronic conditions): Carter (2009) included 37 controlled
studies of interventions involving pharmacists or nurses in the management of hypertension. They found that
these models were significantly associated with improved blood pressure. The authors note that their analysis
could not determine whether there was a preferred level of training or qualification (26). Holland (2005)
included 30 RCTs investigating the impact of multidisciplinary teams in the management of heart failure. They
found that these teams reduce both hospital admission and all-cause mortality, with the most effective
interventions having a home-care delivery component. Johansson (2010) included five RCTs and examined the
impact of multidisciplinary teamwork working with elderly persons living in the community. They concluded that
the intervention was successful in reducing deterioration of health and functional ability, improving activities in
daily living, increasing social activity and general well-being and life satisfaction (30).
GP-specialist consultation models: Seven systematic reviews assessed the effect of shared GP-specialist
consultation across a range of chronic health conditions: depression (Cape 2010; Chang-Quan 2009), stroke
(Mitchell 2008), and mixed chronic conditions (Foy 2010; Smith 2007/Smith 2008; Mitchell 2002,). These
systematic reviews present conflicting information with limited evidence of improved depressive symptoms (Foy
2010; Chang-Quan 2009), and improved patient satisfaction (Mitchell 2002). Smith (2007/2008), a Cochrane
Review, included 19 RCTs and one controlled before and after study of shared-care health service interventions
designed to improve the management of chronic disease; they found no consistent improvements in health
outcomes. GP-specialist consultation models were consistently found to cost more than usual care (Chang-Quan
2009; Smith 2007/Smith 2008; Mitchell 2002).
Mechanism(s) of effective collaborative care: Two systematic
When dealing with an alternative
reviews, Butler (2011), Bower (2006), and a Cochrane Review by
service model, one Canadian CEC-type
Zwarenstein (2009) explored different approaches to improve
centre consulted stated that it is
collaborative practice. Zwarenstein (2009) included results from
important to be aware of the different
five RCTs and found inter-professional interventions (e.g.,
scope of practice of each team member
interdisciplinary rounds, multidisciplinary team meetings, video
and to allow each to work to their full
conferencing compared to audio-conferencing, multidisciplinary
capacity.
meetings with an external facilitator) can improve health care
processes and outcomes, although generalizable inferences
about key elements of inter-professional care are difficult (40). Bower (2006) used meta-regression analysis
including data from 37 studies to identify active ingredients in collaborative care models for addressing
depression in a primary care setting. They found no significant predictors of the effect of collaborative care on
antidepressant use. Key predictors of depressive symptoms included systematic identification of patients,
professional background of staff and specialist supervision (23). Butler (2011) reviewed 26 controlled/quasiexperimental studies exploring level of integration of provider roles. They found no correlation between the
outcomes and the extent of clinician integration or the implementation of structured processes of care, nor was
there evidence that more intensive intervention in both areas produced better results for people with
depression (24).
Limitations of evidence available: These reviews do not have broad generalizability to the whole primary care
field, as most have a narrow focus on chronic health conditions. Collaborative practice is broadly defined in the
literature and results are heterogeneous. Most reviews examined studies of low quality which further limits the
22
generalizability of our results. Only one review of low quality studies was relevant to collaborative practices in
emergency settings. Few studies considered cost and resource use outcomes.
Key Messages
Collaborative care (multidisciplinary models) in primary care settings has been shown to consistently
improve symptoms and management of chronic disease (depression, hypertension).
Collaborative care has been consistently found to be more expensive than usual care (other than
Community Mental Health Teams); although additional high quality economic evaluations are required.
The introduction of multidisciplinary teams to the ED may be successful in improving access, however,
more research is needed.
No consistent improvements in health outcomes were observed in many studies examining shared GPspecialist consultation in primary care management of chronic health conditions.
Generalizability to the Nova Scotia CEC model is limited as these collaborative models focus on physician
collaboration with either another physician or an allied health professional, and do not examine the idea
of two non-physicians working collaboratively.
6. Tele-Consultation/Telehealth
We identified a review of reviews of good quality on the topic of telehealth published before 2009 (41). We
conducted searches to locate reviews published after 2009 (full search strategy in Appendix 7). There were 663
unique results from the database searches, and 612 were excluded through title and abstract screening because
they did not meet inclusion criteria for setting or exposure. Fifty-one records were reviewed in full text. Of these
51, 27 were systematic reviews published after 2009 and of these 14 met inclusion criteria in the data synthesis.
Summary of reviews identified in the search: In addition to one review of reviews considering reviews published
before 2009, we identified 14 systematic reviews published after 2009 (42-55). These systematic reviews
assessed the effectiveness of telehealth in: 1. Off-site consultation, 2. Mechanisms for off-site communication,
and 3. Off-site health care delivery. We identified four recent systematic reviews related to the topic of off-site
consultation for health care delivery. These studies focus on medical fields, including telehealth consultations for
acute stroke management for patients in rural hospitals (Johansson 2010), patients in ICUs (Young 2011), and
dermatology (Warshaw 2011; van der Heijden 2010).
Three recent systematic reviews related to the evaluation of different
Tele-consultation
mechanisms for off-site communication (Verhoeven 2010; Wade 2010; Krishna
and telehealth methods
2009). Verhoeven (2010) evaluated synchronous and asynchronous telewere not reported for five
consultation for diabetes care compared to usual care. Wade (2010) focused
of the 12 Canadian CECon the cost outcomes of using synchronic video technology in dermatology,
type centres consulted.
mental health, paediatric cardiology, home nursing, intensive care, emergency
medicine, neurology, infectious diseases, internal medicine, general practice,
cardiology, oncology, pain management, and four surgical disciplines (ear nose and throat surgery, orthopaedics,
gynaecology, and neurosurgery). Krishna (2009) focused on the use of cell phones and text messaging
interventions for the delivery of health information or educational intervention on health and process
outcomes.
Nine recent systematic reviews were identified relating to off-site health care delivery, where patients call or
connect via web to consult with health care providers directly. Studies focused on a variety of health care fields,
including mental health (Garcia-Lizana 2010; Griffiths 2010; Luxton 2010), diabetes and chronic diseases
(McLean 2010; Polisena 2009a; Polisena 2009b), hearing loss (Swanepoel 2010), and the review of reviews
including a population with various clinical conditions (Ekeland 2010).
23
Off-site consultation
Stroke management: The systematic review conducted by Johansson (2010) included 18 studies: two RCTs, one
clinical controlled trial, and 15 studies with an observational design. They reported positive findings on health
and process outcomes such as improved quality of care and reduced mortality. Neutral findings with respect to
the impact of off-site (telemedicine systems) consultation for health care delivery in acute stroke management
were found. The review stated that telemedicine technologies (telephone-based or real-time video consultation
system) are safe and feasible in acute stroke management and are useful for support in areas with insufficient
neurological services. There are, however, few economic studies on telemedicine so more research is needed on
the clinical and economic impact of telemedicine in stroke management (45).
Intensive Care Units: The systematic review conducted by
Young (2010) included 13 controlled before and after studies
involving 35 ICUs. They investigated the impact of
telemedicine applied to hospital critical care units, including
any telecommunication system installed in the ICU to
facilitate real-time access to critical care specialists (e.g.,
critical care nurses) located elsewhere. The health related
outcomes of interest were: ICU mortality, ICU LOS, in-hospital
mortality, in-hospital LOS. They reported mixed findings on
health outcomes with respect to the application of telehealth
for off-site consultation in intensive care units. They found
that due to the significant resources required for tele-ICU
implementation, further evaluation is needed. Tele-ICU
coverage is associated with a significantly lower ICU mortality
and LOS but not lower in-hospital mortality or hospital LOS
(55).
Tele-dermatology: Overall, mixed findings with respect to the
impact of off-site consultation for tele-dermatology on health
and process outcomes were found, but there were positive
results for cost outcomes (Warshaw 2011; van der Heijden
2010).
Off-site consultation or teleconsultations to referral hospitals for
emergency and specialist opinions were
commonplace. Telephone and videomechanism were the only two
mechanisms discussed. One Canadian
CEC-type centres consulted stated
preference for telephone as a mechanism
for communication: while having
advanced technology to consult with
doctors, surgeons and specialists via
videoconferencing, it is often challenging
to get specialists to leave their busy
workdays to go into a separate room to
discuss with members at the centre.
Often it is much easier to have a phone
conversation, relaying important
information to ensure thorough
understanding of a situation.
Van der Heijden (2010) assessed the use of telehealth for tertiary tele-dermatology on health, process, and cost
outcomes. The systematic review included 11 studies: five observational/descriptive, six analytic, and one
controlled trial. The review concluded that tertiary tele-dermatology research is still in early development. The
authors suggest that future research should focus on identifying the scale of tertiary tele-dermatology and on
what modality of tele-dermatology is most suited for communication among dermatologists. Rigorous studies
evaluating the benefits of tertiary tele-dermatology are lacking (44).
Warshaw (2011) investigated the effect of store and forward (SAF) and live interactive (LI) technology for teledermatology on diagnostic and management accuracy and concordance, clinical outcomes and costs. The
number of studies included in this review is unclear. They concluded that there was insufficient evidence to
determine whether tele-dermatology had an effect on clinical course. Clinic dermatology was superior to teledermatology for diagnostic accuracy and equivalent within 10% for management accuracy. It should be noted
that both SAF and LI tele-dermatology had acceptable diagnostic accuracy and concordance. Clinic dermatology
was superior to both tele-dermatology and tele-dermatoscopy for malignant and premalignant lesion rates,
warranting caution in using tele-dermatology in these cases. Cost studies were limited by variations in
parameters included and perspectives chosen for the analyses. The majority of studies found SAF and LI tele-
24
dermatology to be cost-effective if certain critical assumptions about patient travel distance, tele-dermatology
volume, and costs of clinic dermatology were met (54).
Mechanisms for off-site communication
Summary of the research evidence: Three systematic reviews reported mixed findings on health, process and
cost outcomes, with respect to the impact of synchronous real time video and asynchronous mechanisms for
off-site consultation (Verhoeven 2010; Krishna 2009), and mixed findings regarding cost outcomes (Verhoeven
2010, Wade 2010).
Verhoeven (2010) evaluated 90 studies including 28 RCTs, 48 observational studies, eight quasi-experimental
studies, four cohort studies, and two studies based on expert interviews. They concluded that both synchronous
and asynchronous tele-consultations for diabetes care are feasible, cost-effective, and reliable. Asynchronous
and synchronous applications appeared to differ in the type of contribution they made to diabetes care
compared to usual care: asynchronous applications were more successful in improving clinical values and selfcare, whereas synchronous applications led to relatively high usability of technology, cost reduction in terms of
lower travel costs for both patients and care providers, and reduced unscheduled visits compared to usual care.
Future research needs quasi-experimental study designs and a holistic approach that focuses on multilevel
determinants (clinical, behavioral, and care coordination) to promote self-care and proactive collaborations
between health care professionals and patients to manage diabetes care. Krishna (2009), with 20 RCTs and five
CCTs, concluded that information and educational interventions delivered through wireless mobile technology
resulted in both clinical and process improvements in the majority of studies included. Health care requiring
regular management such as for chronic disease or ongoing advice and support such as smoking cessation
benefited the most from cell phone interventions (52).
Wade (2010) assessed the economic value of synchronous or real time video communication for telehealth. This
systematic review included 36 articles: 18 RCTs, six diagnostic test accuracy, five controlled before and after
studies, two prospective case-controls, two retrospective cohorts, and one each of non-randomized controlled
trial, prospective cohort and economic modelling studies. They reported mixed findings with respect to the
impact of the mechanism of synchronous communication for telehealth on cost. They concluded that
synchronous video delivery is cost-effective for home care, on-call specialists, and potentially cost-effective for
regional and rural care depending upon the circumstances of the service. It is not cost-effective, however, from
the health services perspective, for local delivery of service between hospital specialists and primary care,
particularly due to additional health care staffing. These authors suggest improvement in the quality of
economic analyses is needed to provide data for more accurate modelling of the effects of widespread
introduction of telehealth into the health care system (53).
Off-site health care delivery
Mental health: Three systematic reviews reported mixed findings with respect to the impact of telehealth for
patients with mental health conditions and consultation with health care providers on health outcomes
(symptom management [Garcia-Lizana 2010, Griffiths 2010]) and process outcomes (safety for clinically
unsupervised settings [Luxton 2010]).
The review by Garcia-Lizana (2010) evaluated technology for depression management and included 10 RCTs. A
majority of included studies found no significant difference for evaluating depression symptoms, patient
satisfaction, or QOL, when compared to control. The review reported insufficient evidence regarding the
effectiveness of information and communication technology use in the management of depression and
recommended further research (42).
Griffiths’ review (2010) on preventive and treatment Internet interventions for depression and anxiety disorders
considered 26 RCTs. The review demonstrates that the Internet can be an effective medium for the delivery of
25
interventions designed to reduce the symptoms of depression and anxiety conditions (43).
Luxton (2010) provided some evidence that tele-mental health services delivered to clinically unsupervised
settings can be safely managed. They considered nine studies: six RCTs, one case-study and two non-randomized
controlled trials. The authors reported that the limited data and low count of peer-reviewed studies, however,
limit the ability to make generalized conclusions about the safety of these treatments (47).
Chronic disease management: Three systematic reviews reported neutral to positive findings with respect to the
impact of telehealth for patients with chronic disease consultations with health care providers on health
outcomes (McLean 2010; Polisena 2009b) and cost outcomes (Polisena 2009a; Polisena 2009b).
Polisena (2009a) evaluated the cost-effectiveness of home telehealth for chronic diseases and concluded that
most of the 22 studies (14 RCTs, four case control studies, four pre-post studies) found home telehealth to be
cost saving from both health care system and insurance provider perspectives. Study heterogeneity was
observed due to diverse study populations, interventions, and the health care systems in which they were
based. Economic evaluations were based on studies of poor quality so authors were unable to make informed
decisions on resource allocation (49).
Polisena (2009b) examined home telehealth compared with
usual care for patients with diabetes, by considering 21
studies: 12 RCTs and nine observational studies. The review
concluded that home telehealth interventions were similar or
favourable compared to usual care in terms of QOL, patient
satisfaction, adherence to treatment or compliance. In general,
home telehealth had a positive impact on the use of numerous
health services and glycaemic control. The authors reported
that more studies of higher methodological quality are
required to give more precise insights into the potential clinical
effectiveness of home telehealth interventions (50).
One Canadian CEC-type site
consulted used telehealth for nutrition
and mental health appointments. Other
sites mentioned the use of telehealth for
service provision, but did not clarify for
which services. Another Canadian CECtype centre consulted stated that
telecommunication benefited the health
centre by avoiding unnecessary longdistance travel for patients (94).
McLean (2010) considered 21 RCTs published across 25 reports studying the use of telehealth interventions for
treatment of asthma. They found no evidence of a clinically important impact on patients’ QOL or the number of
visits to the ED over 12 months. With that said, telehealth care is no worse than usual care in its ability to
improve QOL. There was a significant reduction in the number of patients admitted to hospital once or more
over 12 months, especially for patients with severe asthma. It may, therefore, be useful to consider focusing
certain telehealth interventions on groups with higher risk of complications from their asthma (48).
Audiology: Swanepoel (2010) included 26 articles (mostly case reports), and focused on the impact of
synchronous and asynchronous audiological services with a telehealth component on patient-clinician
perceptions. They found that several screening applications have demonstrated the feasibility, reliability, and
effectiveness of telehealth applications compared to conventional methods. The limited information available
on patient perceptions revealed mixed findings. The authors suggest that tele-audiology holds significant
promise in extending services to underserved communities but requires considerable empirical research to
inform future implementation (51).
Ekeland (2010) produced a review of systematic reviews published prior to 2009. Overall, 21 reviews found
telehealth effective, 19 reviews were less confident in the effectiveness of telemedicine, and 22 reviews
concluded that the evidence for the effectiveness of telemedicine is still limited and inconsistent. Despite the
large number of studies and systematic reviews on the effects of telemedicine, they reported that high quality
evidence to inform policy decisions on how best to use telemedicine in health care is still lacking; large studies
26
with rigorous designs are needed to get better evidence on the effects of telemedicine interventions on health,
satisfaction with care, and costs (41).
Limitations: The evidence on telehealth consultation involves a lack of representation of ED or primary care
services, with only a few studies considering alternative on-site providers such as nurses or paramedics. Most
studies included in the systematic reviews vary in quality; many are considered to be of poor quality due to small
sample sizes, lack of study information, and validity issues. Generalizability is a concern as many included studies
had heterogeneous results possibly due to diverse study populations, interventions, and the health care systems
in which they were based.
Key Messages:
Studies on telehealth are heterogeneous making it difficult to draw general conclusions from studies.
Despite a large number of studies and systematic reviews on the effectiveness of telemedicine, high
quality evidence is still lacking (mostly observational studies are available).
Reviews demonstrate that telehealth services do not appear to harm patients and are both reliable and
feasible in this limited assessment of non-emergency conditions.
The effect of tele-consultation on clinical outcomes is not clearly established (findings are mixed and
many studies show no difference from usual care).
Studies of telehealth for service provision in chronic/mental health conditions report neutral to positive
findings.
Few studies examine the cost effectiveness of tele-consultation.
7. Diagnostic services available (primary or emergency care)
No clearly relevant systematic reviews on the topic of the effect of having a comprehensive set of diagnostic
services available in emergency health care delivery or primary health care were identified through a further
scoping search. There is a large amount of literature available on the subject of the effect of specific diagnostic
services in various health care settings, but no review was identified that included studies on a complete set of
diagnostic services.
Based on the literature regarding select Canadian CEC-type centres, the most common diagnostic services
available in select CEC-like centres were: blood work (stated for seven of the Canadian CEC-type centres
consulted) and medical imaging (x-ray was mentioned for eight Canadian CEC-type centres consulted, and
ultrasound services were mentioned by two consulted centres). Two consulted centres explicitly mentioned onsite laboratories. Two centres mentioned electrocardiograms (ECGs).
Non-Prioritized Searches
8. Structure of emergency services
A 2011 systematic review by Harding, Taylor, and Leggott (56) assessed the available evidence on the question,
‘Do triage systems across a broad spectrum of health services affect patient flow?’ Three RCTs were included
among a total of 25 included studies, the r emainder being non-randomized trials or observational studies.
In the review, participants were patients triaged across a broad range of health services. Interventions were
systems that ranked patients in order of priority or sorted patients for the most appropriate service, compared
to no triage or informal triage, no management of patients at point of basic triage, or systems with options for
providing simple treatment or management at the point of triage. Outcomes were related to patient flow (e.g.,
waiting times, effect on waiting lists, LOS).
27
This review included studies from around the world, though the language was limited to English. The authors
concluded that “Moderate evidence exists from a range of health
services that the ability to combine triage and initial treatment in less
Structure of emergency
resource intensive cases can have a positive effect on patient flow.
services was not explicitly
There is conflicting evidence that triage systems that only prioritise
disclosed for any of the 12
patients, without providing any treatment, improve overall patient flow,
Canadian CEC-type centres
although tailoring triage criteria more specifically to the patient
consulted.
population or using triage to prioritise treatable cases may be of
benefit” (p. 371).
9.
Structure of primary care services
A 2011 systematic review by Rose, Ross, and Horwitz (57) assessed the available evidence in order to “describe
patient and physician and/or practice outcomes resulting from implementation of advanced access scheduling in
the primary care setting” (p. 1150). One RCT was included among a total of 24 eligible studies, the remainder
being cross-sectional, controlled or uncontrolled before and after design.
Few centres had explicit
information regarding their structure
of primary care services (while all
centres had primary care services
available). Two Canadian CEC-type
centres consulted stated having family
practice available, while two other
Canadian CEC-type centres consulted
mentioned having a walk-in or
outpatient form of primary care
available. One Canadian CEC-type
centre consulted had prioritized
appointments for patients without a
family doctor, while the Family Health
department of one Canadian CEC-type
centre consulted dedicates half its
time to target population clients (95).
In the review, participants were primary care patients and the
intervention was advanced access scheduling compared to no
advanced access scheduling. Outcomes included patient
satisfaction, wait time for an appointment, no-show rates for
appointments, and outcomes related to presenting to the ED.
The studies identified mostly originated from the US, with two from
the UK, and only English language studies were included. The
authors note that all studies had at least one source of potential
bias. The eight studies evaluating time to third-next-available
appointment showed reductions (range of decrease: 1.1-32 days),
but only two achieved a third-next-available appointment in less
than 48 hours (25%). No-show rates improved only in practices with
baseline no-show rates higher than 15%. Effects on patient
satisfaction were variable. Limited data addressed clinical
outcomes and loss to follow-up. The authors concluded that
“Studies of advanced access support benefits to wait time and noshow rate. However, effects on patient satisfaction were mixed,
and data about clinical outcomes and loss to follow-up were
lacking” (p. 1150).
10. Emergency protocols or use of standing orders in emergency health care delivery
A 2009 summary by Agrawal and Kosowsky (58) was identified on the subject of ‘Clinical practice guidelines in
the emergency department’ in the absence of any clearly relevant systematic reviews on the topic of the effect
of emergency protocols or the use of standing orders in emergency care delivery.
The goals of clinical practice guidelines, the authors note, are as follows:
Selecting the ‘‘best practice’’ when practice varies unnecessarily.
Defining standards for the expected length of hospital stay and for the use of tests and therapies.
Examining interactions between steps in a care algorithm to coordinate steps and decrease delay at the
rate-limiting step.
Providing a common pathway for all staff to view and understand their individual roles in the care
process.
Providing a framework for data collection to troubleshoot and improve efficiency in the pathway.
Decreasing documentation burdens.
28
Improving patient satisfaction through education about plan for care.
The summary concludes that “the use and sheer number of
clinical practice guidelines are proliferating at a rapid rate and
have become an important part of clinical practice in the ED
setting. The effective use of guidelines requires the
appropriate application of relevant decision trees, a critical
understanding of the clinical pathology and research
methodology involved, and acknowledgment of the reasons to
use the guidelines in the first place. Although these guidelines
have the potential for improving the standard of health care,
there are limitations in their use, and any clinician should be
cognizant of their potential medical, legal, and financial
implications. Overall, the need for quick decision making and
expeditious interventions make algorithms and pathways
invaluable in the ED setting” (p. 564).
There is a lack of readily available
information on the use of protocols or
standing orders for 11 of the 12
Canadian CEC-type centres consulted.
One of the Canadian CEC-type centres
consulted is currently developing
concrete protocols and guidelines based
on current practice, with challenges in
determining what to "package" as
transferable to other health centres, and
what is context specific.
11. Destination and transfer plan in emergency health care delivery to manage patients
No clearly relevant systematic reviews on the topic of the effect of using a destination and transfer plan in
emergency care delivery were identified.
There are a variety of transportation mechanisms discussed (ambulance, non-medical transfer, Medevac,
aero-transfer) and a range of higher level centres are also discussed at varying distances (secondary, tertiary).
Three Canadian CEC-type centres consulted mention by-pass protocols being in practice. One Canadian CECtype centre consulted stated that, although having the ability to stabilize and transfer, in emergency situations,
ambulance by-pass protocol (e.g., for trauma cases) is put into place, and patients would be sent to a higher
level centre.
12.
Levels of service infrastructure in emergency and primary health care delivery
A 2011 article by Wakerman and Humphreys (59) was
identified on the subject of ‘sustainable primary health
care services in rural and remote areas: Innovation and
evidence’ in the absence of any clearly relevant
systematic reviews on the topic of the effect of levels
of service infrastructure in emergency and primary
health care delivery.
Levels of service infrastructure vary
considerably between Canadian CEC-type centres
consulted. Five Canadian CEC-type centres
consulted did not have a clear description of their
infrastructure. Two Canadian CEC-type centres
consulted were built with the intent and purpose of
creating a CEC-type model. One Canadian CEC-type
centre consulted has housing for staff available near
the centre while three Canadian CEC-type centres
consulted were either co-located or adjacent to a
long term care facility.
Incorporating an unspecified number of reviews and
studies into what is essentially a scoping synthesis, the
authors note a number of infrastructure components
that influence a rural health centre’s ability to impact
health outcomes. The authors reported “There is a
strong history of primary health care innovation in
Australia. Successful health service models are ‘contextualised’ to address diverse conditions. They also require
systemic solutions, which address a range of interlinked factors such as governance, leadership and
management, adequate funding, infrastructure, service linkages and workforce. An effective systemic approach
relies on alignment of changes at the health service level with those in the external policy environment. Ideally,
every level of government or health authority needs to agree on policy and funding arrangements for optimal
service development. A systematic approach in addressing these health system requirements is also important.
29
Service providers, funders and consumers need to know what type and level of services they can reasonably
expect in different community contexts, but there are gaps in agreed indicators and benchmarks for primary
health care services. In order to be able to comprehensively monitor and evaluate services, as well as
benchmarks, we need adequate national information systems” (p. 118).
13.
Specific ambulatory clinic services available in primary health care delivery
No clearly relevant systematic reviews on the topic
of the effect of specific ambulatory services
available within primary health care were identified.
There is a large body of literature available on the
subject of the effect of specific ambulatory services
(some being explicitly related to primary care) and
practices on individual health outcomes, but no
review was identified that included studies on
ambulatory clinic services in primary health care,
specifically.
The scope of ambulatory services was
unknown for seven of the Canadian CEC-type
centres consulted. Select Canadian CEC-type
centres consulted listed specific ambulatory
services including radiotherapy and
chemotherapy, casting, IV, and blood
transfusions.
14. In-patient beds available within a community health centre
No clearly relevant systematic reviews on the topic of the effect of having in-patient beds available within a
community health centre were identified.
Little information regarding in-patient beds was available. One Canadian CEC-type centre consulted
has three holding beds, but patients are normally assessed, treated and discharged or transferred to a
secondary or tertiary care centre (96). Two Canadian CEC-type centres consulted, which both have long
term care facilities nearby, did not have in-patient beds on site.
15. Formal community health needs assessment for organizing health care services in a
community
No clearly relevant systematic reviews on the topic of the effect of a formal community health needs
assessment were identified.
For 10 of the 12 Canadian CEC-type centres consulted, it is unclear if a formal community health
needs assessment was undertaken.
One of the Canadian CEC-type centres consulted provided their health planning process (93). One
Canadian CEC-type centres consulted included a strategic planning team with regard to the planning of
the centre that was linked with the community advisory committee representatives (95).
16. Specific health promotion & prevention services available in primary health care delivery
A well-conducted 2007 systematic review by Wilhelmsson and Lindberg (60) assessed the available evidence on
‘Prevention and health promotion and evidence-based fields of nursing’. The goal of the review was “to
summarize evidence-based knowledge regarding prevention and health promotion and education that is
applicable to nurses in primary care” (p. 255). Fifteen studies were included along with 16 Cochrane Reviews. Of
the 15 original studies, six were RCTs, eight were before-after design, and one was a mixed RCT and before-after
design.
30
In Wilhelmsson and Lindberg (60), included studies used interventions involving
nurses conducting promotion or prevention activities compared with no
promotion or prevention activities. Outcome areas were related to alcohol
consumption, coronary heart disease, myocardial infarction, diabetes, smoking
cessation, breast feeding, fall prevention, asthma, and cardiovascular disease.
Health promotion
and prevention services of
varying scope were
available in all 12
Canadian CEC-type
centres consulted.
The included studies and reviews published in the English language came from
Western countries as specified in the inclusion criteria. The authors report that
“The main results from this systematic literature review are that few studies
were of high scientific quality, and that only limited areas are scientifically elucidated, relevant and applicable to
nurses in primary care with respect to prevention, health promotion and education" (p. 263).
“Further, there is also a lack of evaluated methods and methodology. […] Based on these facts, there is naturally
limited evidence regarding interventions in prevention, health promotion and education. A great deal of
preventive work by nurses in primary care is presumably ongoing, but both knowledge and tradition are lacking
with respect to evaluating and documenting scientifically. If this is the case, the consequence will be that limited
new knowledge will be generated in this area” (p. 263).
17. Specific governance structure for a community health centre
No clearly relevant systematic reviews on the topic of the effect of a specific governance structure for a
Nine of the health centres were governed by their local health authority. One Canadian CEC-type centre
consulted was governed by a hospital organization. It was not possible to determine the governance of two
other Canadian CEC-type centres consulted.
18. Formal program evaluation for a community health centre
No clearly relevant systematic reviews on the topic of the effect of having a formal program evaluation for a
Information on program evaluations was unavailable for eight Canadian CEC-type centres consulted.
Two of the Canadian CEC-type centres consulted discussed program evaluations at a centre level during the
early stages of program development. A publication by McKim (95), on the Northeast Community Health
Centre in Edmonton, Alberta stated that “an early enhancement was the identification of evaluation as a key
component for the success of the Centre, and a regional program evaluator was seconded to NECHC's planning
team”.
One of the Canadian CEC-type centres consulted mentioned the role of program evaluations at a health
authority level by using the principles of Continuous Quality Improvement (97).
The Health Council of Canada explicitly stated that no formal program evaluations of inter-professional primary
health care teams in Nunavut have been performed, and none is currently planned. Informally, however,
regional and community health centres have regular meetings to assess how well teams are functioning (98).
31
19. Program funding structure for a community health centre
No clearly relevant systematic reviews on the topic of the effect of having a specific program funding structure
for a community health centre were identified.
Funding model information for programs and centres is not readily available information, beyond press releases
regarding donations or government funding put forward to support certain centres (e.g., construction funding for
new health care facility put forward by provincial or federal government) (99).
20. Funding structure for health professionals at a community health centre
A well-conducted 2011 Cochrane Review by Scott (61) examined ‘The effect of financial incentives on the quality
of health care provided by primary care physicians’. This review subsumed and broadened the scope of two
earlier Cochrane Reviews (100, 101). Seven studies were included in the review, including three cluster RCTs,
two controlled before and after studies, one controlled interrupted time series study, and one uncontrolled
interrupted time series study.
In the Scott (61) review, participants were primary care
physicians and primary care teams. The intervention was the
impact of different financial interventions on the quality of
care delivery. Outcomes were quality of care related to
patients' health and well-being.
The authors concluded that: “The use of financial incentives to
reward PCPs for improving the quality of primary health care
services is growing. However, there is insufficient evidence to
support or not support the use of financial incentives to
improve the quality of primary health care” (p. 2). Scott note
that there is a large body of literature on the subject of how to
design and implement financial incentives, and that better use
should be made of the existing literature when primary health
centres are implementing incentives. The authors continue,
“studies should also examine the potential unintended
consequences of incentive schemes by having a stronger
theoretical basis, including a broader range of outcomes, and
conducting more extensive subgroup analyses. Studies should
more consistently describe i) the type of payment scheme at
baseline or in the control group, ii) how payments to medical
groups were used and distributed within the groups, and iii)
the size of the new payments as a percentage of total revenue.
Further research comparing the relative costs and effects of
financial incentives with other behaviour change interventions
is also required” (p. 2).
Staff funding models were not
readily available for Canadian CEC-type
centres consulted. Two Canadian CECtype centres briefly discussed funding
models.
One of the Canadian CEC-type centres
consulted stated that “Traditionally,
doctors have been paid a fee for each
patient visit, called fee-for-service. A new
payment method blends an annual fee
for each registered patient, based on a
patient’s age and health care needs. This
new system allows physicians at the clinic
to involve other health professionals in
care, and spend more time helping
patients manage complex and chronic
conditions" (102).
The Canadian CEC-type centre consulted
which has yet to open its doors stated
that: physician payments are [to be]
covered by agreements between Ministry
of Health & BC Medical Association. Nonphysician staff will be employees of the
centre (103).
A second systematic review was identified with a broader
scope than Scott (61), looking at ‘Financial incentives for return of service in underserved areas’ by Bärnighausen
and Bloom (62). This well-conducted review identified 43 observational studies.
Participants in the studies included in the Bärnighausen (62) review were health care providers in underserved
areas. The interventions were financial incentives. Outcomes were program results (descriptions of recruitment,
retention, and participant satisfaction), program effects (effectiveness in influencing health workers to provide
32
care, to remain, and to be satisfied with work and personal life in underserved areas), and program impacts
(effectiveness in influencing health systems and health outcomes).
The majority of the included studies were from the US, though authors did not place any geographic or language
restrictions on their search. The remaining studies came from Canada, Japan, New Zealand, and South Africa.
The authors concluded that: “Financial-incentive programs for return of service are one of the few health policy
interventions intended to improve the distribution of human resources for health on which substantial evidence
exists. However, the majority of studies are from the US, and only one study reports findings from a developing
country, limiting generalizability. The existing studies show that financial-incentive programs have placed
substantial numbers of health workers in underserved areas and that program participants are more likely than
non-participants to work in underserved areas in the long run, even though they are less likely to remain at the
site of original placement. As none of the existing studies can fully rule out that the observed differences
between participants and non-participants are due to selection effects, the evidence to date does not allow the
inference that the programs have caused increases in the supply of health workers to underserved areas” (p. 1).
21. Community awareness campaigns for a community health centre and availability of
services
No explicit mentions were found
of community awareness campaigns.
Two Canadian CEC-type centres
consulted mentioned the awareness of
the community of their services – they
have received positive feedback from
the community regarding outreach
programs and rapid access to
ambulatory services.
A 2011 Cochrane Review by Flodgren (63) examined the available
evidence assessing the effect of local opinion leaders to improve
professional practice and patient outcomes. Eighteen cluster RCTs
were included in this well-conducted systematic review.
The authors considered any intervention evaluating the
effectiveness of local opinion leaders in improving the behaviour of
health care professionals and patient outcomes, compared to no
intervention, or any other single intervention. Outcomes were
professional performance and/or patient outcomes. In each of the
trials the opinion leaders delivered educational initiatives to
members of their own health care profession. Physicians were the
target in 14 trials, nurses in two trials and two trials targeted
physicians, nurses, and midwives.
This review included studies from around the world, and no restrictions were placed on language. The authors
concluded, “Opinion leaders alone or in combination with other interventions may successfully promote
evidence-based practice, but effectiveness varies both within and between studies. These results are based on
heterogeneous studies differing in terms of type of intervention, setting, and outcomes measured. In most of
the studies the role of the opinion leader was not clearly described, and it is therefore not possible to say what
the best way is to optimise the effectiveness of opinion leaders” (p.2).
22. Recruitment & retention programs for rural health centres
A well-conducted 2011 systematic review by Gagnon (64) aimed to explore the impact of interventions using
information and communication technologies (ICTs) on recruitment and retention of health care professionals.
Thirteen studies were included, including four of quantitative designs, five qualitative designs, and four using
mixed methods. Although detailed search strategies were not provided, considerable detail was given about
which databases were searched as well as grey literature sources and additional health websites.
33
Participants were health care professionals and
interventions were various ICTs, mostly telehealth.
Outcomes were effects on recruitment and retention. The
authors noted that the studies that met inclusion were
extremely heterogeneous, given the diversity of health care
professionals and many forms of ICTs.
There was very little information on
recruitment and retention initiatives for
individual centres or of jurisdictions as a
whole (for rural health centre staff) in
available literature on Canadian CEC-type
centres consulted.
Included studies were limited to those published in French,
English, or Spanish. The authors concluded, “despite the conclusions of nine of 13 studies reporting a possible
positive influence of ICTs on the recruitment and retention of health care professionals, we believe that these
results are only the beginning of a deeper reflection that is needed on this topic. Caution should be exercised
when generalizing the results, and other studies are certainly needed to better understand the scale and
subtleties of this complex relation” (p. 273).
A brief report from the Health
Council of Canada (98) stated that the
Department of Health of Nunavut
offers support and incentives,
including scholarships, bursaries, and
subsidized child care, to nursing
students in the Nunavut Nursing
Program at Nunavut Arctic College.
An additional systematic review from 2009 by Wilson (65) provides
“a critical review of interventions to redress the inequitable
distribution of health care professionals to rural and remote areas”.
There were 110 studies found through a search in PubMed; these
include retrospective observational studies and surveys due to a
lack of primary intervention studies.
The search was limited to English language studies. The value in
this systematic review lies in the classification system Wilson
devised to summarize the existing evidence. The 110 articles were
sorted into five intervention categories: Selection, Education,
Coercion, Incentives, and Support. The authors provide, in table form, an overview of interventions that aim to
reduce urban-rural staffing imbalances, viewable here in the
The provincial government of
open access journal Rural and Remote Health, the International
Saskatchewan
has a Recruitment Grant
Electronic Journal of Rural and Remote Health Research,
Program in place to entice health
Education, Practice and Policy:
professionals to move north. The
http://www.rrh.org.au/articles/subviewnew.asp?ArticleID=1060
program provides grant money to a
The authors conclude that universal definitions for the concepts
variety of health professionals including
of “rural” and “remote” are needed to help compare the large
physicians, registered nurses, dieticians,
number of studies available in this area. Wilson (2009) write
and pharmacists who accept positions in
that there are strategies to meet short term staffing
rural or northern Saskatchewan
requirements, but little evidence to demonstrate the long term
communities (104).
impact of these interventions. The authors write, “current
evidence only supports the implementation of well-defined
selection and education policies, although incentive and support schemes may have value. There remains an
urgent need to evaluate the impact of untested interventions in a scientifically rigorous fashion in order to
identify winning strategies for guiding future practice and policy” (p. 2).
23. Affiliation with an educational institution
No clearly relevant systematic reviews on the topic of the effect of affiliation with an educational institution for
a community health centre were identified.
34
Related to educational institutions and their support role in
Affiliation with educational
training health professional staff who will work in rural areas
educations is unknown for 10 of the
that might support a CEC-type setting, Rabinowitz (66)
Canadian CEC-type centres consulted.
examined the outcomes of comprehensive medical school
Two Canadian CEC-type centres
programs designed to increase the rural physician supply. This
consulted explicitly stated having a
2008 systematic review resulted in the development of a
presence of medical students and
model to estimate the impact of replicating these medical
residents through university teaching
education programs. The authors only looked at English
programs within their health centres.
language studies, due to a focus on US medical education.
The value in this systematic review lies in its efforts to locate
data regarding all US-based allopathic medical school
programs designed to increase the rural physician supply and which included recruitment and retention
outcomes.
24. Conducting research at a community health centre
No clearly relevant systematic reviews on the topic of the effect of a community health centre being involved in
conducting research were identified.
Whether research was conducted within health centres was unknown for 11 Canadian CEC-type
centres consulted. One Canadian CEC-type centre consulted was affiliated with a Centre for Rural Health
Studies.
35
Knowledge Translation
A second integrated knowledge translation workshop was delivered to the same group of stakeholders invited to
the first workshop. Our group of attendees brainstormed a list of potential stakeholders to disseminate all or a
targeted selection of this project’s findings to. These stakeholders included:
Professional groups (colleges, associations)
Health care providers
Researchers (in part, to identify gaps in the literature, or opportunities to study the CEC model)
NSHRF
Department of Health and Wellness
- Research
- Policy
- Operators / District Health Authorities
Other government entities
Administrators of CECs and health care providers
Communities (members of the public and users of health services in communities)
The research team asked the workshop attendees to think about how to reach out to each of the identified
stakeholders, and which specific stakeholders might be interested in which messages or groups of messages.
36
Acknowledgments
We appreciate the assistance and support of Fred Burge, Alana MacLellan, Jenny Cartwright, and Kristy McGill
throughout this rapid evidence synthesis project. We also thank all stakeholder workshops attendees for their
support.
Contributions of Authors
Research team
Jill Hayden (team lead) – Overseeing planning and conduct of all stages of the evidence synthesis; critical editing
of early drafts and the final report.
Jessica Babineau – Drafting proposal, jurisdictional review coordination, team coordination, workshop
coordination, literature searches, citation screening, data extraction, data management, drafting of final report.
Lara Killian – Literature searches, citation screening, data extraction, data management, workshop facilitation,
drafting and editing of final report.
Austin Zygmunt – Citation screening, data extraction, review of final report.
Investigator team
Ruth Martin-Misener – Defining key terms, search terms, content advising, analysis of extracted data and
workshop outcomes, workshop participation, contributing to critical editing of final report and subsequent
publications.
Alix Carter – Defining key terms, search terms, content advising, analysis of extracted data and workshop
outcomes, contributing to critical editing of final report and subsequent publications.
Jan Jensen – Defining key terms, search terms, content advising, analysis of extracted data and workshop
outcomes, workshop participation, contributing to critical editing of final report and subsequent publications.
Declarations of Conflict of Interest
No conflicts of interest have been declared by the authors.
How to Cite Full Report Document
Hayden J, Babineau J, Killian L, Martin-Misener R, Carter A, Jensen J, Zygmunt A. Collaborative emergency
centres: Rapid knowledge synthesis. Full report. Halifax, Nova Scotia: Nova Scotia Cochrane Resource Centre;
2012.
Sources of Support
The Nova Scotia Health Research Foundation (NSHRF) funded this Rapid Evidence Synthesis project. NSHRF
exists to improve the health of Nova Scotians through health research by working with stakeholders, including
provincial government, health authorities, and health researchers on a number of initiatives and funding
opportunities.
37
Appendices
Appendix 1: Jurisdictional Review Scoping Searches – Resource List
Each jurisdictional search began with a scan of major government and health sites: websites were scanned for
relevant documents or pages. In the case of government sites, this included reports or publications oriented
towards health services. Health sites included a scan for lists of health centres, lists of services provided, and
news releases. All pages seeming to be of possible interest were scanned.
Search tools, when available, were also used to search terms such as “primary AND emergency”, “collaborative
care”, “team model”, “integrated care”, “health centre”, and “community health centre”. Specific location
names, determined through preliminary scanning of sites, were also searched when relevant. Inconsistency of
naming structures between jurisdictions required adding additional terms to each search strategy.
Finally, select databases and search engines (CBCA, PubMed, Google, Google Scholar, and Google News) were
searched for terms related to potential health centres identified in each jurisdiction.
PROVINCE/TERRITORY
ALBERTA
BRITISH COLUMBIA
MANITOBA
NEWFOUNDLAND AND
LABRADOR
Organization
Government of Alberta
Alberta Department of Health
Alberta Health Services
Health Quality Council of
Alberta
BC Department of Heath
Vancouver Island Health
Northern Health
Frasier
Government of Manitoba
Manitoba Health
Assiniboine Regional Health
Authority
Brandon Health Authority
Burntwood Health Authority
Central Manitoba Health
Authority
Churchill Health Authority
Interlake Health Authority
Nor-man Health Authority
Parkland Health Authority
South Eastman Health
Authority
Government of
Newfoundland and Labrador
Department of Health and
Community Services
Eastern Health Authority
Web page address
alberta.ca/home
www.health.alberta.ca
www.albertahealthservices.ca
www.hqca.ca
Central Health Authority
Western Health Authority
Labrador-Grenfeld Health
Authority
www.centralhealth.nl.ca
westernhealth.nl.ca
www.lghealth.ca/index.php
38
www.gov.bc.ca/health
www.viha.ca
www.northernhealth.ca
www.fraserhealth.ca
gov.mb.ca
www.gov.mb.ca/health
www.assiniboine-rhs.ca
www.brandonrha-mb.ca
www.brha.mb.ca
www.rha-central.mb.ca
www.churchill.mb.ca
www.irha.mb.ca
www.neha.mb.ca
www.prha.mb.ca
www.sehealth.mb.ca
www.health.gov.nl.ca/health
www.easternhealth.ca
NEW BRUNSWICK
NORTHWEST TERRITORIES
NUNAVUT
ONTARIO
PRINCE EDWARD ISLAND
QUEBEC
SASKATCHEWAN
YUKON
Government of NB
NB Department of Health and
Wellness
Vitalite Health Authority
Horizon Health Authority
River Valley Health Authority
Government of the
Northwest Territories
Northwest territories Health
and Social Services
Dehcho Health and Social
Services Authority
Government of Nunavut
Department of Health and
Social Services
Government of Ontario
Minister of Health and Long
Term Care
Ontario’s Local Health
Integration Networks
Government of PEI
Health PEI
PEI Health Sector Council
Nunatsiavit Government
Portail Quebec
Government of Saskatchewan
Saskatchewan Health
Saskatoon Health Authority
Athabasca Health Authority
Keewatin Yatthe
Mamawetan Churchill River
Prairie North Health
Authority
Prince Albert Parkland Health
Authority
Kelsey Trail Health Authority
Heartland Health Authority
Sunrise Health Authority
Regina Qu’appelle Health
Authority
Five Hills Health Authority
Cypress Health Authority
Sun Country Health Authority
Winnipeg Health Authority
Yukon Health and social
services
Yukon Health Guide
39
www.gnb.ca
www.gnb.ca/0051/index-e.asp
www.santevitalitehealth.ca/en
www.horizonnb.ca
www.rivervalleyhealth.nb.ca
www.gov.nt.ca
www.hlthss.gov.nt.ca
www.dhssa.ca
www.gov.nu.ca/en/Home.aspx
www.hss.gov.nu.ca
www.ontario.ca
www.health.gov.on.ca/en
www.lhins.on.ca
www.gov.pe.ca
www.healthpei.ca
peihsc.ca
www.nunatsiavut.com
www.gouv.qc.ca
www.gov.sk.ca
www.health.gov.sk.ca
www.saskatoonhealthregion.ca
www.athabascahealth.ca
www.kyrha.ca
www.mcrrha.sk.ca
www.pnrha.ca/bins/index.asp
www.paphr.sk.ca
www.kelseytrailhealth.ca
www.hrha.sk.ca
www.sunrisehealthregion.sk.ca
www.rqhealth.ca
www.fhhr.ca
www.cypresshealth.ca
www.suncountry.sk.ca
www.wrha.mb.ca
www.hss.gov.yk.ca
www.ykhealthguide.org
Appendix 2: Data Extraction Form for Scan of Jurisdictions Outside of Nova Scotia
JURISDICTIONAL DATA EXTRACTION FORM
ID
PROV/COUNTRY
CITY/OTHER LOCATION/HEALTH
AUTHORITY
NAME OF CENTRE
POTENTIAL CONTACT PERSONS
CONTACT NOTES
ADDITIONAL INFORMATION
AREA SERVED [e.g. rural/urban;
population; density]
HEALTH CARE SYSTEM CONTEXT [e.g.
established, “fit”]
CEC ‘Characteristics’
Hours of Service:
Emergent Service
Hours of Service:
Urgent Service
Hours of Service:
Walk-in/low acuity
Service
Staff Members
□ 24 hours/day
□ Daytime only
□ Not available
□ Other:
Source:
□ 24 hours/day
□ Daytime only
□ Not available
□ Other:
Source:
□ 24 hours/day
□ Daytime only
□ Not available
□ Other:
Source:
Practitioner Type
Qualification
□ MD
□ GP
□ EMERGENCY
□ RADIOLOGY
□ SURGERY
□ PEDIATRICS
□ Other:
40
Source:
□ NP
□ RN
□ LPN
□ PCW
□ Other:
□
□ RN
Source:
□ PCP
□ ACP
□ CCP
□ PARAMEDIC
Source:
□ OT
□ PHYSIOTHERAPY
□ X-RAY
□ MEDICAL LAB TECHS
□ RT
□ NUTRITION
□ SOCIAL WORK
□ PHARMACY
□ Other:
□ ALLIED HEALTH
Health Care Provider
(HCP) Collaboration
Triage (are patients
triaged upon arrival)
Source:
□ No
□ Yes
□ Other:
□ Notes (e.g., Leadership roles, collaborative team structure and composition)
Source:
□ No
□ Yes
□ CTAS
□ Other scale: _______________
Emergency
Protocols/Standing
Orders
Source:
□ None
□ Staff other than MD can initiate
Source:
Destination Plan
□ No
(pre-determined
□ Yes
destination based on
□ Community hospital
patient presentation
□ Tertiary care centre
– e.g., STEMI,
□ Other:
trauma)
Source:
Transfer Plan
□ No
41
□ Yes
□ EMS
□ HEMS
□ Other:
Source:
Capacity
(equipment,
services) to treat
various levels of
acuity
Ambulatory care
Describe (e.g., facility size and structure [e.g., square footage, number of rooms];
equipment [e.g., resuscitation equipment, casting equipment])
Source: [1]
□ No
□ Yes
□ XR
□ Day surgery
□ Blood work
□ Diagnostic Imaging (CT, mammo, etc)
□ ECGs
□ Orthopedics follow-up
□ Other:
In-patient beds
Consulting/Offsite
communication
Health promotion &
prevention services
Governance
Evaluation
Source:
□ No
□ Yes
□ Notes:
□ On-call MD
□ Consult ED
□ Consult specialist
□ Other:
□ Phone report
□ Video-consult
□ Other:
Source:
□ No
□ Yes
□ Notes:
Source: [1]
□ Department of Health
□ District Health Authority
□ Hospital
□ Other:
Source:
Source:
□ Formal Program evaluation
□ Continuous Quality Improvement (chart audit, advent reporting)
□ Other:
Source:
What outcomes were evaluated? [e.g., availability of emergency services,
patient/provider satisfaction, patient health outcomes, efficient delivery of
emergency and primary care, time to definitive care, safety of care]
42
Source:
What are the results of the evaluation? What was considered successful? What
improvement opportunities were identified?
Program Funding
Practitioner Funding
Source:
□ Publicly funded
□ Performance-based contracts
□ Lump sum
□ Other:
□ Fee
□ Private insurance
□ Other:
Source:
□ Salary
□ Fee-for-service (physicians)
□ On-call pay
□ Other:
Source:
Notes
References
43
Appendix 3: Original CEC Evidence Synthesis Review Questions
OVERALL REVIEW QUESTION
1. What is the effect of CEC-type models of health care delivery (see definition) on outcomes related to
individual or community health? (Comparison: traditional health care delivery)
STRUCTURES/PROCESSES QUESTIONS
2. What is the effect of (greater or lesser) hours of access to emergency services in a community?
3. What is the effect of the structure of emergency services (i.e. triage) on individual or community health
outcomes?
4. What is the effect of (greater or lesser) hours of primary care services on individual or community health
outcomes?
5. What is the effect of the structure of primary care services (i.e. walk-in, same day availability) on individual
or community health outcomes?
6. What is the effect of (additional, specific listed) health care professional staff available in an emergency
care delivery environment on individual or community health outcomes? (Comparison: traditional health
care delivery)
- Physician/Specialist(s)
- Nurse Practitioner(s)
- Nurse(s) with additional training
- Paramedic with additional training
- Allied Health Professional(s) (Regulated)
- Allied Health Professional(s) (Other)
- Additional Support Staff
7. What is the effect of (additional, specific listed) health care professional staff available in a primary health
care delivery environment on individual or community health outcomes? (Comparison: traditional health
care delivery)
- Physician/Specialist(s)
- Nurse Practitioner(s)
- Nurse(s) with additional training
- Allied Health Professional(s) (Regulated)
- Allied Health Professional(s) (Other)
8. What is the effect of collaborative practices in emergency health care delivery on individual or community
health outcomes? (Comparison: traditional health care delivery)
9. What is the effect of collaborative practices in primary health care delivery on individual or community
health outcomes? (Comparison: traditional health care delivery)
10. What is the effect of having emergency protocols or use of standing orders in emergency health care
delivery on individual or community health outcomes? (Comparison: traditional health care delivery)
11. What is the effect of managing patients using a destination and transfer plan in emergency health care
delivery on individual or community health outcomes? (Comparison: traditional emergency care delivery)
12. What is the effect of (levels of) service infrastructure in emergency and primary health care delivery on
individual or community health outcomes?
13. What is the effect of having (a comprehensive set of) diagnostic services available in emergency health care
delivery on individual or community health outcomes?
14. What is the effect of having (a comprehensive set of) diagnostic services available in primary health care
delivery on individual or community health outcomes?
15. What is the effect of having (specific) ambulatory clinic services available in primary health care delivery on
16. What is the effect of having in-patient beds available within a community health centre on individual or
community health outcomes?
44
17. What is the effect of accessing or having available off-site consultation for health care delivery in a
community on individual or community health outcomes?
18. What is the effect of emergency and primary health care centres using (different/specific listed)
mechanisms for off-site communication on individual or community health outcomes?
19. What is the effect of emergency and primary health care centres using (different/specific listed) mechanisms
for off-site health care delivery on individual or community health outcomes?
20. What is the effect of organizing health care services for a community based on a formal community health
needs assessment?
21. What is the effect of having (specific listed) health promotion & prevention services available in primary
health care delivery on individual or community health outcomes?
- Health Education
- Public Health
- Nutrition
- Recreation
- Specialist Services
- Chronic Disease
- Infection Control
- Mental Health & Addictions
- Home Care
- Health Clinics (specific groups)
22. What is the effect of having a specific (listed) governance structure for a community health centre, on
23. What is the effect of having a formal program evaluation for a community health centre, on individual or
24. What is the effect of having a specific (listed) program funding structure for a community health centre, on
25. What is the effect of having a specific (listed) funding structure for health professionals at a community
health centre, on individual or community health outcomes?
26. What is the effect of community awareness campaigns for a community health centre and availability of
services, on individual or community health outcomes?
27. What is the effect of recruitment & retention programs for rural health centres, on individual or community
health outcomes?
28. What is the effect of a community health centre to be affiliated with an educational institution, on
29. What is the effect on individual or community health outcomes for a community health centre to be
involved in conducting research?
45
Appendix 4: Jurisdiction Review Centre Selection Flowchart
Centres identified through
scoping searches (n=25)
Centres identified through
expert suggestion (n=1)
Potentially relevant centres screened
for eligibility (n=26)
Centres considered
for eligibility (n=15)
Records excluded
through CEC type
centre
operationalization
process (n=11)
Exclusions through
contact with health
centre (n=3)
Centres included in qualitative synthesis (n = 12)
CEC-type centres with Nova Scotia context (n=3)
CEC-type centres (n=9)
46
Appendix 5: CEC-type Centre Summaries
Prioritized Components
Centre/Location
Structure
Hours
Staffing
Collaborative Practice
Telehealth
Diagnostic services
Primary care
centre (family
practice) with
urgent care.
Primary care by
appointment,
priority given to
patients who do
not have a local
practitioner. (93)
Family practice open standard
day hours (MonFri), with urgent
care centre open
until 7:30-10:30
(93)
GPs, NP, RNs, Public Health Nurses,
Midwife, Long Term Care Case
Manager, Home Care Nurse, Home &
Community Care Clinician “Support
Staff”. Also have OT, Physio, X-ray,
Medical lab techs, Nutritionist. (93,
105)
The goal of the Centre is to provide
integrated and collaborative team care
to patients by the appropriate provider
in the appropriate setting in an
appropriate time and in an appropriate
type and format of intervention for
their needs. (93)
Unknown
X-ray, blood work, have
lab and collection station
Has primary care
and "emergency"
(defined as "rural
ambulatory" (106)
Standard day time
hours (107)
Team teleconference with
regional hospital on weekly
basis
While having advanced
technology to consult with
surgeons and specialists via
videoconferencing, it is
often challenging to get
specialists to leave their
busy workdays to go into a
separate room to discuss
with members at the centre
– can be easier to use
phone conservation, where
you relay the important
information to ensure
thorough understanding of
the situation.
Unknown
Centre does not have
technological telehealth
systems in place, although
being considered. At night,
GP and second nurse are on
call - available via
telephone.
Lab, EKGs, X-ray - after
hours referred to
Carbonear or St. John’s
(96).
CEC-type models with Nova Scotia context
Ladysmith
Community Health
Centre, Ladysmith,
BC
Rainbow Lake
Health Centre,
Rainbow Lake
Alberta
Online registry ensures continuous and
proactive care for patients (102).
Paramedics role: patient assessments,
lab draws and suturing. Normally
staffed with NP (retired) (92).
It is far easier to be proactive rather
than reactive in terms of training –
should be increased training prior,
rather than when needed for
paramedic staff working on site. No
additional formal training has occurred
for paramedic staff (92).
While collaborating, it is important to
be aware of the different scope of
practice each team member has (e.g.
NPs and paramedics) and to work with
that – discussed how this strategy failed
in other locations, as paramedics would
be made to sweep the floors rather
than working within their scope of
practice.
Teleconference with Regional Hospital
Hospital Management has an important
role at the centre.
Dr. W. H.
Newhook
Community Health
Centre,
Whitbourne,
Newfoundland
Primary Care and
Emergency
services. Rapid
access to
ambulatory care
services.
Primary care
(Weekdays,
standard hours)
and 24 hour
emergency care
(96).
Value of communication and flexibility
of staff is necessary due to ongoing
challenges in staffing (only one nurse
on site and one utilities person at night
– with a second nurse and doctor on
call).
Nurse on duty at night for emergencies.
During the day, physicians have clinics
but also one is on duty at the ED (called
when necessary) and are on call at
night.
Staff has standard qualifications.
47
Value of communication and flexibility
of staff is valuable.
CEC-type models
Cumberland
House Health
Centre, Norther
Village of
Cumberland
House,
Saskatchewan
Primary Care
centre with
emergency (NP on
staff)
Outpatient/Prima
ry care: M-F,
standard daytime
hours (North
Saskatchewan
Health Services,
2009).
Nurse on call 24/7
(108).
GP 3 days/week; NP; Pharmacy; First
Responder, Community Health
Developer/Rep (108).
Unknown
Telehealth as "two-way
videoconferencing
technology that is used as a
tool to provide an optional
way for patients
to see their referred
clinicians without the need
to travel to an urban
centre" (Hrychuk, 2010).
Centre was a "Satellite
Initiative site" for telehealth
(see additional reading)
Blood work, "laboratory
services"(109).
Hopedale
Community Clinic,
Hopedale,
Newfoundland
Primary Care and
Emergency care
available during
daytime hours.
Focused on
primary care, but
has basic trauma
and resuscitation
equipment,
including a
defibrillator and 3
holding beds on
site (110).
Primary Care and
Emergency care
available during
daytime hours.
M-F (closed
Thursday
afternoons for
administration;
emergency
services available)
(110).
Regional Nurse II, a Regional Nurse I, a
Personal Care Attendant, a Mental
Health Counsellor, two Maintenance
Repairmen and a Domestic Worker.
Labrador-Grenfell Health partners with
the Nunatsiavut Department of Health
and Social Development in the
provision of health care. Community
health services are provided by the
Nunatsiavut Government, through a
team consisting of a Public Health
Nurse, a Public Health Aide, Community
Service Workers, and Child Care
Workers (110)
The core values of Labrador-Grenfell
Health offer principles and a guiding
framework for all employees as they
work in their various capacities to
deliver health and community services
and enhance the health status of the
residents of the region, i.e.,
Collaboration: Each person actively
engages others to develop positive
partnerships and promote productive
teamwork. A visiting psychologist
provides additional counseling services
as needed. A behavior management
Specialist also visits on a regular basis
(111)
Unknown
Unknown
Primary Care Open weekdays
daily.
Emergency
services - 24/7
(112).
4 RNs and a home care nurse are
employed at the centre. Support staff
(hired by band). EMS staff operate
beyond traditional scope - working in
the health facility with doctors and
nurses in the ED and labour/delivery,
assist in acute care, and long term care
in collaboration with an
interdisciplinary team (LPN as case
manager). Paramedics also do training
for AHA and general public (e.g. CPR,
First aid, first responder). AHA
paramedics have Canadian Aero
medical and transportation association
Level 1 course (113)
Visiting services: Psychiatric, physician,
dentist, Mental health and additctions,
pharmacist.
Nurses are considered primary
caregivers, with telephone access to
GPs at Stoney Rapids (25 km away).
Black Lake has the
advantage of a full-fledged
hospital located in Stony
Rapids, a community 25 km
away, so nurses have access
to doctors via telephone if
they need them.
Unknown
Black Lake Health
Centre, Black
Lake,
Saskatchewan
48
EMS staff operate beyond traditional
scope - working in the health facility
with doctors and nurses in the ED and
labour/delivery, assist in acute care,
and long term care in collaboration
with an interdisciplinary team (LPN as
assesspr/case manager) (112)
Igloolik
Community Health
Centre, Igloolik,
Nunavut
Only health centre
in community primary care and
Emergency.
Primary Care Open weekdays
from 9am to 5pm.
Nurse on call for
emergencies 24/7
(114)
Registered nurse (Community Health
Nurse - The Department of Health and
Social Services supports training in a
number of disciplines, including
maternal care, midwifery, and mental
health (98). Doctors, dentists, and
other specialists visits town on a
regular basis (114). Social worker,
community health representatives (98).
Fort Simpson
Health Centre,
Fort Simpson,
NWT
On call emergency
services after
hours. Primary
care structure
unknown.
Unknown
Nurse on-call for
emergencies
24/7. Primary
care daytime
hours (115).
Unknown
Visiting GP; 5 Community Health
Nurses and 1 Nurse Administrator
(115).
Primary Care:
walk- in/
outpatient/ clinic
for primary care.
Emergency: on-call
(after primary care
hours) (94).
Primary care: M-F
daily. Emergency
care: 24/7 on-call
NP (Dawson
Medical Clinic,
n.d.)
Wrigley, NWT
Health Centres
(case: Dawson
City), Yukon
In Nunavut, interdisciplinary care is
seen as the most sustainable model and
the best way to deliver primary health
care. The community health nurse is
the backbone of the team and the first
point of contact for patients. The core
team in the community health centres
consists of at least two community
health nurses, plus a social worker,
community health representatives,
clerk interpreters, and X‐ray technician.
The nurse in charge provides both
clinical and administrative leadership
for the team. Teams provide a whole
spectrum of regular and special needs
care, including care for mental health
and addictions (98).
Unknown
Unknown
X-rays, blood work blood tests are flown out
of the community and
results are then faxed
back to the health centre
(98).
Unknown
X-rays, and blood
work(115)
Centre primarily run by the Community
Health Worker (CHW) and Community
Health Representative (CHR) along with
the Home Support Worker (HSW).
The Fort Simpson Health and Social
Services team (Physicians, Community
Health Nurses, Community Social
Services Workers, Mental Health and
Addictions Counselors and Community
Wellness Workers) have regular
scheduled visits to Wrigley(116).
The CHW and CHR provide health care
in the absence of trained medical
and/or nursing personnel under the
long-distance direction and guidance of
the medical/nursing staff of the Fort
Simpson Health and Social Services
Center. When providing basic and
emergency care or assessment, the
CHW and CHR will be required to
independently perform a basic
assessment (vital statistics) and provide
the results to medical/nursing
personnel, in Fort Simpson for
diagnosis and treatment(116).
Unknown
GPs (3 during the summer, 2 during the
winter); Several medical students and
Family Practice Residents choose to do
their rural elective experience in
Dawson every year; NP; Community
Health nurse; Home care nurse; Private
pharmacy
The medical clinic is housed in the same
building as the nursing station (94).
The CHW and CHR provide
health care in the absence
of trained medical and/or
nursing personnel under
the long-distance direction
and guidance of the
medical/nursing staff of the
Fort Simpson Health and
Social Services Center.
When providing basic and
emergency care or
assessment, the CHW and
CHR will be required to
independently perform a
basic assessment (vital
statistics) and provide the
results to medical/nursing
personnel, in Fort Simpson
for diagnosis and
treatment(116).
Telehealth appointments
with dietitian and Mental
Health/ Counselling at the
Health Centre (117).
Tele- consultation with
specialists in Vancouver;
often avoiding unnecessary
distance travel for patients
(94).
49
X-ray, blood work
(Specimen collection
Mon, Wed, Fri 8:30-10:30
), ECGs (94)
Northeast
Community Health
Centre, Edmonton
Alberta
Oceanside Primary
& Urgent Centre,
Parksville, BC
The Northeast
Community Health
Centre in
Edmonton, is an
innovative model
of primary health
care delivery that
combines
community-based
services with a 24hour ED(88).
Family Health
dedicates half its
time to target
population clients
(95).
Emergency
services - 24
hours/day
Primary CareUnknown (88).
Primary Care and
Urgent care
(including
stabilization and
transfer)
Primary Care daytime hours
Urgent care Extended hours
(7:30AM10:30PM) (118).
Complete staff listing undefined.
In 2003, plans to introduce NPs into the
ED (95).
Shortages of medical generalists and
specialists in northeast Edmonton,
particularly the latter, were identified
through analysis of regional statistics
and through the community
consultation focus groups held during
planning for the Centre. E.g. ED
identified a need for follow-up services
for minor orthopaedic injuries; in
response, the Centre established a
regular follow-up clinic for amateur
sports injuries and simple fractures. A
consultant psychiatrist works with the
NECHC Mental Health Service,
providing regular mental health rounds
for the Centre and other communitybased PCPs. This model allows the
psychiatrist to support primary care
physicians and mental health providers
in interventions beyond the range of
usual primary care process. (95).
A collaborative work space is being
designed for up to ten health care
practitioners, including: family
physicians, NPs and associated staff.
These professionals will provide the
typical health care services associated
with family practice, including treating
illness, managing chronic disease,
prevention and referrals. Pharmacist on
site. (119).
50
NECHC provides services to ensure
client-centred service delivery. Close
working relationships were established
with community-based services,
agencies and resources. Today, NECHC
providers continue to work with these
partners in case management, healthy
living initiatives and client referrals.
Unknown
X-ray, blood work,
diagnostic imaging,
audiology services, and
ultrasound services (88).
Tele-consultation capacity
(120).
Onsite laboratory,
medical imaging (e.g. xray and ultrasound)
(119).
Maximizing multidisciplinary teams to
provide integrated client-centred
services is a critical feature of the
Centre. The make-up of these teams
varies according to specific client
needs, but could include GPs,
multicultural health brokers, social
workers, RNs, dieticians, nutritionist,
etc.(95).
Plan is for a multidisciplinary care team
– this will be GP led, and NP will be part
of the team (118).
Non-Prioritized Components (1/2)
Centre/
Location
Protocols/
Destination/
Standing
Transfer plans
orders
Service Infrastructure
Ambulatory services
Community Heath Needs
Assessment
Health Promotion
and Prevention
Governance
Structure
Ladysmith
Community
Health Centre,
Ladysmith, BC
Unknown
Centre is 25 minutes away
from a higher level facility.
Centre has the capacity to
stabilize and transfer,
however, for emergency
situations have an
ambulance by-pass
protocol (e.g. for Trauma
cases). Originally has the
term “emergency” in
name, but changed to
Community Health centre
and changed the name to
Urgent once the by-pass
protocol was put into
place.
A privately run long term
residential care facility is located
adjacent to the centre. Centre
converted from General Hospital.
All residential care, palliative care
and respite beds were transferred
to a brand new purpose built
facility. The previous inpatient
space was renovated to
accommodate other health care
services that were previously
located throughout Ladysmith and
in neighbouring communities. The
new service model was part of
VIHA’s strategy for enhancing
primary health care services and
chronic disease management in
central Vancouver Island (93).
Yes - clinical day care
(eg. casting and IV
and blood
transfusions) (121).
Planning for this primary
health care site began in
2003 and included a review
of the health services
provided to the Ladysmith
community (93).
Yes (93).
District Health
Authority governed
(121).
Rainbow Lake
Health Centre,
Rainbow Lake,
Alberta
Currently
developing
concrete
protocols
and
guidelines
based on
current
practice.
Centre had a very close
relationship with Regional
hospital (still at a distance)
– all calls and consultations
were made at this centre.
Transfers would be made
to the location, but it was
possible to “trump” this
destination to a higher
level medivac when
needed.
Unknown
Yes- Bloodwork,
suturing (122)
Unknown
Yes
Alberta Health
Services governed
(88)
Dr. W. H.
Newhook
Community
Health Centre,
Whitbourne,
Nfld
Unknown
Centre has holding beds,
but patients are normally
generally assessed, treated
and discharged or are
transferred to secondary or
tertiary care centres (96)
Unknown.
Yes - Chemotherapy,
Holter Monitoring,
Blood Pressuce [BP]
Monitoring,
Intravenous
Medications (96)
Unknown
Yes - mostly as
visiting services
(Visiting Services:
Dietitian, Respiratory
Therapist, Mental
Health Counsellor)
(96)
Health Authority
Governed (123)
51
CEC-type models
Cumberland
House Health
Centre,
Northern Village
of Cumberland
House, Sask
Unknown
Unknown
Unknown
Unknown
Unknown
Yes (108).
Governed by
Health authority
(108).
Hopedale
Community
Clinic, Hopedale,
Nfld
Unknown
Emergency patients are
medevaced to the
appropriate referral
centre (110).
Unknown
Unknown
Unknown
Yes
Black Lake
Health Centre,
Black Lake, Sask
A future
priority for
development
of ICP Drug
protocols to
provide
improved
quality of
emergency
care for
patients on
long flights to
the south.
(112).
Hospital 25 km away in
Stoney Rapid (transfers
by ambulance) - aero
transfer occurs during
emergency situations
(104, 113).
Nurse residence and clinic
renovations completed in 20052006 (112).
Unknown
Unknown
Yes(112).
Health Authority
with partnership
with the
Nunatsiavut
Department of
Health and Social
Development in
the provision of
health care (110).
Governed by
Health authority
(as part of the
Transfer
Agreement) (112).
Some staffing
employed by Band.
Igloolik
Community
Health Centre,
Igloolik, Nunavut
Unknown
Serious medical
conditions, procedures,
or emergencies are flown
to Iqaluit or Ottawa (98).
Unknown
Unknown
Unknown
Yes (e.g. RN’s in
Igloolike make home
visits and offer
structured
appointment’s for
prenatal wellwoman and wellchild clinics (124).
Unknown
Fort Simpson
Health Centre,
Fort Simpson,
NWT
Unknown
The maximum patient
observation is for 6 hours
before the patient is
transferred (medivac) to
Stanton Territorial
Hospital, in Yellowknife
or to Edmonton, Alberta
(115).
Fort Simpson is the largest
community in the Dehcho and also
serves as the administrative
headquarters for the Authority
(second level of health centre)
(125). Also near the Residential
Long Term Care facility renamed
the “Elders Care Home” provides
quality care to the elderly and
disabled, and has 20 beds (115).
Unknown
Unknown
Yes
District Health
Authority (125).
52
Wrigley, NWT
Unknown
Unknown
Health Centres
(case: Dawson
City), Yukon
Unknown
A 12-bed hospital facility
is located in Watson
Lake. The Watson Lake
Hospital provides 24-hour
emergency medical
treatment, short term
admissions and respite
care clients requiring
more specialized care
may be referred to
Whitehorse General
Hospital (6 hours via
medivac) or hospitals out
of the territory (117).
Northeast
Community
Health Centre,
Edmonton
Alberta
Unknown
Oceanside
Primary &
Urgent Centre,
Parksville, BC
Unknown
Centre has 2 emergency rooms and
5 clinic rooms (115).
Small centre with Health "cabin"
Unknown
Unknown
Yes
Medical clinic and nursing station
are co-located with the addition on
a private pharmacy(94). However,
construction of a new hospital is
planned - replacing the health
centre as of 2010 (126).
Specific medication
dispension is
provided during
daytime hours (127).
Unknown prior to
development of current
centre. However, complete
a functional assessment of
the community’s acute
care needs by the
government and the Yukon
Hospital Corporation to
have occurred in
preparation for hospital
development. Community
meetings to discuss the
needs of the community,
including health centre
staff, other health
professionals in the
community, the Tr’ondëk
Hwëch’in First Nation,
community stakeholders to
have been invited.(126).
Yes
Unknown
The City of Edmonton leased
Northeast Community Health
Centre land. The lease expires in
2048 (122).
General radiology
(88).
A strategic planning team
was developed regarding
the planning of the centre
which included RNs, a NP,
physicians, a program
evaluator, a strategic
planner and a senior
administrator, and was
linked with the community
advisory committee
representatives (95).
Yes
Unknown
Urgent care also includes
assessment and
stabilization for transfer by
ambulance to hospital, if
required (119). When
possible and appropriate
VIHA uses other
transportation providers to
provide non-medical
transfers (patients that do
not require monitoring)
(103).
Newly constructed centre. In
progress. Floor plans available:
http://www.viha.ca/NR/rdonlyres/
8ADA786D-0D2F-4F23-A0A91B6817965574/0/BG_Oceanside_u
rg_care_ctrdrawingsdoc.pdf
Unknown
Potential CHNA results:
http://www.viha.ca/NR/rd
onlyres/C07376F5-0B894702-9B32A1805C4FA1DA/0/oceansid
e_health_centre_overview
_and_community_benefits.
pdf
Yes
DHA governed
53
District Health
Authority (125).
Dawson City Clinic
is under a current
change in
governance model
- a new hospital
facility will be
constructed under
supervision of the
Yukon Hospital
Corporation (126).
Other health
centres are
governed by the
Yukon Department
of Health Services
(128).
Non-prioritized components (2/2)
Centre/Location
Program Evaluation
Program Funding
Staff funding
Community
Awareness
Recruitment and
Retention
Educational
Affiliation
Research
Ladysmith Community
Health Centre, Ladysmith,
BC
Unknown
Unknown
"Traditionally, doctors have been
paid a fee for each patient visit,
called fee-for-service. A new
payment method blends an annual
fee for each registered patient,
based on a patient’s age and
health care needs. This new system
allows physicians at the clinic to
involve other health professionals
in care, and spend more time
helping patients manage complex
and chronic conditions." (102)
Unknown
Unknown
Unknown
Unknown
Rainbow Lake Health
Centre, Rainbow Lake
Alberta
Currently, an
evaluation of the
standing model is
occurring at the
centre - in hopes of
establishing this
model type in other
locations across the
province.
Unknown
Unknown
Health centre has had
positive feedback
from the community Community outreach
helped community
realize benefits of
new HC system.
Unknown
Unknown
Unknown
Dr. W. H. Newhook
Community Health Centre,
Whitbourne,
Newfoundland
Unknown
Unknown
Unknown
Quick access to
ambulatory services
recognized by the
community.
Unknown
Memorial
University
Teaching
Program (i.e.
Residents,
Clinical Clerks,
Medical
Students,
Foreign Medical
Graduates) (96)
Affiliation
with centre
for Rural
Health
Studies (96)
54
CEC-type models
Cumberland House Health
Centre, Norther Village of
Cumberland House,
Saskatchewan
Unknown
Construction funding: Health
Minister $200 000 for
planning and design of the
new health care facility.
Health Canada investing $60
000 to support the planning
and design phase of the
Cumberland house health
centre (99).
Unknown
Unknown
Unknown
Unknown
Unknown
Current program funding:
Unknown
Hopedale Community
Clinic, Hopedale,
Newfoundland
Labrador-Grenfell
Health uses the
principles of
Continuous Quality
Improvement (97).
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
To entice health
professional to
move north, the
provincial
government
established the
Recruitment Grant
Program (104).
Unknown
Unknown
Igloolik Community Health
Centre, Igloolik, Nunavut
No formal evaluation
of inter-professional
primary health care
teams in Nunavut has
been performed, and
none is currently
planned. Informally,
however, regional
and community
health centres have
regular
meetings to assess
how well teams are
functioning (98).
Unknown
Unknown
Unknown
The department of
Health offers
support and
incentives—
including
scholarships,
bursaries, and
subsidized child
care—to nursing
students in the
Nunavut Nursing
Program at
Nunavut Arctic
College(98).
Unknown
Unknown
Fort Simpson Health
Centre, Fort Simpson,
NWT
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Wrigley, NWT
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Black Lake Health Centre,
Black Lake, Saskatchewan
55
Health Centres (case:
Dawson City), Yukon
Unknown.
Unknown.
Unknown.
Unknown.
Unknown
Several medical
students and
Family Practice
Residents choose
to do their rural
elective
experience in
Dawson every
year (94).
Unknown.
Northeast Community
Health Centre, Edmonton
Alberta
Formal program
evaluation - As the
Centre developed,
the conceptual
model was refined.
An early
enhancement was
the identification of
evaluation as a key
component for the
success of the
Centre, and a
regional program
evaluator was
seconded to NECHC's
planning team (95).
Unknown
Unknown
Community members
in north Edmonton
had been lobbying for
health services in
their neighbourhood
for almost 20 years
before the Centre
became a reality.
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Oceanside Primary &
Urgent Centre, Parksville,
BC
During the planning
phase, community
consultations were
held to gather the
community's input on
what services should
be provided at the
Centre (95).
Physician payments are covered by
agreements between Ministry of
Health & BC Medical Association.
Non-physician staff will be
employees of centre (103).
56
Unknown - However,
from a narrative
perspective, there
have been meetings
within the
community, in
addition to press
releases and
presentations made
available via the VIHA
website.
Appendix 6: Final CEC Evidence Synthesis Review Questions
Prioritized Questions
1. What is the effect of CEC-type models of health care delivery (see definition) on outcomes related to
individual or community health? (Comparison: traditional health care delivery)
2. What is the effect of (greater or lesser) hours of access to emergency or primary care services in a
community?
3. What is the effect of (additional, specific listed) health care professional staff available in an emergency
care delivery environment on individual or community health outcomes? (Comparison: traditional
health care delivery)
4. What is the effect of (additional, specific listed) health care professional staff available in a primary
health care delivery environment on individual or community health outcomes? (Comparison:
traditional health care delivery)
5. What is the effect of collaborative practices in emergency or primary health care delivery on individual
or community health outcomes? (Comparison: traditional health care delivery)
6. What is the effect of using telehealth or teleconsultation, in general or through specific mechanisms,on
a. What is the effect of accessing or having available off-site consultation for health care delivery
in a community on individual or community health outcomes?
b. What is the effect of emergency and primary health care centres using (different/specific listed)
mechanisms for off-site communication on individual or community health outcomes?
c. What is the effect of emergency and primary health care centres using (different/specific listed)
mechanisms for off-site health care delivery on individual or community health outcomes?
7. What is the effect of having (a comprehensive set of) diagnostic services available in emergency or
primary health care delivery on individual or community health outcomes?
Non-Prioritized Questions
8. What is the effect of the structure of emergency services (i.e. triage) on individual or community health
outcomes?
9. What is the effect of the structure of primary care services (i.e. walk-in, same day availability) on
10. What is the effect of having emergency protocols or use of standing orders in emergency health care
delivery on individual or community health outcomes? (Comparison: traditional health care delivery)
11. What is the effect of managing patients using a destination and transfer plan in emergency health care
delivery on individual or community health outcomes? (Comparison: traditional emergency care
delivery)
12. What is the effect of (levels of) service infrastructure in emergency and primary health care delivery on
13. What is the effect of having (specific) ambulatory clinic services available in primary health care delivery
on individual or community health outcomes?
14. What is the effect of having in-patient beds available within a community health centre on individual or
15. What is the effect of organizing health care services for a community based on a formal community
health needs assessment?
16. What is the effect of having (specific listed) health promotion & prevention services available in primary
health care delivery on individual or community health outcomes?
17. What is the effect of having a specific (listed) governance structure for a community health centre, on
18. What is the effect of having a formal program evaluation for a community health centre, on individual
or community health outcomes?
57
19. What is the effect of having a specific (listed) program funding structure for a community health centre,
on individual or community health outcomes?
20. What is the effect of having a specific (listed) funding structure for health professionals at a community
health centre, on individual or community health outcomes?
21. What is the effect of community awareness campaigns for a community health centre and availability of
services, on individual or community health outcomes?
22. What is the effect of recruitment & retention programs for rural health centres, on individual or
23. What is the effect of a community health centre to be affiliated with an educational institution, on
24. What is the effect on individual or community health outcomes for a community health centre to be
involved in conducting research?
58
Appendix 7: Search Strategies
1. CEC-type model: Search conducted October 18-21, 2011
Due to the broad nature of this question we were unable to identify any reviews of studies examining CEC-type models in
general in PubMed, Embase, or The Cochrane Library. Using CADTH’s Grey Matters tool (http://cadth.ca/resources/greymatters), a list of grey literature sources was identified to conduct a grey literature search. These ten sources were selected
based on generalizability and for their focus on health contexts most likely to be relevant to Canada and Nova Scotia. During
the searches, two additional grey literature sources were identified and added to the original list. With each grey literature
source, the following steps were followed, and notes taken to document website browsing and searches conducted if
possible:
Check for organization of website (e.g., by topic area, using filters, alphabetized list of reports, other)
Follow up on potential subject areas of interest or scan content lists
If search functionality exists, search for the following terms as likely descriptors for CEC-type models of health care
delivery:
o Collaborative care
o Enhanced primary care
o Health Facility/facilities
o Multidisciplinary center/centre/centers/centres
o Nursing station(s)
o Polyclinic(s)
o Satellite clinic(s)
o Wellness center/centre/centers/centres
Number of results from searches was noted
Titles of results were assessed using the title screening criteria “Is the content of this record relevant to the
component search at hand?” (i.e., Does this document appear to describe CEC-type models?)
Full text of potentially relevant grey literature was retrieved to be assessed in full text
The itemized lists of exactly which filters, headings, tabs, or the like were accessed and scanned is available on request; it is
difficult to include this information in detail as every website is laid out differently and search functionality varies. Our team
members used the guidelines above to search and explore each of the sites in the following table. For description of
individual searches conducted, please contact the Nova Scotia Cochrane Resource Centre.
Source/site:
Turning Research Into Practice (TRIP) database
www.tripdatabase.com
Centre for Health Services and Policy Research
(CHSPR), University of British Columbia
www.chspr.ubc.ca/cgi-bin/pub
Health Quality Council, Saskatchewan
www.hqc.sk.ca
World Health Organization Regional Office for
Europe (WHO): Health Evidence Network (HEN)
www.euro.who.int/en/what-we-do/data-andevidence/health-evidence-networkhen/publications
Belgian Health Care Knowledge Centre (KCE)
www.kce.fgov.be/index_en.aspx?SGREF=5212
Intute www.intute.ac.uk
Included/
Excluded
Excluded
Results (full notes on search/exploration of
site available on request):
Content not relevant
Included
3 documents saved for further assessment
Excluded
Included
Content not relevant; search not functioning
correctly
Excluded
Content not relevant
Excluded
Content not relevant; site no longer being
59
NHS Evidence
www.evidence.nhs.uk
Australian Institute of Health and Welfare
www.aihw.gov.au/publications
Healthcare Improvement Scotland
www.healthcareimprovementscotland.org
(Previously NHS Quality Improvement Scotland
www.nhshealthquality.org/nhsqis/1816.140.144.
html)
OpenGrey http://www.opengrey.eu
Australian Primary Health Care Research Institute
www.anu.edu/aphcri
National Primary Care Research and
Development Centre (Manchester, UK)
www.npcrdc.ac.uk
2.
Included
updated
Included
Included
1 document saved for further assessment
Excluded
Included
Content out of date and frequently in
languages other than English
Included
Hours of access
Emergency care: Search conducted August 15, 2011
PubMed
1. "Emergency service, Hospital"[MH] OR (emergency service[TIAB] OR emergency service/hospital[TIAB] OR emergency
services[TIAB]) OR "Emergency medical services"[MH] OR (emergency medical service[TIAB] OR emergency medical
services[TIAB]) OR Emergency medicine[TIAB] OR (emergency room[TIAB] OR emergency room/trauma[TIAB] OR
emergency room/triage[TIAB] OR emergency rooms[TIAB] OR emergency rooms/clinics[TIAB]) OR (emergency
department[TIAB] OR emergency department/hospital[TIAB] OR emergency department/observation[TIAB] OR emergency
departments[TIAB]) OR accident and emergency[TIAB] OR "A&E"[TIAB] OR emergent[TIAB] OR emergency[TIAB] OR
emergencies[TIAB] [190734 results]
2. Urgent care centre*[TIAB] OR Urgent care center*[TIAB] OR "Emergency primary care centre"[TIAB] OR "Emergency
primary care center"[TIAB] OR "Emergency primary care centres"[TIAB] OR "Emergency primary care centers"[TIAB]
3. "Ambulatory care"[MH] OR "Ambulatory care facilities"[MH]
4. "Hospitals, Satellite"[MH] OR "Hospitals, Rural"[MH] OR "Hospitals, Community"[MH]
5. #1 OR #2 OR #3 OR #4
6. "Hours of operation"[TIAB] OR "Hours of service"[TIAB] OR "Business hours"[TIAB]
7. #5 AND #6
8. "After-hours care"[MH] OR "after hours"[TI] or "out of hours"[TI]
9. (#5 AND #8) OR (#7 AND #8)
10. “24 hours”[TI] OR “24-hours”[TI] OR “on-call”[TI] OR “on call”[TI]
11. (#7) OR (#9) OR (#5 AND #10)
12. #11 AND English[lang] [667 results/ 16 reviews]
Embase
1. 'emergency health service'/exp OR 'emergency ward'/exp OR 'hospital care'/exp OR 'hospital utilization'/exp OR
'emergency care'/exp AND [humans]/lim AND [english]/lim AND [Embase]/lim
2. 'health care access'/exp AND [humans]/lim AND [english]/lim AND [Embase]/lim
3. hours AND [humans]/lim AND [english]/lim AND [Embase]/lim
4. #1 AND #2 AND #3 AND [humans]/lim AND [english]/lim AND [Embase]/lim
5. #1 AND #2 AND #3 AND [Embase]/lim AND [review]/lim AND [humans]/lim AND [english]/lim AND [medline]/lim [7
results]
60
Primary care services: Search conducted September 2, 2011
PubMed
1. "Community Health Services"[Mesh] OR "Community Health Centers"[Mesh] OR "Primary Health Care"[Mesh] OR
"General Practice"[Mesh] OR "Physicians, Family"[Mesh] OR “Primary care nursing”[Mesh] OR Community Health
Care[TIAB] OR Community Health Centre[TIAB] OR Community Health Center[TIAB] OR General practitioner[TIAB] OR
General practice cooperatives[TIAB] OR Family physician[TIAB] OR Primary care nurse practitioner [TIAB] OR Nurse
practitioner [TIAB] OR Out of hours general practice[TIAB] OR After hours general practice[TIAB] OR Primary care[TIAB]
2. Hours of operation[TIAB] OR Business hours[TIAB] OR office hours[tiab]
3."After-hours care"[MH] OR "Health Facility closure"[Mh]
4. 1 AND (2 OR 3)
5. #4 AND English[lang]
6. #5 and (Systematic[sb] OR ((systematic review [ti] OR meta-analysis [pt] OR meta-analysis [ti] OR systematic literature
review [ti] OR (systematic review [tiab] AND review [pt]) OR consensus development conference [pt] OR practice guideline
[pt] OR cochrane database syst rev [ta] OR acp journal club [ta] OR health technol assess [ta] OR evid rep technol assess
summ [ta]) OR ((evidence based[ti] OR evidence-based medicine [mh] OR best practice* [ti] OR evidence synthesis [tiab])
AND (review [pt] OR diseases category[mh] OR behavior and behavior mechanisms [mh] OR therapeutics [mh] OR
evaluation studies[pt] OR validation studies[pt] OR guideline [pt])) OR ((systematic [tw] OR systematically [tw] OR critical
[tiab] OR (study selection [tw]) OR (predetermined [tw] OR inclusion [tw] AND criteri* [tw]) OR exclusion criteri* [tw] OR
main outcome measures [tw] OR standard of care [tw] OR standards of care [tw]) AND (survey [tiab] OR surveys [tiab] OR
overview* [tw] OR review [tiab] OR reviews [tiab] OR search* [tw] OR handsearch [tw] OR analysis [tiab] OR critique [tiab]
OR appraisal [tw] OR (reduction [tw]AND (risk [mh] OR risk [tw]) AND (death OR recurrence))) AND (literature [tiab] OR
articles [tiab] OR publications [tiab] OR publication [tiab] OR bibliography [tiab] OR bibliographies [tiab] OR published [tiab]
OR unpublished [tw] OR citation [tw] OR citations [tw] OR database [tiab] OR Internet [tiab] OR textbooks [tiab] OR
references [tw] OR scales [tw] OR papers [tw] OR datasets [tw] OR trials [tiab] OR meta-analy* [tw] OR (clinical [tiab] AND
studies [tiab]) OR treatment outcome [mh] OR treatment outcome [tw])) NOT (letter [pt] OR newspaper article [pt] OR
comment [pt]) [14 systematic review results]
Embase
1 - 'community care'/exp OR 'community care'
2 - 'health center'/exp OR 'health center'
3 - 'primary health care'/exp OR 'primary health care'
6 - 'general practice'/exp OR 'general practice'
7 - 'general practitioner'/exp OR 'general practitioner'
8 - 'primary care physician'
10 - 'general practice cooperatives' OR 'general practice cooperative'
11 - 'primary care nurse practitioner'
12 - 'nurse practitioner'/exp OR 'nurse practitioner'
13 - 'out of hours general practice'
14 - 'after hours general practice'
15 - 'primary care'/exp OR 'primary care'
16 - #1 OR #2 OR #3 OR #6 OR #7 OR #8 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15
17 - hour*:ab,ti
18 - #16 AND #17
19 - 'review'/exp OR 'review'
20 - (literature NEAR/3 review*):ab,ti
21 - 'meta analysis'/exp OR 'meta analysis'
22 - 'systematic review'/exp OR 'systematic review'
24 - #19 OR #20 OR #21 OR #22
2,474,242
25 - medline:ab,ti OR medlars:ab,ti OR Embase:ab,ti OR pubmed:ab,ti OR cinahl:ab,ti OR amed:ab,ti ORpsychlit:ab,ti OR
psyclit:ab,ti OR psychinfo:ab,ti OR psycinfo:ab,ti OR scisearch:ab,ti OR cochrane:ab,ti
26 - 'retracted article'/exp OR 'retracted article'
27 - #25 OR #26
28 - #24 OR #27
61
29 - (systematic* NEAR/2 (review* OR overview)):ab,ti
30 - 'meta analysis':ab,ti
31 - #28 OR #29 OR #30
32 - #18 AND #31
33 - hour*:ti
34 - #16 AND #31 AND #33
35 - #16 AND #31 AND #33 AND [humans]/lim AND [Embase]/lim [40 results]
The Cochrane Library
1. (hours):kw,ti
2. (after-hours care):kw,ti,ab OR (Health Facility closure):kw,ti,ab
3. MeSH descriptor After-Hours Care explode all trees
4. MeSH descriptor Health Facility Closure explode all trees
5. MeSH descriptor Community Health Services explode all trees
6. MeSH descriptor Community Health Centers explode all trees
7. MeSH descriptor Primary Health Care explode all trees
8. MeSH descriptor General Practice explode all trees
9. MeSH descriptor Physicians, Family explode all trees
10. MeSH descriptor Primary Care Nursing explode all trees
11. (Community Health Care:ti,ab,kw)
12. (Community Health Centre:ti,ab,kw)
13. Community Health Center:ti,ab,kw
14. General practitioner:ti,ab,kw
15. General practice cooperatives:ti,ab,kw
16. Family physician:ti,ab,kw
17. Primary care nurse practitioner:ti,ab,kw
18. Nurse practitioner:ti,ab,kw
19. Out of hours general practice:ti,ab,kw
20. After hours general practice:ti,ab,kw
21. Primary care:ti,ab,kw
22. (#1 OR #2 OR #3 OR #4)
23. (#5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR
#21)
24. (#22 AND #23) 59 TOTAL [1 Cochrane Review, 3 reviews = total of 4]*
*Only look at Cochrane reviews & systematic reviews
3. Health professional staff (emergency): Search conducted September 14, 2011
PubMed
1: Collaborative care[TIAB] OR Enhanced primary care[TIAB] OR Wellness centre[TIAB] OR Wellness centres[TIAB] OR OR
Wellness center[TIAB] OR Wellness centers[TIAB] OR Nursing stations[TIAB] OR Nursing station[TIAB] OR Health
Facilities[TIAB] OR Health facility[TIAB] OR Satellite clinic[TIAB] OR Satellite clinics[TIAB] OR Polyclinic[TIAB] OR
Polyclinics[TIAB] OR Multidisciplinary centre[TIAB] OR Multidisciplinary centres[TIAB] OR Multidisciplinary center[TIAB] OR
Multidisciplinary centers[TIAB]
2: "Hospitals, Rural"[Mesh] OR "Hospitals, Community"[Mesh] OR "Hospitals, Satellite"[Mesh] OR "Emergency Medical
Services"[Mesh] OR "Emergency Nursing"[Mesh] OR "Ambulatory Care" [Mesh] OR "Ambulatory Care Facilities"[Mesh] OR
Rural hospital[TIAB] OR Rural hospitals[TIAB] OR Emergency nursing [TIAB] OR Accident and emergency [TIAB] OR
Emergency Service [TIAB] OR Emergency Services [TIAB] OR urgent care[TIAB] OR (emergency[TIAB] and (nursing [TIAB] or
care[TIAB] or health service[TIAB] or health services[TIAB] or medical service[TIAB] or medical services[TIAB] or outpatient
service[TIAB] or outpatient services[TIAB] or outpatient unit[TIAB] or outpatient units[TIAB] or department[TIAB] or
departments[TIAB]))
3: #1 OR #2
4: "Physicians"[Mesh] or "Nurse Practitioners"[Mesh] or nurse practitioner[TIAB] or nurse practitioners[TIAB] or Allied
Health Personnel[MeSH] or Allied Health Personnel[TIAB] or allied health professional[TIAB] or allied health
professionals[TIAB] or "Nurses' Aides"[Mesh] or "Physician Assistants"[Mesh] or "Emergency Medical Technicians"[Mesh] or
62
paramedics[TIAB] or paramedic[TIAB] or rescue personnel[TIAB] or "Nursing Staff, Hospital"[Mesh] or "Medical Staff,
Hospital"[Mesh]
5: #3 AND #4
6: (systematic review [ti] OR meta-analysis [pt] OR meta-analysis [ti] OR systematic literature review [ti] OR
(systematic review [tiab] AND review [pt]) OR consensus development conference [pt] OR practice guideline [pt] OR
cochrane database syst rev [ta] OR acp journal club [ta] OR health technol assess [ta] OR evid rep technol assess summ [ta])
OR ((evidence based[ti] OR evidence-based medicine [mh] OR best practice* [ti] OR evidence synthesis [tiab])AND(review
[pt] OR diseases category[mh] OR behavior and behavior mechanisms [mh] OR therapeutics [mh] ORevaluation studies[pt]
OR validation studies[pt] OR guideline [pt]))OR
((systematic [tw] OR systematically [tw] OR critical [tiab] OR (study selection [tw]) OR (predetermined [tw] OR inclusion [tw]
AND criteri* [tw]) OR exclusion criteri* [tw] OR main outcome measures [tw] OR standard of care [tw] OR standards of care
[tw]) AND (survey [tiab] OR surveys [tiab] OR overview* [tw] OR review [tiab] OR reviews [tiab] OR search* [tw] OR
handsearch [tw] OR analysis [tiab] OR critique [tiab] OR appraisal [tw] OR
(reduction [tw]AND (risk [mh] OR risk [tw]) AND (death OR recurrence))) AND (literature [tiab] OR articles [tiab] OR
publications [tiab] OR publication [tiab] OR bibliography [tiab] OR bibliographies [tiab] OR published [tiab] OR
unpublished [tw] OR citation [tw] OR citations [tw] OR database [tiab] OR Internet [tiab] OR textbooks [tiab] OR
references [tw] OR scales [tw] OR papers [tw] OR datasets [tw] OR trials [tiab] OR meta-analy* [tw] OR (clinical [tiab] AND
studies [tiab]) OR treatment outcome [mh] OR treatment outcome [tw])) NOT (letter [pt] OR newspaper article [pt] OR
comment [pt])
7: #5 AND #6
8: #7 [limited to English] [295]
Embase
1: 'community care'/exp OR 'health center'/exp OR 'health centre'/exp OR ('community health center' OR 'community
health centre' OR 'community health care' OR 'collaborative care' OR 'enhanced primary care' OR 'wellness centres' OR
'wellness centre' OR 'wellness centers' OR 'wellness center' OR 'nursing stations' OR 'nursing station' OR 'health facilities'
OR 'health facility' OR 'satellite clinic' OR 'satellite clinics' OR polyclinic OR polyclinics OR 'multidisciplinary centre' OR
'multidisciplinary centres' OR 'multidisciplinary center' OR 'multidisciplinary centers' OR 'community care' OR 'health center'
OR 'health centre'):ab,ti
2: ‘ambulatory care’/exp OR ‘emergency nursing’/exp OR ‘outpatient department’/exp OR ‘emergency care’/exp OR
‘emergency health service’/exp OR ‘hospital’/exp OR (‘ambulatory care’ OR ‘outpatient department’ OR ‘rural hospital’ OR
‘accident and emergency’ OR ‘urgent care’ OR (emergency and (nursing OR care OR ‘health service’ OR ‘health services’ OR
‘medical service’ OR ‘medical services’ OR ‘outpatient service’ OR ‘outpatient services’ OR ‘outpatient unit’ OR ‘outpatient
units’ OR department OR departments))):ab,ti
3: #1 OR #2
4: 'hospital personnel'/exp or 'paramedical personnel'/exp or 'physician assistant'/exp or ('hospital physician' or 'hospital
Physicians' or 'Nurse Practitioners' or 'nurse practitioner' or 'Allied Health Personnel' or 'allied health professional' or 'allied
health professionals' or 'nursing assistant' or 'nursing assistants' or 'physician assistant' or 'Physician Assistants' or
'Emergency Medical Technicians' or 'rescue personnel' or paramedics or paramedic or 'Nursing Staff' or 'Medical Staff'):ab,ti
5: #3 AND #4
6: 'meta-analysis':ab,ti OR 'systematic review':ab,ti
7: #5 AND #7
8 limit #7 to Embase only (excludes MEDLINE results), English only [183]
(physician or nurse or paramedic or allied health or support staff):ti,ab,kw and (emergency or urgent):ti,ab,kw
[28 Cochrane reviews, 12 other reviews = 40 total results]
4. Health professional staff (primary): Search conducted September 20, 2011
PubMed
1: Collaborative care[TIAB] OR Enhanced primary care[TIAB] OR Wellness centre[TIAB] OR Wellness centres[TIAB] OR OR
Wellness center[TIAB] OR Wellness centers[TIAB] OR Nursing stations[TIAB] OR Nursing station[TIAB] OR Health
Facilities[TIAB] OR Health facility[TIAB] OR Satellite clinic[TIAB] OR Satellite clinics[TIAB] OR Polyclinic[TIAB] OR
63
Polyclinics[TIAB] OR Multidisciplinary centre[TIAB] OR Multidisciplinary centres[TIAB] OR Multidisciplinary center[TIAB] OR
Multidisciplinary centers[TIAB]
2: "Community Health Services"[Mesh] OR "Community Health Centers"[Mesh] OR "Primary Health Care"[Mesh] OR
"General Practice"[Mesh] OR Community Health Care[TIAB] OR Community Health Centre[TIAB] OR Community Health
Centres[TIAB] OR Community Health Center[TIAB] OR Community Health Centers[TIAB] OR general practice[TIAB] OR
Primary care[TIAB]
3: #1 OR #2
4: "Physicians, Primary Care"[Mesh] or "Physicians, Family"[Mesh] OR "Primary care nursing"[Mesh] or primary care
nurs*[TIAB] or "Nurse Practitioners"[Mesh] OR Family physician[TIAB] OR Nurse practitioners[TIAB] OR Nurse
practitioner[TIAB] OR "General Practitioners"[Mesh] OR General practitioner[TIAB] or primary care physician[TIAB] or Allied
Health Personnel[MeSH] or Allied Health Personnel[TIAB] or allied health professional[TIAB] or allied health
professionals[TIAB] or "Emergency Medical Technicians"[Mesh] or paramed*[TIAB] or rescue personnel[TIAB]
5: #3 AND #4
6: (systematic review [ti] OR meta-analysis [pt] OR meta-analysis [ti] OR systematic literature review [ti] OR
(systematic review [tiab] AND review [pt]) OR consensus development conference [pt] OR practice guideline [pt] OR
cochrane database syst rev [ta] OR acp journal club [ta] OR health technol assess [ta] OR evid rep technol assess summ [ta])
OR ((evidence based[ti] OR evidence-based medicine [mh] OR best practice* [ti] OR evidence synthesis [tiab])AND(review
[pt] OR diseases category[mh] OR behavior and behavior mechanisms [mh] OR therapeutics [mh] OR evaluation studies[pt]
OR validation studies[pt] OR guideline [pt])) OR ((systematic [tw] OR systematically [tw] OR critical [tiab] OR (study selection
[tw]) OR (predetermined [tw] OR inclusion [tw] AND criteri* [tw]) OR exclusion criteri* [tw] OR main outcome measures
[tw] OR standard of care [tw] OR standards of care [tw]) AND (survey [tiab] OR surveys [tiab] OR overview* [tw] OR review
[tiab] OR reviews [tiab] OR search* [tw] OR handsearch [tw] OR analysis [tiab] OR critique [tiab] OR appraisal [tw] OR
publications [tiab] OR publication [tiab] OR bibliography [tiab] OR bibliographies [tiab] OR published [tiab] OR unpublished
[tw] OR citation [tw] OR citations [tw] OR database [tiab] OR Internet [tiab] OR textbooks [tiab] OR references [tw] OR
scales [tw] OR papers [tw] OR datasets [tw] OR trials [tiab] OR meta-analy* [tw] OR (clinical [tiab] AND studies [tiab]) OR
treatment outcome [mh] OR treatment outcome [tw])) NOT (letter [pt] OR newspaper article [pt] OR comment [pt])
7: #5 AND #6
Embase
OR 'health centre'):ab,ti [120,476]
2: 'primary care'/exp OR 'general practice'/exp OR 'primary health care'/exp OR ('primary care' OR ‘general practice’ OR
'primary health care' OR ‘primary medical care’ OR 'general practice'):ab,ti [176,018]
3: #1 OR #2
4: 'general practitioner'/exp OR 'paramedical personnel'/exp or 'physician assistant'/exp or ('family physician' OR ‘family
physicians’ OR ‘family practitioner’ OR ‘family practitioners’ OR 'general practitioner' OR 'general practitioners' or 'Nurse
Practitioners' or 'nurse practitioner' or 'primary nursing' or 'Allied Health Personnel' or 'allied health professional' or 'allied
health professionals' or 'Emergency Medical Technicians' or 'rescue personnel' or paramedics or paramedic):ab,ti
5: #3 AND #4
7: #5 AND #7
8 limit #7 to Embase only (excludes MEDLINE results), English only
(physician or nurse or paramedic or allied health or support staff):ti,ab,kw and (primary or general):ti,ab,kw
[91 Cochrane reviews, 43 other reviews= 134 total results]
5. Collaborative practice (primary or emergency): Searches conducted October 12, 2011
64
PubMed
1: Enhanced primary care[TIAB] OR Wellness centre[TIAB] OR Wellness centres[TIAB] OR Wellness center[TIAB] OR
Wellness centers[TIAB] OR Nursing stations[TIAB] OR Nursing station[TIAB] OR Health Facilities[TIAB] OR Health
facility[TIAB] OR Satellite clinic[TIAB] OR Satellite clinics[TIAB] OR Polyclinic[TIAB] OR Polyclinics[TIAB] OR Multidisciplinary
centre[TIAB] OR Multidisciplinary centres[TIAB] OR Multidisciplinary center[TIAB] OR Multidisciplinary centers[TIAB]
2: "Hospitals, Rural"[Mesh] OR "Hospitals, Community"[Mesh] OR "Hospitals, Satellite"[Mesh] OR "Emergency Medical
Services"[Mesh] OR "Emergency Nursing"[Mesh] OR "Ambulatory Care" [Mesh] OR "Ambulatory Care Facilities"[Mesh] OR
Rural hospital[TIAB] OR Rural hospitals[TIAB] OR Emergency nursing [TIAB] OR Accident and emergency [TIAB] OR
Emergency Service [TIAB] OR Emergency Services [TIAB] OR urgent care[TIAB] OR (emergency[TIAB] and (nursing [TIAB] or
care[TIAB] or health service[TIAB] or health services[TIAB] or medical service[TIAB] or medical services[TIAB] or outpatient
service[TIAB] or outpatient services[TIAB] or outpatient unit[TIAB] or outpatient units[TIAB] or department[TIAB] or
departments[TIAB])) [206591]
3: "Community Health Services"[Mesh] OR "Community Health Centers"[Mesh] OR "Primary Health Care"[Mesh] OR
"General Practice"[Mesh] OR "Physicians, Family"[Mesh] OR "Primary care nursing"[Mesh] OR primary care nurs*[TIAB] or
"Nurse Practitioners"[Mesh] or Community Health Care[TIAB] OR Community Health Centre[TIAB] OR Community Health
Centres[TIAB] OR Community Health Center[TIAB] OR Community Health Centers[TIAB] OR "General Practitioners"[Mesh]
OR General practitioner[TIAB] OR general practice[TIAB] OR Family physician[TIAB] OR Nurse practitioners [TIAB] OR Nurse
practitioner [TIAB] OR Primary care[TIAB]
4: #1 OR #2 or #3
5: Collaborative care[TIAB] or collaborative practice[TIAB] or collaborative practices[TIAB] or "Interprofessional
Relations"[Mesh] or "Cooperative Behavior"[Mesh] or "Patient Care Team"[Mesh] or "Nursing, Team"[Mesh] or
"Interdisciplinary Communication"[MESH] or interdisciplinary team[TIAB] or inter-profession*[TIAB] or
interprofession*[TIAB] or inter-disciplin*[TIAB] or interdisciplin*[TIAB] or interdepartment*[TIAB] or interdepartment*[TIAB] or multi-profession*[TIAB] or multiprofession*[TIAB] or multi-disciplin*[TIAB] or multidisciplin*[TIAB]
6: #4 AND #5
7: (systematic review [ti] OR meta-analysis [pt] OR meta-analysis [ti] OR systematic literature review [ti] OR (systematic
review [tiab] AND review [pt]) OR consensus development conference [pt] OR practice guideline [pt] OR cochrane database
syst rev [ta] OR acp journal club [ta] OR health technol assess [ta] OR evid rep technol assess summ [ta]) OR ((evidence
based[ti] OR evidence-based medicine [mh] OR best practice* [ti] OR evidence synthesis [tiab])AND(review [pt] OR diseases
category[mh] OR behavior and behavior mechanisms [mh] OR therapeutics [mh] ORevaluation studies[pt] OR validation
studies[pt] OR guideline [pt]))OR ((systematic [tw] OR systematically [tw] OR critical [tiab] OR (study selection [tw]) OR
(predetermined [tw] OR inclusion [tw] AND criteri* [tw]) OR exclusion criteri* [tw] OR main outcome measures [tw] OR
standard of care [tw] OR standards of care [tw]) AND (survey [tiab] OR surveys [tiab] OR overview* [tw] OR review [tiab] OR
reviews [tiab] OR search* [tw] OR handsearch [tw] OR analysis [tiab] OR critique [tiab] OR appraisal [tw] OR (reduction
[tw]AND (risk [mh] OR risk [tw]) AND (death OR recurrence))) AND (literature [tiab] OR articles [tiab] OR publications [tiab]
OR publication [tiab] OR bibliography [tiab] OR bibliographies [tiab] OR published [tiab] OR unpublished [tw] OR citation
[tw] OR citations [tw] OR database [tiab] OR Internet [tiab] OR textbooks [tiab] OR references [tw] OR scales [tw] OR papers
[tw] OR datasets [tw] OR trials [tiab] OR meta-analy* [tw] OR (clinical [tiab] AND studies [tiab]) OR treatment outcome [mh]
OR treatment outcome [tw])) NOT (letter [pt] OR newspaper article [pt] OR comment [pt])
8: #6 AND #7
Embase
OR 'health centre'):ab,ti
2: ‘ambulatory care’/exp OR ‘emergency nursing’/exp OR ‘outpatient department’/exp OR ‘emergency care’/exp OR
‘emergency health service’/exp OR ‘hospital’/exp OR (‘ambulatory care’ OR ‘outpatient department’ OR ‘rural hospital’ OR
‘accident and emergency’ OR ‘urgent care’ OR (emergency and (nursing OR care OR ‘health service’ OR ‘health services’ OR
‘medical service’ OR ‘medical services’ OR ‘outpatient service’ OR ‘outpatient services’ OR ‘outpatient unit’ OR ‘outpatient
units’ OR department OR departments))):ab,ti
3: 'primary care'/exp OR 'general practice'/exp OR 'general practitioner'/exp OR 'primary health care'/exp OR ('primary care'
OR ‘general practice’ OR 'general practitioner' OR ‘general practitioners’ OR 'primary health care' OR ‘primary medical care’
65
OR 'family physician' OR ‘family physicians’ OR ‘family practitioner’ OR ‘family practitioners’ OR 'general practice' OR 'nurse
practitioner'):ab,ti
4: #1 OR #2 OR #3
5: 'teamwork'/exp OR 'public relations'/exp OR ('multiprofessional' OR 'multi-professional' OR 'interprofessional' OR 'interprofessional' OR 'interorganizational' OR 'inter-organizational' OR 'teamwork' OR 'multidisciplinary' OR 'multi disciplinary'
OR 'collaborative practices' OR 'collaborative practice' OR 'interdepartmental' OR 'inter departmental'):ab,ti
6: #4 AND #5
8: #6 AND #7
9 limit #8 to Embase only (excludes MEDLINE results), English only [60]
6. Telehealth/Tele-consultation: Searches conducted August 22, 2011
PubMed
((systematic review [ti] OR meta-analysis [pt] OR meta-analysis [ti] OR systematic literature review [ti] OR (systematic
review [tiab] AND review [pt]) OR consensus development conference [pt] OR practice guideline [pt] OR cochrane database
syst rev [ta] OR acp journal club [ta] OR health technol assess [ta] OR evid rep technol assess summ [ta]) OR ((evidence
based[ti] OR evidence-based medicine [mh] OR best practice* [ti] OR evidence synthesis [tiab]) AND (review [pt] OR
diseases category[mh] OR behavior and behavior mechanisms [mh] OR therapeutics [mh] OR evaluation studies[pt] OR
validation studies[pt] OR guideline [pt])) OR ((systematic [tw] OR systematically [tw] OR critical [tiab] OR (study selection
[tw]) OR (predetermined [tw] OR inclusion [tw] AND criteri* [tw]) OR exclusion criteri* [tw] OR main outcome measures
[tw] OR standard of care [tw] OR standards of care [tw]) AND (survey [tiab] OR surveys [tiab] OR overview* [tw] OR review
[tiab] OR reviews [tiab] OR search* [tw] OR handsearch [tw] OR analysis [tiab] OR critique [tiab] OR appraisal [tw] OR
publications [tiab] OR publication [tiab] OR bibliography [tiab] OR bibliographies [tiab] OR published [tiab] OR unpublished
[tw] OR citation [tw] OR citations [tw] OR database [tiab] OR Internet [tiab] OR textbooks [tiab] OR references [tw] OR
scales [tw] OR papers [tw] OR datasets [tw] OR trials [tiab] OR meta-analy* [tw] OR (clinical [tiab] AND studies [tiab]) OR
treatment outcome [mh] OR treatment outcome [tw])) NOT (letter [pt] OR newspaper article [pt] OR comment [pt])
OR
Cochrane Database Syst Rev [TA] OR search[Title/Abstract] OR meta-analysis[Publication Type] OR MEDLINE[Title/Abstract]
OR (systematic[Title/Abstract] AND review[Title/Abstract]))
AND
("Remote Consultation"[mesh term] OR teleconsultation[tiab] or telehealth[tiab] or telemedicine[mesh term] or
telemedicine[tiab]) OR teleemergency[tiab] OR telemergency[tiab])
AND humans[Mesh term]
AND English[la] [Results= 344 results]
Embase
1. 'review'/exp
2. (literature near/3 review*):ti,ab
3. 'meta analysis'/exp
4. "systematic review"/exp
5. or/1-4
6. (medline or medlars or Embase or pubmed or cinahl or amed or psychlit or psyclit or psychinfo or psycinfo or scisearch or
cochrane):ti,ab
7. 'RETRACTED ARTICLE'
8. 6 OR 7
9. 5 OR 8
10. (systematic* near/2 (review* or overview)):ti,ab
11. 'meta analysis':ti,ab
12. 9 Or 10 OR 11
13. 'telemedicine'/exp OR 'telemedicine' OR 'telehealth'/exp OR 'telehealth' OR 'teleconsultation'/exp OR 'teleconsultation'
AND [humans]/lim AND [english]/lim AND [Embase]/lim
14. #12 ANd #13 [318]
66
(teleconsultation OR telehealth OR telemedicine OR "Remote consultation" or "telemergency" OR
"teleemergency"):ti,ab,kw [6 systematic review/ 57 reviews - 54 imported, 3 duplicates]
67
Appendix 8: Flow Charts of Database Search Results
Overall database screening results for all prioritized questions:
Records identified through
database searching
(n=6545)
Records screened
after duplicates
removed (n=6277)
Records excluded
at title/abstract
stage (n=5931)
Full text assessed
for eligibility
(n=259)
Full text identified
as primary studies
(n=203)
Reviews
identified and
data extracted
(n=56)
Articles included
in synthesis
(n=55)
68
1. CEC-type models
grey literature searching
(n=12)
database searching
(n=1758)
Records screened
after duplicates
removed (n=1723)
Full text assessed
for eligibility
(n=45)
Records excluded
at title/abstract
stage (n=1678)
as primary studies
(n=32)
Grey literature
assessed and found
unsuitable (n=12)
Reviews
identified and
data extracted
(n=1)
Articles included
in synthesis (n=0)
69
2. Hours of access
database searching
(n=845)
Records screened
after duplicates
removed (n=835)
Records excluded
at title/abstract
stage (n=824)
Full text assessed
for eligibility
(n=11)
as not relevant to
questions (n=9)
Reviews
identified and
data extracted
(n=2)
Articles included
in synthesis (n=2)
70
3. Health professional staff (emergency care)
database searching
(n=518)
Records screened
after duplicates
removed (n=495)
Records excluded
at title/abstract
stage (n=449)
Full text assessed
for eligibility
(n=46)
as primary studies
(n=22)
Reviews
identified and
data extracted
(n=24)
Articles included
in synthesis (n=8)
71
4. Health professional staff (primary care)
database searching
(n=1116)
Records screened
after duplicates
removed (n=1052)
Records excluded
at title/abstract
stage (n=974)
Full text assessed
for eligibility
(n=78)
as primary studies
(n=30)
Reviews
identified (n=48)
Reviews data
extracted and
included in
synthesis (n=11)
72
Reviews excluded with
reasons (n=37)
-Setting/exposure not
relevant (n=32)
-Not matched to
question (n=5)
5. Collaborative Practices (primary and emergency care)
database searching
(n=1583)
Records screened
after duplicates
removed (n=1521)
Records excluded
at title/abstract
stage (n=1394)
Full text assessed
for eligibility
(n=127)
Full text excluded, with
reasons (n = 55)
-primary study (n=49)
-withdrawn review (3)
-not available
electronically (3)
Reviews
identified (n=69)
Articles included
in synthesis
(n=19)
73
Reviews excluded, with
reasons (n=50)
-Setting/exposure not
relevant (n=47)
-Not matched to
question (n=3)
6. Telehealth/Tele-consultation
database searching
(n=725)
Records screened
after duplicates
removed (n=663)
Records excluded
at title/abstract
stage (n=612)
Full text assessed
for eligibility
(n=51)
Full text excluded, with
reasons (n=24)
-published before 2010
review of reviews
(n=23)
-not available
electronically (1)
Reviews
identified and
data extracted
(n=27)
Articles included
in synthesis
(n=15)
74
Appendix 9: Data Extraction Questions from Distiller Form
Inclusion criteria:
Is the exposure evaluated relevant
to the research question?
Is the setting relevant to the
research question?
Are outcome(s) related to:
Yes/No; text box for notes
Health outcomes
(morbidity, mortality,
quality of life, patient
satisfaction)
Process outcomes (quality
of care, professional
satisfaction, adherence to
recommended practice)
Costs or Resource Use
If the answer is No to any of the
above three questions, tick box to
flag record
Flag; text box for notes
Search details & PICO strategy
Purpose/Objectives of the review
Types of studies/reviews included
Population
Intervention/Exposure
Comparison
Outcome(s) - Select any/all as
appropriate, text boxes for notes:
Text box for notes
Text box for notes
Text box for notes
Text box for notes
Text box for notes
Health related outcomes (Morbidity, mortality,
quality of life, patient satisfaction)
Process Outcomes (Quality of care, professional
practice, adherence to recommended practice,
professional satisfaction)
Cost or Resource Use
Quality of Review
Authors provided an adequate
search strategy
Authors assessed study quality:
Authors provided a table of
included studies:
Review Results
Population evaluated
Intervention/Exposure evaluated
Outcome(s) - Select any/all as
appropriate, text boxes for notes:
Yes/(blank), text box for notes
Yes/(blank) , text box for notes
Yes/(blank) , text box for notes
Text box for notes
Text box for notes
Health related outcomes (Morbidity, mortality,
quality of life, patient satisfaction)
Process Outcomes (Quality of care, professional
practice, adherence to recommended practice,
professional satisfaction)
75
Cost or Resource Use
Results by Outcome
Health Outcomes
Process Outcomes
Results
Author’s conclusions
Author’s conclusions: select
positive/neutral/negative
Additional notes
Results
Additional notes
Results
Additional notes
Quality of Evidence
Health Outcomes
Process Outcomes
Notes
Other notes:
Text boxes for notes:
Type of evidence included
(e.g., RCTs, Observational, Qualitative)
Potential Bias (Comments from authors)
Generalizability
Generalizability
Generalizability
Generalizability
Text box for notes
76
Appendix 10: Evidence Tables for Included Reviews
Reviews included for prioritized searches were summarized into evidence tables. Review objectives, results
and conclusions were extracted, in addition to the quality of review methods and quality of evidence
available. Conclusions were listed as positive, neutral or negative. Positive results suggested intervention
leading to improved outcomes. Neutral results concluded that intervention had no impact on, or had similar
outcomes. Negative results concluded that intervention led to decreased outcomes.
Methods:
CS: Comprehensive Search strategy
QA: Quality Assessment
IS: Identified list of Studies
2. Hours of access (primary or emergency care)
Author
Year
Carret and
Domingues
2009
Review Objectives
Leibowitz
2003
Effect of different
models of out-ofhours primary
medical care
services (practicebased service,
deputizing services,
EDs, co-operatives,
primary care
centres, and
telephone triage
and advice services)
Measure and
identify factors
associated with
inappropriate ED
use by adults
Studies
included
22 studies:
Crosssectional (19),
case-control
(2), and
cohort (1)
studies
Methods
Reported Results
CS; QA; IS
Reported 2 studies evaluated and found an association between difficult
access to primary health care and inappropriate ED use. An included
cohort study conducted in the US found difficulty in scheduling primary
care, difficult telephone contact for primary care, and longer waiting
time for a primary care appointment were associated with inappropriate
ED use.
In the cohort study in the United States, the association was statistically
significant. The variables comprising this indicator, difficulty in
scheduling primary care, difficult telephone contact for primary care,
and longer waiting time for a primary care appointment were also
associated with inappropriate ED use. Meanwhile, in the Brazilian study,
difficulty in obtaining a primary care appointment, refusal by the
primary care physician to treat patients without a previously scheduled
appointment, and primary care being open for shorter hours were
associated with inappropriate ED use in the 15-49 age group.
19
comparative
studies: RCTs
(4), pseudoRCTs (2),
observational
(7), pre-post
(5)
CS; QA; IS
Reported that there is very little evidence about the advantages of one
service model compared with another in relation to clinical outcome.
The only area where there is some limited evidence is about differences
in prescribing habits. The evidence suggests that deputizing doctors may
prescribe less appropriately than doctors from practice-based or cooperative services, and that GPs prescribe more appropriately than
junior emergency medical staff. Telephone triage and advice services
appear to reduce medical workload through the substitution of
telephone consultations for in-person consultations and have potential
to reduce costs. This has to be balanced with the finding of reduced
patient satisfaction when in-person consultations are replaced by
telephone consultations.
77
Summary of
conclusions
Cost Outcomes:
Neutral
Quality of Evidence available
Health and
Process
Outcomes:
Neutral
Studies included in this review were from the UK,
Australia, Denmark, Ireland, Canada and the USA.
There variation between how GP systems operate
between countries. The highest quality studies have
come from the UK, possibly because government
funding and organization of the health service make
such studies more feasible. This has perhaps given
the review a bias towards findings applicable to the
UK system.
"A shortcoming of our categorization is that some of
our models are types of organization, e.g. cooperatives and deputizing services, and others are
modes of delivery. The difficulty in comparing the
results of studies carried out in one health care
setting with those carried out in a different setting
need to be borne in mind when evaluating the
studies"
Eight studies conducted were in European countries,
seven in North America, one in Central America, one
in Oceania, three in China, and two in South America.
Observational study designs, but studies had to meet
Downs & Black criteria.
Salisbury
2003
(Broad
narrative
review)
Experience with
walk-in centres in
primary &
emergency care
(centres/clinics
designed to offer
primary care on a
non-appointment
walk-in basis minor injuries &
illness; excluded
centres designed
for medical
emergencies and
major trauma;
‘Drop-in’ clinics
that catered only
for one specific
health need, such
as contraception,
were excluded)
244 articles
considered
relevant
(discussion
documents,
review
articles, and
primary
research);
only some
discussed in
publication.
CS
Patient satisfaction: Studies from both the USA and Canada have
demonstrated high levels of satisfaction among patients attending walkin centres.
To summarise the evidence from the international literature, it appears
that users of walk-in centres in other countries are predominantly a
relatively affluent population of working age and a different population
from those using conventional general practice services. The majority of
calls to walk-in centres are made when other health services are closed.
The problems presented are mainly minor illnesses and minor injuries.
People choose this form of care mainly for reasons of convenience, and
they are generally very satisfied with the service they receive. The very
limited evidence available suggests that walk-in centres provide care of
reasonable quality. There is insufficient evidence to draw any confident
conclusions about the issues of the impact of walk-in centres on other
health care services or on the costs of care.
There is a marked lack of available information about the costs of walkin centres. Only one study was identified (with methodological
limitations), which suggested that the cost of care in walk-in centres in
Canada was similar to costs in general practice and lower than the costs
of hospital emergency departments.
Health outcomes:
Positive
Authors do not comment on potential bias. Authors
do not discuss the quality of the care provided. I think
that because 244 studies were used however and the
results were fairly consistent, this might be an
advantage to this study
3. Health professional staff (Emergency care)
Author
Year
Review objectives
Studies included
Methods
Reported Results
Summary of
conclusions
Quality of evidence available
Wilson
2009
ENP for adults
presenting to an ED for
treatment of a minor
injury (care delivered
included referral to
other practitioners/
services, medication,
radiographs and other
treatment, such as
bandaging and
suturing)
9 studies: RCTs, nonrandomized clinical
trials, case-series,
case–control and
cohort studies
CS; QA; IS
Patient satisfaction with the care received and acceptance of being treated by
NP was generally high in all the studies reporting on this outcome. Reducing
the amount of medical officer time spent on specified presentations logically
has an effect in improving patient access to interventions, reducing issues of
ED overcrowding and improving patient satisfaction with health service.
Two studies reported that care provided by ENP was effective in reducing wait
times for treatment and overall LOS in the ED. Based on evidence from nine
studies included, there is no significant difference between the effectiveness of
ENP and junior doctors. There were no comparative studies between ENP and
other health professionals in the management of minor injuries that could be
included. A study comparing ENP with physiotherapists and doctors did not
meet the inclusion criteria. Therefore, this conclusion must be interpreted with
caution because of the poor to fair methodological study designs used and
variable types of outcome measures used. Anecdotally, there does appear to
be a significance in the reduction of waiting times for patients to be assessed,
waiting times for treatment and overall LOS times, consequently improving the
flow of patients through EDs.
A single study was identified that compared the clinical and cost-effectiveness
of ENP.
Health
Outcomes:
Positive;
The overall quality of the included
studies was generally low (study
designs other than RCTs) and studies
were heterogeneous (differing
triage scoring systems and
diagnostic categories used in EDs
internationally).
78
Process and
Cost
outcomes:
Neutral
Carter
2007
Effect of NPs in the ED
(adult and pediatric
patients)
36 studies: RCTs (3),
surveys (7), case–
control (18) and
cohort studies (8).
CS; QA; IS
Kleinpell
2008
Effect of NPs and
physician assistants
(PAs) in acute and
critical care settings
31 studies (all
settings); 17 research
studies in ED (2 RCTs
in ED)
CS; IS
Hoskins
2011
Effect of ENPs,
expanded scope
physiotherapists (ESPs)
and emergency care
practitioners (ECPs) in
all emergency care
settings (adult and
pediatric)
All studies (primary
studies & reviews),
also commentaries/
editorials. 23 papers
included: Qualitative,
survey data, ECTs,
systematic reviews,
case control studies.
CS; IS
Patient satisfaction was consistently high for both NPs and residents, but was
often higher for NPs. A survey found 72.5% would be willing to see an NP,
although 21% of those people also expected to see a staff physician. Of the
12.1% who were unwilling to see an NP, 36% said they would never be willing
and 81.2% said they would see an NP only if they had a different problem.
Twenty-five percent said that they would see an NP if it would result in cost
savings to the health care system, and 37.5% said they would agree, if it would
result in shorter ED wait times.
Several of the studies looking at quality of care examined the accuracy of x-ray
interpretation. Resident physicians and NPs were found to be equally
competent, with a trend toward greater accuracy with more experience,
regardless of profession. Most studies found attending physicians have judged
NP care to be appropriate (based on protocols); one older (1979) study
reported worse performance of NPs judged by staff physicians. One RCT (in
rural isolated Australian ED) found documentation, accuracy of physical exam
and appropriateness of urgent referrals were higher for the NPs.
NPs appear to be more expensive than residents, on a per patient basis
(studies have factored in more than the salary, although it is unknown whether
the training costs of residents were included). These studies did not compare
NPs to attending physicians. The addition of an NP, whether in a minor injury
unit in the ED or in a free standing unit, wait times are reduced. The studies do
not compare the addition of an NP with the addition of any other staff (e.g.,
more residents, another attending physician or a physician’s assistant); in a UK
study, average wait time to see a practitioner dropped from 56 to 30 minutes,
the average time in the department decreased from 1 hour and 39 minutes to
1 hour and 17 minutes. Most studies examined NPs in minor treatment areas;
2 studies suggested that NPs could also reduce wait times by seeing higher
acuity patients.
Health and
process
outcomes:
Positive
overall;
Two RCTs assessed the impact of NPs in ED settings. In a large RCT comparing
NP with resident Medical doctor (MD) care, there were no differences found in
accuracy of exams, adequacy of treatment, planned follow-up, or requests for
interpretation of x-rays. NPs found to record more medical histories, and fewer
patients seen by the NP had to seek unplanned follow-up advice about their
injury. A second RCT compared NP-led care for patients with senior house
officer care and found no differences in recovery times, levels of symptoms,
time off work, or unplanned follow-up between groups. Patients reported
higher levels of satisfaction with NP care compared with MD care and NP
clinical documentation was rated of higher quality.
23 studies reported patient satisfaction with “nonmedical roles” in ED care.
While the studies all report high levels of patient satisfaction with “nonmedical” roles in the ED, one study reported that overall patient satisfaction
was higher in patients seen by a doctor rather than an ENP. The most
significant feature of patients dissatisfaction in this study was a practitioners
perceived lack of social skills irrespective of their professional background.
Patients also cite a lack of professional confidence particularly in the ENP group
as a reason for dissatisfaction. While all other studies reported that the
majority of patients would agree to see an ENP in the future this still meant
that significant numbers of patients would prefer to see a doctor. Several
authors reported that patients seen by ENPs were more likely to seek follow up
in primary care following their initial visit to the ED and this is an area which
urgently requires further investigation.
Health and
Process
Outcomes:
Positive
Limited generalizability (small
sample sizes, use of selected
settings, limited populations of
interest, and short duration of
outcome assessment); small number
of studies available. Messages focus
on RCT results
Health
Outcomes:
Positive
No discussion of potential bias by
authors - several study designs with
high potential bias included. Unclear
generalizability (considered UK
context)
79
Cost
outcomes:
Neutral
Potential bias not discussed. Results
focused around non-RCT studies
(only one RCT available). Limited
generalizability of studies included
due to different practices
internationally (e.g. UK and
Australian systems provide much of
their emergency care using senior
house officers, whose positions
would be about equivalent to North
American mid-level residents. This is
not the standard in Canada or in the
United States, where patients may
initially be seen by a resident, but
are always directly overseen by a
staff physician). Cost–benefit is
unclear. Most of the reviewed
papers focused on NPs in a minor
injury or fast track setting.
Rowe
2011
Compare the effect of
triage liaison physicians
(TLPs) with nurse-led
triage in adult (17 years
or older) or mixed (i.e.,
child/ adult)
populations.
28 studies: RCTs
(parallel or cluster
group)(2), CCTs,
prospective or
retrospective cohort
studies, interrupted
time series (ITS), case–
control studies, and
before–after designs
CS; QA; IS
Two RCTs indicated a significant reduction in ED LOS when comparing TLP
interventions to nurse-led triage(mean 37 minutes shorter). All the non-RCT
studies except for three reported statistically significant reductions in the
individual estimates of ED LOS. One RCT showed a significant reduction in the
time to physician initial assessment associated with TLP presence when
compared to nurse-led triage (mean 30.00 minutes shorter). Most non-RCTs
also showed a significant reduction in this indicator patients leaving the ED
without being seen; this was not significantly different in included RCT.
Individual study results on 'leaving against medical advice' were inconsistent.
Process
outcomes:
Positive
Cohen
2009
Descriptive review of
pharmacy practice or
services provided in the
ED
16 studies (from 12
institutions) included.
All study designs
considered.
CS; IS
Process and
Cost
Outcomes:
Cautiously
positive
Doan
2011
Use of PAs in the ED.
66 studies: Included
surveys, retrospective
and prospective
controlled and
observational studies,
as well as
comprehensive
reviews.
CS; QA; IS
Intervention categories differed among institutions, suggesting a need for
standardization. Documentation methods differed among institutions and
included paper cards, personal digital assistants, and computer programs.
Services provided by pharmacists in the ED included traditional clinical
pharmacy services, responding to medical emergencies, providing
consultations on medication issues. An observational study found medication
histories to be more complete with pharmacist than ED providers; more
documentation of medication allergies.
Suggestion of cost savings/cost avoiding with pharmacist. Cost-avoidance data
reported in the articles reviewed lack formal structured pharmacoeconomic
analysis. In most cases, these figures were calculated to justify ED services and
pharmacy service expansion.
Two studies evaluated patient satisfaction with PA care in the ED. Both found
high rates of satisfaction with PA care, although response rates were low (11%
and 25%, respectively). The quality of the care provided by PAs was
comparable with that of ED specialist (attending) physicians and senior
residents, and their use resulted in shorter wait times for ED patients. It is
unclear whether this was attributable to PA presence, or the effect of having
additional health-care providers (of any type) within the department.
Although there were some statistical differences in the practice patterns
between physicians and PAs such as rate of investigations ordered (PAs
ordered more throat cultures for pharyngitis and fewer blood cultures for
febrile children), no studies addressed whether these differences had an
impact on patient outcome. Procedure performance: Four studies compared
PAs’ skills in performing procedures. PAs appear equally capable of performing
procedures if adequately trained and supervised.
PAs represent a less expensive alternative for increased staffing. Indirect
evidence suggests some differences in total visit duration and cost for some
clinical conditions managed by an emergency physician versus a PA. Role and
scope remains to be defined.
11 studies: 3 RCTs, 2
controlled before-andafter studies, and 6
non-controlled
before-and after
studies
CS; QA; IS
Three of the 11 studies reported clinical outcomes, and each of these tested
case management. Conflicting findings reported (1 study significant reduction
in alcohol and drug use at 12 months; 1 study identified a reduction in alcohol
use but no difference in psychiatric symptoms 24 months after intervention
and 1 study found no differences in drug use).
Use of ambulatory care was evaluated in 6 studies: 2 studies identified a
benefit of the intervention (increase in primary care & community care
engagement; another described a significant increase in the median number of
medical outpatient visits & a significant reduction in the number of patients
Health and
cost
outcomes:
Neutral;
Althaus
2011
Effect of interventions
targeting adult
frequent users of
hospital EDs; mosttested intervention was
case management
referring to
coordination of health
services on behalf of
80
Health
Outcomes:
Positive;
Process and
cost
outcomes
Reported as
neutral
Process
outcomes:
Positive
Heterogeneous findings; small
number of small studies (no
multicentre). Reports of important
outcomes (e.g., times, LWBS, costs)
were commonly missing. Due to
insufficient data, anticipated
subgroup comparisons and
sensitivity analyses were not always
possible; however, subgroup
analyses for triage level 3 patients
and by type of intervention (team
triage vs. single-physician triage)
were completed. Funnel plot
suggested some publication bias.
Most of the studies published were
not of high quality (descriptive). No
quality assessment is clearly
described. Selection bias may have
occurred as the search strategy
selected articles that reported on
the benefits of pharmacists in the
ED. Heterogeneous scope of
pharmacist involvement described.
Methodological quality of studies
was weak to moderate. The
heterogeneity in the type of EDs
studied and the fact that PAs were
often used in combination with NPs
prevented pooling of data. Small
number of PAs or patients studied,
use of historical controls and
comparison of study populations
with different baselines without
adequate adjustment. Similar
limitations were observed in studies
that evaluated the impact of PAs on
patient flow and satisfaction.
Cost data suggest savings, but
financial implications of PAs might
be significantly different in countries
other than the USA.
Generalizability was limited.
The quality of the included studies
on the whole was moderate and
sample sizes were small in all but 3
studies; publication bias could not
be assessed; heterogeneity in the
selected studies in terms of design,
definition of frequent users,
intervention type, outcomes, and
outcome measurement
the patient by
multidisciplinary teams
lacking a primary care practitioner) None of the 4 studies assessing
hospitalization identified significant differences. Finally, although one study
reported no significant difference in patient satisfaction, (before-after) another
revealed high physician satisfaction.
11 studies reported amount of ED use; 7 studies showed reduction in ED use, 1
demonstrated an increase in ED use, and 3 revealed no significant changes.
None of the 4 studies assessing hospitalization identified significant
differences. Finally, although one study reported no significant difference in
patient satisfaction before and after the intervention, another revealed high
physician satisfaction. Case management may be intervention of choice to
reduce ED use for specific groups of vulnerable patients and for all frequent
users of EDs.
Cost analyses conducted in 3 studies have indicated that the
introduction of a case management team could reduce ED costs by at least as
much as the cost of the team itself.
4. Health professional staff (Primary care)
Author
Year
Review Objectives
Studies
included
Metho
ds
Reported Results
Overall
Conclusions
Quality of Evidence Available
Bower 2000
Onsite mental
health
professionals in the
reduction of
frequency of
consultations,
prescriptions, and
referrals to offsite
services by GP.
40 studies: 31
RCTs and 9
before and
after trials.
QA
Direct effects: 3/13 studies on consultation rates reported statistically
significant effects, with lower rates in the mental health professional groups.
Of the 12 studies of prescribing behaviour, five found significant reductions in
the mental health professional group. The effects were not always consistent
within studies in terms of the different drugs examined and the duration of the
effect. 3/6 RCTs of referral behaviour reported significant reductions in the
mental health professional group. Two others reported lower rates and costs in
the mental health professional group, and one reported no difference.
Process
outcomes:
Positive
Variable quality of included studies but statistically
significant results was not restricted to studies with
methodological weaknesses.
Pooling was not undertaken because data, such as
variance statistics, were frequently not reported.
No discernible publication bias favouring positive
effects on behaviour of GPs, possibly because most
included studies were primarily concerned with the
clinical effectiveness of mental health professionals
and not their impact on the GP. For the same reasons
the quality of information on behaviour of GPs was
variable.
Indirect effects: None of the studies reported a significant association between
onsite mental health professionals and practice prescribing of psychotropics.
One controlled before and after study reported a significant association
between an onsite mental health professional and higher rates of referral to
secondary care. The authors conducted a second analysis using a smaller
subset of practices matched for deprivation, population size, fundholding
status, and location, and they found no differences in referral rates.
Concerns have also been raised about the external
validity of such primary care studies. Prescribing
behaviour in trials may differ from routine care.
Overall Conclusion: Referral to an onsite mental health professional may
reduce referrals and prescribing by GPs, but there is no evidence that such
changes are enduring or particularly broad in scope
Brown 1995
NPs in primary care
roles compared to
physician care for
patients receiving
care.
38 studies (12
RCTs)
CS, IS
NPs ordered slightly more laboratory tests than did physicians. Resolution of
pathological conditions involved improvements in DBP and blood sugar levels,
symptom relief, and resolution of otitis media. NPs received higher patient
satisfaction scores. There was no difference on quality of care, prescription
drugs, functional status, number of visits per patients, and use of emergency
room.
81
Health
related:
Neutral
Authors acknowledge that the studies lack
methodological rigor in their research. Lack of strong
evidence likely limits generalizability. Horrocks (2002)
stated that this systematic review on the role of NPs
is dated and focuses on the North American context.
Boer 2005
(Cochrane
Review)
Paraprofessional
performed
psychological
treatment of
anxiety and
depressive
disorders for adults
(326 participants,
mostly women)
compared to
psychological
treatment by
professionals, or
with waiting list or
placebo condition.
5 RCTs
CS, QA,
IS
The pooled results indicated no significant difference between
paraprofessionals and professionals at post treatment and follow-up .A
significant difference was found favouring paraprofessionals compared to the
control condition, though heterogeneity was found between studies. Removing
one study from pooling because of indistinct definition of post treatment
measurement resulted in a strongly significant effect and homogeneity. One
study reported follow-up data, with no significant differences found between
paraprofessionals and professionals, or between paraprofessionals and the
control condition.
Health
related:
Positive when
compared
with no
treatment.
Fahey 2005
Educational and
organisational
strategies by allied
health
professionals
(nurse or
pharmacist) to
improve control of
BP
for adult patients
with essential
hypertension
7 RCTs
CS, QA
Allied Health professional (nurse or pharmacist) led care, for all three
outcomes pooling of results from individual RCTs produced heterogeneous
results, so pooled mean differences are not reported. However, nearly all
individual RCTs produced favourable results. Mean difference in SBP was
reported in five RCTs with a range of difference in mean systolic BP from -13–0
mmHg. Mean difference in diastolic BP was reported in six RCTs, ranging from 8–0 mmHg. Control of BP produced heterogeneous results. Use of health care
professionals such as nurses and pharmacists, though producing significantly
heterogeneous results in terms of mean systolic BP and diastolic BP, did have
mainly favourable results and was associated with improved control of BP
Health
related:
Positive
The reported methodological quality of included
studies was generally poor to moderate; presumably,
this deems the generalizability of the studies low.
Gilbody
2003
Organizational and
educational
interventions
(collaborative care,
Stepped
Collaborative Care,
Quality
Improvement, Case
Management,
PharmacistProvided
Prescribing
Information and
Patient Education)
to improve the
management of
depression in
primary care
setting on health
and cost outcomes.
36 studies: 29
RCTs and CTs,
with 5
controlled
before and
after studies
and 2
interrupted
time series
studies
CS, QA
Pharmacist-provided prescribing information and patient education: Clinician
education on medication (but not recognition and other management)
provided by expert pharmacists resulted in improved prescribing of
antidepressants among patients older than 60 years (RR, 0.55; 95% CI, 0.330.92)
Health and
Cost
outcomes:
Neutral.
All studies with positive and negative results are
listed. Authors are unable to weight the results
according to the size of the effect and the quality or
size of each individual study.
Most studies were conducted in US primary care
practices. Studies were heterogeneous, and many
studies used complex and multifaceted interventions.
Paraprofessionals definitions varied between studies.
(Four studies: volunteers without professional
background; 1 study: advanced undergraduates in the
experimental condition). Measurements varied
between eight weeks and one year. Majority of
population were women.
The few studies included in the review did not allow conclusions about the
effect of paraprofessionals compared to professionals, but three studies
(women only) indicated a significant effect for paraprofessionals (all
volunteers) compared to no treatment. The evidence to date may justify the
development and evaluation of programs incorporating paraprofessionals in
treatment programs for anxiety and depressive disorders.
Integrated quality improvement strategies that involve combinations of
clinician and patient education, nurse case management, enhanced support
from specialist psychiatric services, and monitoring of medication adherence
have been shown to be clinically effective and cost-effective in the short term,
but this effect disappears in long-term follow-up studies. Evidence showing
successful and unsuccessful strategies are again in line with other reviews of
organizational and educational interventions targeted at changing professional
behaviour.
82
Four studies were moderate in quality, and one was
low in quality. Caution must be made in interpreting
the results because of the small number of studies
using small samples, different treatment duration,
performance bias (blinding treatments), and raterbias (use of self-rated and lack of blinding in observer
rated measures). Sensitivity analyses and subgroup
analyses were required on various aspects of quality.
Harkness
2009
(Cochrane
Review)
On-site mental
health workers
(MHWs) delivering
psychological
therapy and
psychosocial
interventions in
primary care on the
clinical behaviour
of PCPs on process
outcomes
42 studies
were
included: 26
RCTs, and 16
controlled
before and
after studies.
CS, QA,
IS
MWHs included: counsellors (16 studies); psychologists (11 studies);
psychiatrists (five studies); community psychiatric nurses (seven studies), nurse
therapists (one study), practice nurses (one study), and social workers (one
study). In two studies, the MHW profession was not clear)
Process
outcomes:
Positive to
neutral
The quality of studies of direct effects was variable.
Information was often not presented on quality
issues, for example the proportion of patients for
whom information was available from medical
records about PCP behaviour.
It should be noted that data were lacking on the
degree to which the PCPs and organisations in the
studies were representative. It is likely that
volunteers to such research studies differed from
non-volunteers. It is not clear how such bias would
impact on the results.
The evidence does not support the addition of MHWs
to primary care teams with the aim of reducing
demand on PCPs or achieving enduring changes in
their clinical behaviour which will generalise to the
wider practice population.
Cost
outcomes:
Negative
Limitation of the current analysis is the recognition
that an economic assessment of the efficiency of
employing NPs in comparison with GPs requires
knowledge of outcomes as well as costs. There is
evidence that NP consultations are associated with
some benefits in terms of patient satisfaction, but
there is limited evidence about other health
outcomes.
Evidence provides some support for the hypothesis that MHWs providing
psychological therapy and psychosocial interventions on-site in primary care
cause reductions in consultation rates, psychotropic prescribing, and mental
health referrals among patients treated by the MHW. However, the effects are
modest. There is evidence that on-site MHWs do not impact on prescribing
behaviour towards the wider practice population. The impact on referral rates
is very inconsistent and no firm conclusions can be stated
Overall, the present evidence suggests that on-site MHWs are associated with
changes in PCP behaviour. The evidence does not support the addition of
MHWs to primary care teams with the aim of reducing demand on PCPs or
achieving enduring changes in their clinical behaviour which will generalise to
the wider practice population.
Hollinghurst
2006
A meta-analysis on
the cost of
employing an extra
salaried GP
compared to a NP
to deal with excess
patient demand
2 RCTs (from
Horrocks
2002
systematic
review)
QA
Results suggest that employing NPs to provide first-line care in UK general
practice is likely to cost the same or slightly more than employing doctors. This
is the case from the perspective of general practices and the NHS. The
sensitivity analysis shows that, from the perspective of the NHS, these findings
are robust under most assumptions. From the perspective of a general
practice, halving the amount of time spent by GPs with patients who originally
consulted nurses, results in the greatest reduction in the cost of a NP. In the
future, GP involvement in NP consultations is likely to be reduced as nurses
gain wider experience and as the regulation of nurse prescribing is relaxed. The
contribution of GP costs to initial nurse consultations was mostly from followup consultations with GPs within 2 weeks of initial consultations. This may be a
result of patient choice, or the relative availability of GPs and nurses for followup consultations.
83
This review is focused on UK based research, limiting
generalizability. Further, "Attempting to compare the
costs of NPs and GPs is complex because of the
different ways in which practitioners are trained and
employed in general practice".
Horrocks
2002
NPs vs. doctors as
first point of
contact (previously
undiagnosed
patients with
undifferentiated
health problem) in
a primary care
setting.
11 RCTs and
23
observational
studies
QA
Patients are at least as satisfied with care at the point of first contact with NPs
as they are with that from doctor. Although all of the RCTs found no significant
differences between doctors and NPs in health outcomes, the research has
important limitations.
Health
related:
Cautious
positive
Although assessments of the quality of care and short term health outcomes
seem to be equivalent to that of doctors, further research is needed to confirm
that NP care is safe in terms of detecting rare but important health problem: a
large study with adequate length of follow up is now justified
The studies used many different outcome measures,
reflecting the difficulty in measuring changes in
health outcomes after single consultations
predominantly about minor illnesses. None of the
studies in our review was adequately powered to
detect rare but serious adverse outcomes.
The review was limited by the quality of the available
studies: few recent RCTs were available and many
observational studies were of poor quality. Ambiguity
exists over the use of the term “NP,” with much
debate about this role.
Noticeable heterogeneity was observed between the
studies on almost all outcomes. Although differences
between studies in terms of setting, level of nurse
training, and the period of time studied were
anticipated and explored in our review, much
heterogeneity remained after allowing for these
factors.
Keleher
2009
Koshman
2008
Primary and
community care
nurse in primary
care setting (nurse
led care, or nurses
working as
supplements)
compared to
doctor led-care or
usual care
2 systematic
reviews (with
Cochrane
review by
Laurant
(2005)), six
RCTs, and
one RC –
crossover-T
QA, IS
Pharmacist care for
heart failure
compared to care
with no pharmacist
12 RCTs
CS, QA,
IS
Evidence presented in this review suggests that nurses in primary care and
community settings can provide effective health care and that they are
particularly effective in enhancing patient knowledge and patient compliance.
Gathering stronger data would contribute to an evidence base about the most
effective and efficient use of nurses’ time
Gathering stronger data would contribute to an evidence base about the most
cost-effective ways for these nurses to work
All 12 RCTs (2060 patients) reported all-cause mortality. One study showed a
significant difference in all-cause mortality between intervention and control.
The pooled estimate of the 12 RCTs showed a non-significant reduction in
mortality for pharmacist care compared with control (OR, 0.84; 95% CI, 0.611.15; I2, 19%).
Eleven RCTs (2026 patients) reported all-cause hospitalization rates (i.e., the
number of patients hospitalized at least once). The pooled OR for all-cause
hospitalization rates demonstrated a significant benefit of pharmacist care (OR,
0.71; 95% CI, 0.54-0.94) (Figure 3). There was, however, heterogeneity in these
results (I2, 50%).
Of the 11 RCTs (1977 patients) reporting hospitalization rates, 3 demonstrated
statistically significant reductions with pharmacist care, and the pooled-effect
estimate revealed a significant benefit with pharmacist care (OR, 0.69; 95% CI,
0.51-0.94) . There was also some heterogeneity in these results (I2, 40%).
Interventions that include some element of pharmacist care reduced the rates
of both all-cause hospitalization and heart failure hospitalization by almost
one-third
84
Health
related:
Positive;
Cost
outcomes:
Neutral
Health
related:
Positive
Reviewed studies were limited to those from
developed countries.
No discussion of potential bias from authors. Overall2/31 studies were conducted in Australia, 14 in the
UK, 6 in the USA, 4 in the Netherlands, 2 in Canada,
and 1 in each of Sweden, New Zealand and Hong
Kong.
The role of the nurse varied across all included
studies.
Quality assessment showed many studies of low to
moderate quality. Studies with low quality
methodology had consistently more positive results
than studies with higher scores. In terms of allocation
concealment, the results were similar when studies
with adequate allocation concealment were
compared with those with inadequate allocation
concealment for the outcomes of all-cause
hospitalizations and mortality.
Poor quality studies may influence generalizability.
There were notable differences in pharmacist
activities between studies, making it difficult to define
precisely which intervention provides the best
outcomes. Not all studies included are primary care
setting. Some might be considered primary care such
as community pharmacy. Some are not at all such as
in hospital, home care. It is not clear if outpatient
clinics were in a primary care setting
Laurant
2005
(Cochrane
Review)
Qualified nurses in
primary care
working as
substitute for
primary care
doctors compared
to doctors
providing the same
services to patients
as the nurses
16 studies:
controlled
before-andafter studies
(3) and
Randomized
quasi-random
or CTs (13)
CS, QA,
IS
Studies included suggest appropriately trained nurses can produce as high
quality care as primary care doctors and achieve as good health outcomes for
patients. Nurses providing first care for patients needing urgent attention tend
to provide more health advice and achieve higher levels of patient satisfaction
compared with doctors. Nurse-doctor substitution has the potential to reduce
doctors’ workload. However this benefit will not be realised in practise if
doctors continue to provide the types of care that have been transferred to
nurses. Doctors’ workload may remain unchanged either because there was
previously unmet need that nurses now fulfil or because nurses generate
demand for care where previously there was none.
Cost, particularly societal cost, has not been well investigated despite the
widely held view that nurse-led care will generate savings. Cost savings are
highly dependent on salary differentials between doctors and nurses and these
may vary across locations and over time
Loveman
2003
(Cochrane
Review)
Diabetes specialist
nurses / nurse case
manager in
diabetes on the
metabolic control
of patients with
type 1 and
type 2 diabetes
mellitus in children
and adults (1382
participants)
compared with
usual care in
hospital clinics of
primary care with
no specialist
nursing input
6 RCTs and
CCTs
CS, QA,
IS
Despite there being an improvement in glycemic control in the intervention
groups of many of the trials reviewed,HbA1c in the intervention groups was
not found to be significantly different from the control groups over a 12 month
follow up period.
One study demonstrated a reduction in HbA1c in the intervention group when
compared to the control group at six month. In sub-groups of patients with
higher baseline levels of HbA1c, a significant difference was observed between
the intervention and control groups at 12 months, with the intervention groups
having better metabolic control. Similarly, the proportion of participants with a
greater than 10%drop inHbA1c was statistically significantly different between
groups. Other outcomes such as hypoglycaemic or hyperglycaemic episodes
were not found to be different as a result of the intervention and were
generally poorly reported.
Included studies were RCTs in all cases with the exception a controlled clinical
trial, where a geographical region was divided into two. The duration of
included trials was 12 months in four trials 18months in the trial and six
months in the trial. No significant differences between emergency room visits
in the intervention or control groups of their study of adolescents. One study
reported an increase in emergency room visits amongst the intervention group
throughout the period of the study which was not statistically significant. There
were no statistical differences in hospital admissions.
From currently available trials the effects of a diabetes specialist nurse / nurse
case manager does not appear to be strong. No implications for practice over
longer periods of time can be drawn from available data.
5. Collaborative Care (Emergency and Primary)
Effect of multidisciplinary teams in management of health conditions
85
Health and
process
outcomes:
Positive
(limited
evidence);
Cost
outcomes:
Positive
(limited
evidence)
Health
outcomes:
Neutral
None of the three controlled before-and-after studies
reported the statistical power.
All RCTs had methodological shortcomings. The
power was reported in five of 13 trials and two
studies reported that the study lacked the statistical
power to detect clinically meaningful differences.
Many studies had methodological limitations, and
patient follow-up was generally 12 months or less.
A final concern is the narrow range of nurse roles that
has been subjected to rigorous evaluation. Nurses in
many countries provide a far wider range of care than
is represented in the current research literature.
Related to this is the question of what levels of
training and experience are required by nurses
working as doctor substitutes. The characteristics of
nurses and doctors (numbers, training, experience)
need to be reported more often and more
consistently in studies in order to shed light on this
issue.
The quality of the trials was generally low and this
leads to difficulties in assessing the implications for
practice.
The entry levels of the outcomes were also different
in all studies, with no trials reporting change scores,
leading to difficulty with standardisation. Pooling of
data were therefore deemed to be inappropriate due
to heterogeneity between trials.
Wide range of study populations. Participants’ gender
was approximately distributed equally, except in the
1 study which was of a group of veterans, the
majority of whom were male. Gender was not
reported in one trial. Two trials were teenagers.
Mean ages in adults ranged from 45-61.
Author Year
Review Objectives
Studies
Included
Methods
Reported Results
Overall
Conclusions
Kilner, 2009
Role of teamwork and
communication in the
ED, specifically related to
physiotherapy practice
CS, QA, IS
Teamwork and communication play a role in four main areas in the
ED: improving patient satisfaction, improving staff satisfaction,
reducing clinical errors and improving patient safety, and positively
affecting access block; very limited evidence.
Health
outcomes:
teamwork and
communication
in ED positive
(limited
evidence)
Australian ED context
Carter 2009
Team-based care
involving pharmacists or
nurses; effect in patients
with hypertension
No
experimental
studies; Before
and after
studies (5),
descriptive
case studies
(5); descriptive
cross-sectional
(4) design
37 studies
were included;
89% RCTs (also
included
controlled
before-after
studies,
interrupted
time-series
studies); 1
study provided
cost outcomes.
Poor
reporting
of SR
methods
Interventions involving pharmacists or nurses were associated with
significantly improved BP control. Our analysis found that studies
involving pharmacists resulted in not only lower BP but a greater OR
of achieving BP control compared to studies involving nurses.
However, the reductions in systolic BP and confidence intervals for
controlled BP overlap for the different providers.
Health
outcomes:
Positive;
Cost/Resource
Use: Neutral
Most studies were RCTs, but QA not conducted;
search strategy was not comprehensive; suggestion
of no publication bias; Only one study performed a
cost-effectiveness analysis. Analysis could not
determine if there is a preferred level of
qualifications such as a PharmD degree with
residency or a MS NP degree. Twenty-five studies
conducted in the US; twelve studies (9 nursing, 2 in
community pharmacies, 1 pharmacist in clinics)
were conducted in countries other than the U.S.
30 RCTs
CS; QA; IS
Health related: Multidisciplinary interventions reduced both
hospital admission and all-cause mortality. The more effective
interventions were delivered at least partly in the home.
Health related:
Positive
Funnel plots suggest little evidence of publication
bias; no discussion of generalizability
5 RCTs (2 low
quality)
CS; QA; IS
Health related:
Intervention was successful in reducing deterioration of health and
functional ability, improving activities in daily living, and increasing
social activity, as well as general well-being and life satisfaction;
continuous evaluation and management benefited the possibility of
maintaining health status and improving health perception.
Health related:
Positive
Two low quality studies included
37 RCTs (11
provided longterm
outcomes)
CS; IS
Results confirm that collaborative care is effective in improving
short-term outcomes in depression and, to our knowledge,
summarize for the first time the emerging evidence of longer-term
benefit.
Health related:
Positive
Moderate level of heterogeneity between studies (I
2=52.8%); generalizability not discussed
Holland,
2005
Johansson,
2010
Gilbody,
2006
Multidisciplinary (team:
GP+other) interventions
on hospital admission
and mortality in heart
failure
Multidisciplinary
teamwork applied to
teams working with
elderly persons living in
the community
(Comprehensive
Geriatric Assessment
concept).
Collaborative care in
patients with depression
(multifaceted, 3 distinct
professionals working
collaboratively within the
primary care setting: a
case manager, a primary
care practitioner, and a
mental health specialist;
2 of these 3 required)
Only one study performed a cost-effectiveness analysis. Clinic visit
costs were significantly higher in the pharmacist-managed clinic
($131 per patient) than the physician clinic ($74) (p<0.001), but the
costs for emergency room visits was significantly lower in the
pharmacist-managed clinic than the physician clinic ($0 vs $10.84
per patient, p<0.04). The cost of decreasing SBP/mm Hg was $27 for
the pharmacist-managed clinic and $193 for the physician clinic. The
cost of decreasing DBP/mm Hg was $48 in the pharmacist managed
clinic and $151 in the physician clinic.
86
van
SteenbergenWeijenburg,
2010
Cost-effectiveness of
collaborative care for
major depressive
disorder in primary care
adults (40-70y);
collaborative care
included network with >2
professionals (case
manager, specialist, GP),
monitored/ modifiable,
evidence-based care.
8 RCTs
CS; QA; IS
Collaborative care seems a promising option to deliver the right
treatment for patients with major depressive disorder. However,
the economic information is insufficient for policy decisions; all
studies found that collaborative care is usually more expensive than
care as usual. The number of studies on cost-effectiveness of
collaborative care is limited; limitations in quality of economic
evaluations Information on the (cost-) effectiveness of CC in other
settings than primary care is needed before CC can be broadly
implemented
Cost/Resource
use:
Neutral/Positive
Included studies scored maximum of 10 points out
of 19 on the CHEC-list, indicating that the quality of
the studies can be improved; younger adults
underrepresented; most studies from US.
Malone,
2007
(Cochrane
Review)
Community Mental
Health Team
management for serious
mental illness
(presenting to psychiatric
services).
3 RCTs (587
participants)
CS; QA; IS
No statistically significant differences in death from any cause
(n=587, 3 RCTs, RR 0.47 CI 0.2 to 1.3) during medium term
evaluation (3 - 12 months). Fewer deaths occurred in the CMHT
group (n=5), compared with the control group (n=12)
Satisfaction with care: One study showed an improved patient
satisfaction in the CMHT groups.
Health related:
Positive
Studies judged of `poor quality ‘were not included.
No explicit discussion of quality of evidence.
Simmonds,
2001
Community Mental
Health Team
management
(multidisciplinary
providing full range of
interventions) in adults
with severe mental
illness
Community Mental
Health Team
management (more than
one person working in a
team; multidisciplinary
assessment and reviews;
focus on continuity of
care) in adults with
severe mental illness
(schizophrenia was most
common diagnosis)
5 RCTs
CS; IS
CMHT management is effective in comparison with standard care
with respect to acceptance of treatment (statistically significantly
fewer drop-outs), trend toward reducing death by suicide and
suspicious circumstances (not statistically significant), and
suggestion of reducing costs.
Health related:
Positive for
acceptance;
trend toward
decrease
deaths; possible
cost reductions
Studies from Australia (1), Canada (1), and the UK
(3).
5 RCTs (854
participants)
CS; QA; IS
CMHT management may reduce suicide and be more acceptable to
those with mental illness than a non-team standard care approach.
It is also likely that a person managed within a CMHT is more likely
to avoid hospital admission and to spend less time as an in-patient
but the data are not easily summarised. There is, however, no
substantial data supporting or refuting the use of CMHT
management with respect to mental state, social functioning and
family burden.
Fewer patients in CMHT left treatment early.
CMHT less expensive in all studies, but small numbers, synthesis not
possible.
Health related:
Positive
(mortality and
process
outcomes);
Neutral
(morbidity and
cost)
Studies from Australia (1), Canada (1), UK (3) - all
mental health research teams; published 20 years
ago
Tyrer, 2000
Process
outcomes:
Neutral
Effect of GP-specialist collaboration in management of health conditions
Author Year
Review Objectives
Studies included
Methods
Reported Results
Summary of
conclusions
Cape, 2010
Consultation-liaison professionals providing
advice/support to primary
care professionals; range
of interaction
(management of
depression)
5 RCTs
CS; QA; IS
There was no significant effect of consultation–liaison on
antidepressant use (risk ratio 1.23, 95% CI 0.91 to 1.66) or
depression outcomes in the short- (standardized mean difference
−0.04, 95% CI −0.21 to 0.14) or long-term (standardized mean
difference 0.06, 95% CI −0.13 to 0.26).
Health
outcomes
(antidepressant
use): Neutral
Restricting the review to depression may have
excluded patient groups who are more likely to
benefit. It is also noteworthy that most studies
recruited through screening, and it is possible that
such patients have lower levels of motivation for
care or reduced capacity to benefit.
87
ChangQuan, 2009
Collaborative care
interventions (including
mental health
professionals and PCPs) in
the treatment of
depression in older patient
3 RCTs (1 study
provided cost
data)
CS; QA; IS
CCIs more effective in reducing suicidal ideation and depressive
symptoms in depressed older primary care patients; CCIs were
superior to usual care in all outcomes of depression scores,
treatment response (antidepressant medication/psychotherapy),
remission and suicidal ideation.
Collaborative care intervention models cost more; they require
more services from mental health providers than usual care;
treatment cost and patient compliance may become barriers to
successful dissemination of CCI
Health related:
Positive; Cost:
positive
Only 3 RCTs were included in this review; results
were heterogeneous; studies identified in the
review were conducted in the US or UK so
generalizability is limited.
Foy, 2010
Collaborative
arrangements that
facilitated interactive
communication between
collaborating primary care
physicians and key
specialists on outcomes for
patients receiving
ambulatory care (included
psychiatry, endocronology,
oncology)
11 RCTs (6 cluster
and 5 patientlevel) ; 1 CCT ; 3
Controlled Before
and After; and 8
uncontrolled
before–after
studies
CS; QA; IS
Interactive communication is associated with improved patient
outcomes (improvement on depression scale; HbA1c in diabetic
patients). We found evidence only relating to collaborations with
psychiatrists and endocrinologists.
Health related:
Positive
Significant heterogeneity; inclusion of study
designs with lower internal validity increased risk
for bias. No studies involved oncologists. Studies
included were generalizable to U.S. contexts (such
as Western Europe, Australia, and Canada).
Mitchell,
2002
Formal liaison of GPs with
specialist service providers
(organized cooperation
including consultation,
case conferences) on
patient health outcomes
and resource use; range of
illness groups.
7 studies: 4 RCTs,
1 cluster RCT, 1
matched controls,
and 1 pragmatic
controlled study
CS; QA; IS
Health
outcomes:
Positive; Costs:
negative
Small number of heterogeneous studies; quality
of studies assessed but not reported.
Mitchell
2008
Co-ordinated multidisciplinary care (GP
participant or leader)on
outcomes in stroke
18 publications (5
trials, 7 qualitative
studies, 6
described
guidelines and
local care models);
publications
represent only 3
separate RCTs
CS, QA, IS
GP-specialist liaison in the care of chronic or complicated cases
has mixed success for physical and functional health outcomes in
physical conditions. In most cases, physical function is not
changed. Some outcomes improve (less nocturnal asthma), but
some deteriorate (weight gain in diabetics). GP and specialist
collaboration does appear to improve functional outcomes in
chronic psychiatrically ill patients. Indirect or long-term benefits
to health may accrue as a result of improved attendance at
medical care, and also from changes in physician behaviours that
facilitate early detection and treatment of the complications of
chronic disease
Patients express greater satisfaction when GPs deliver part of the
care in the community setting, than for the traditional outpatient
setting. This may be important in encouraging compliance with
treatment or surveillance for disease complications.
Increased costs may be offset by long-term savings. However,
insufficient data and heterogeneity, prevent estimates of any
relative cost efficiencies.
Unclear whether coordinated care planning involving GPs and
primary care health professionals makes an unequivocal
difference to patients outcomes to patients with completed
stroke (mixed results for early discharge home, independence; no
difference in mortality; one study showed improved QOL). The
inconsistency in results suggests that further study around the
type of involvement of GPs in the multidisciplinary planning
process could be illuminating.
Health related:
Neutral
Small number of heterogeneous studies; diversity
of interventions and outcomes.
88
Smith, 2008
(Published
as a
Cochrane
Review in
2007)
Shared-care health service
interventions designed to
improve the management
of chronic disease across
the primary-specialty care
interface (any structured
intervention: liason
meetings, shared care
records cards, computer
assisted shared care and email, other); diabetes,
hypertension, asthma, and
COPD.
19 RCTs (3 met QA
criteria), 1
Controlled before
and after or ITS
studies (9296 is
similar review)
CS; QA; IS
No consistent improvements in physical and mental health
outcomes, psychosocial outcomes, psychosocial measures
including measures of disability and functioning, hospital
admission, default of participation rates, recording of risk factors
and satisfaction with treatment. Improvements in prescribing. No
evidence from health outcomes to support the widespread
introduction of shared care services at present. Eleven studies
reported cost data, although only 3 of these reported economic
analyses linking costs to outcomes. Results were mixed.
Health,
process, cost
outcomes:
Negative
Majority were suboptimal quality studies;
insufficient detail about participating primary care
practitioners make it difficult to determine
generalizability (studies conducted in United
Kingdom, the United States, Australia, New
Zealand, Denmark, Ireland, and Sweden); shortterm follow-up only.
Exploring different approaches to improve collaborative practice
Review Objectives
Studies
included
Methods
Reported Results
Limitations
Bower, 2006
Identify active ingredients in
collaborative care models for
depression in primary care
(case management role in
primary care; fostering closer
liason between primary care
clinicians and mental health
specialists; mechanism to
collect and share patient
information).
Updated
systematic
review search
from Gilbody
2003 (included
37 RCTs) ; metaregression to
explore
important
components of
collaborative
care
CS; IS
As a complex intervention, collaborative care defies simple definition. Our decisions
about inclusion and exclusion were informed by our previous conceptual work
(Bower & Gilbody, 2005), but we took a liberal approach to inclusion precisely
because the study focused on the degree to which variability in collaborative care
models influenced outcomes.
There was no significant predictor of the effect of collaborative care on
antidepressant use. Key predictors of depressive symptom outcomes included
systematic identification of patients, professional background of staff and specialist
supervision.
The validity of the coding scheme used
to extract data on the interventions has
not been confirmed. Problems of
inconsistent reporting and missing data
in the published studies limit results.
Most studies were conducted in the USA.
Butler, 2011
Level of integration of
provider roles or care
process affects clinical
outcomes (considered 2
dimentions: (1) the level of
integration of the steps in
the process of care and (2)
the degree of systematic
linkage between the roles of
clinicians) (depression care)
26 Controlled
trials and quasiexperimental
design studies.
US studies only.
CS; QA
There was no correlation between the outcomes and the extent of clinician
integration or the implementation of structured processes of care, nor was there
evidence that more intensive intervention in both areas produced better results for
persons with depression.
Models are limited to select settings in
the US. Quality of studies reported as
'fair'
89
Zwarenstein,
2009
(Cochrane
Review)
Evidence on practice-based
interventions designed to
change inter-professional
collaboration between any
types of health professionals
5 RCTs (1 high
quality; 4
moderate)
CS; QA; IS
Practice-based IPC interventions can improve health care processes and outcomes,
although generalizable inferences about the key elements of IPC are difficult. One
study on daily interdisciplinary rounds in inpatient medical wards showed positive
impact on LOS and total charges, but another study on daily interdisciplinary rounds
in a community hospital telemetry ward found no impact on LOS. Monthly
multidisciplinary team meetings improved prescribing of psychotropic drugs in
nursing homes. Video conferencing compared to audio-conferencing
multidisciplinary care conferences showed mixed results; there were a decreased
number of case conferences per patient and shorter length of treatment, but no
differences in occasions of service or length of the conference.
Multidisciplinary meetings with an external facilitator, who used strategies to
encourage collaborative working, was associated with increased audit activity and
reported improvements to care.
Small number of studies; challenges to
conceptualize collaboration;
heterogeneity of interventions and
settings.
6. Telehealth/Tele-consultation
Tele-consultation
Author
Year
Johansson,
2010
Review
Objective
Telemedicine
systems
(telestroke) in
acute stroke
management
compared to
traditional care
on health,
process and
cost outcomes
Studies
Included
Eighteen
studies: two
RCTs and one
controlled
clinical trial,
fifteen
observational
study design
such as case
series or
prospective
cohorts.
Methods
Reported Results
CS; IS
Telemedicine technologies, whether using a telephone-based system or a
real-time VC system, are safe and feasible in acute stroke management.
Telestroke interventions can support areas with insufficient neurological
services with evidence-based stroke care. All the telemedicine networks
reported a positive experience and improved quality of care, suggesting
that the implementation of such systems is feasible and acceptable.
There are few economic studies on telemedicine technologies in stroke
managements. More research is needed to explore the clinical and
economic impact of telemedicine technologies in stroke management, so
as to support policy makers in making informed decisions.
Young,
2011
Telemedicine
ICU (tele-ICU)
coverage
compared to
pre- tele-ICU
usage
13 studies
involving 35
ICUs. All the
studies used
before and after
designs.
CS;QA; IS
Given the significant resources required for tele- ICU implementation,
further evaluation is dearly needed. Tele-ICU coverage is associated with
lower ICU mortality and LOS but not with lower in-hospital mortality or
hospital LOS.
Health
outcomes:
Positive
(mortality and
LOS)
Neutral: (Hospital
mortality and
LOS)
Often found important information missing (lack of
consistent measurement, reporting, and adjustment
for patient severity). Limited by ability to examine
differences in the impact of tele-ICU coverage in
subgroup and meta-regression analyses.
High degree of heterogeneity.
Van der
Heijden,
2010
Uses of
telehealth) for
tertiary
teledermatology
on dermatology
patients on
health, process
and cost
outcomes
11 studies: 5
observational. 6
analytic, one
controlled
intervention
study, 5
descriptive
studies. No
RCTs were
found.
CS; IS
Tertiary teledermatology research is still in early development. Future
research should focus on identifying the scale of tertiary teledermatology
and on what modality of teledermatology is most suited for what purpose
in communication among dermatologists. Patient and physician
satisfaction were both reported once. In the study in which patient
satisfaction was measured, it was the sole focus of the study. Satisfaction
was measured by means of a survey. The satisfaction reported was high No
study performed a cost analysis. Diagnostic accuracy, validity, and
reliability were measured in four studies. Diagnostic accuracy was
measured by comparing telediagnosis to histopathological diagnosis and
Health
outcomes:
Positive
Lack of intervention studies found, the reported
outcome measures are not as solid as outcome
measures would be in studies with an experimental
setting. In the descriptive and observational studies,
the outcome measures reported were more a
qualitative description of the parameters than a
quantitative measurement. Population and
Generalizability not defined or discussed. No explicit
quality assessment was discussed.
90
Overall
Conclusions
Health and
process
outcomes:
Positive
Cost outcomes:
Neutral
Quality of the Evidence Available
Lack of discussion on bias. Lack of discussion on
generalizability. There was no explicit quality
assessment (with many case reports being
considered). Study locations: ten were located in the
United States, three in Germany, and one each in
Canada and China.
resulted in a 78.8 % accuracy rate in teledermatology
Warshaw,
2011
Store and
forward (SOF 6634 subjects
total) and live
interactive (LI 1290 subjects
total)
teledermatology
on health,
process and
cost outcomes
52 "repeated
measures
studies" , 1 RCT.
Final number of
studies
considered is
unclear.
QA; IS
There was insufficient evidence to conclude whether teledermatology had
an effect on clinical course, although one study with more than 500
patients reported comparable outcomes. Patients noted waiting time for
an appointment and travel time/distance as factors when considering
preference. Time to treatment was significantly shorter and clinic
dermatology visits were avoided when patients had an initial
teledermatology visit.
Health
outcomes:
Neutral
Both SAF and LI teledermatology had acceptable diagnostic accuracy and
concordance compared with clinic dermatology. Teledermatology may still
be superior to dermatologic care provided by nondermatologists; studies
are needed to compare teledermatology with primary care.
Cost/Resource
use: Positive
(conditional)
Process
outcomes:
Negative
The majority of studies (including both SAF and LI technologies) found
teledermatology to be cost-effective if certain critical assumptions were
met; the most important included patient travel distance, teledermatology
volume, and costs of clinic dermatology.
The majority of studies using SAF technology did not
clearly address patient selection biases such as
enrolling a representative spectrum of general
dermatologic patients or clearly describing exclusion
criteria. Heterogeneity in studies (design, skin
conditions, outcomes) limited the ability to pool data.
Studies took place in the US, UK, Turkey, New Zealand
and Norway. Mean age of 40. Some studies used
children or adolescents. Majority of subjects were
caucasian. Women were majority of subjects (54%
mean) Although this review suggests that diagnostic
accuracy of teledermatology is inferior toin-person
dermatologic care, teledermatology may still be
superior to dermatologic care provided by
nondermatologists; studies are needed to compare
teledermatology with primary care.
Mechanisms
Author
Year
Wade,
2010
Review
Objective
Synchronous or
real time video
communication
used to patients
in any clinical
discipline on
cost outcomes
Studies included
Methods
Reported Results
Overall Conclusions
Quality of Available Evidence
36 articles met the
inclusion criteria.
CS;QA; IS
It is concluded that synchronous video delivery is costeffective for home care, and for on-call hospital
specialists, and it can be cost-effective for regional and
rural health care, depending upon the particular
circumstances of the service. However, it is not costeffective, from the health services perspective, for local
delivery of service between hospital specialists and
primary care, particularly due to additional health care
staffing.
Cost/Resource use:
Positive = home care, on-call
hospital specialists, rural care
(distance).
A higher proportion of the non-random
comparisons showed lower costs and better
outcomes than did the RCTs, suggesting that the
studies with a lower level of evidence are biased
in favour of telehealth.
Generalizability is a problem for telehealth
research as a whole, due to variability in clinical
disciplines, environmental settings, workforce
and health care financing. This review attempts
to deal with this by considering only real time
video communication, which has similar
infrastructure and ways of clinical practice, and
also by grouping the results into similar
organisational settings; however this variability
means that generalisation should still be
considered with caution. Although there are
patterns in the results by organisational setting,
numbers in these groups are low, and the
conclusions would be strengthened by additional
research in each area.
Improvement in the quality of economic analyses is also
needed to provide data for more accurate modelling of
the effects of widespread introduction of telehealth into
the health care system.
91
Negative = local delivery of
services between primary &
specialist care.
Verhoeven,
2010
Synchronus and
asynchronus
teleconsultation
for patients
with type 1 and
2 gestational
diabetes care
compared to
usual care on
health, process
and cost
outcomes.
90 studies met inclusion
criteria. The most
frequently applied
methodological approach
was an observational study
(case series or before–after
design), which was used in
48 studies. Twenty-eight
studies were RCTs, and 8
involved quasiexperimental studies.
CS;QA; IS
The included studies suggest that both synchronous and
asynchronous teleconsultations for diabetes care are
feasible, cost-effective, and reliable. However, it should
be noted that many of the included studies showed no
significant differences between control (usual care) and
intervention groups. Future research needs quasiexperimental study designs and a holistic approach that
focuses on multilevel determinants (clinical, behavioral,
and care coordination) to promote self-care and
proactive collaborations between health care
professionals and patients to manage diabetes care.
Health, process and cost
outcomes: Positive
Most frequently mentioned were the lack of a
significant difference between the intervention
and the control group, the inability to measure
long-term effects of the intervention, the fact
that interventions sometimes inherently lead to
improved results because of a selection bias,
some patient groups benefit more from the
intervention than others, e.g., patients with poor
metabolic control, high use of health care,
motivated patients, and inexperienced patients,
or other shortcomings
Studies were performed mainly in the United
States (n = 45). Six were conducted in Asia, four
in Australia, and the remainder in Europe. There
was significant statistical heterogeneity among
the pooled RCTs.
Krishna,
2009
Cell phones and
text messaging
delivery of
health
information or
education
interventions to
adults and
children (
38,060
participants
with 10,374
adults and
27,686
children)
20 RTCs and 5CTs. English
language publications with
a complete English
abstract. Excluded studies
that did not use a control
group.
QA; IS
Information and education interventions delivered
through wireless mobile technology resulted in both
clinical and process improvements in the majority of
studies included in this review. Chronic diseases such as
diabetes and asthma, requiring regular management, as
well as smoking cessation requiring ongoing advice and
support, benefited most from the cell phone
interventions. Use of cell phones and text messaging in
improving health care, although gaining interest, is still
in its infancy. As the ownership and use of cell phones
increases, and more patients are willing to incorporate
them into their daily lives for regular disease
management such as for diabetes or asthma, more
benefits will be documented.
Health and process
outcomes: Positive
The reviewed studies did not express any
concerns over the impediments to the use of cell
phones such as lack of reimbursements to health
professionals receiving the call, time
commitment, or potential abuse of cell phone
and SMS privilege.One of the limitations of this
review is the small sample sizes, with two studies
included in this review having less than 20
participants. The findings of these studies may
not be generalizable to other population. The
strength of this study is in the international
applicability of this technology. Studies were
conducted on several continents—America,
Europe, and Asia—indicating that this technology
can be used all over the world.
Telehealth
Author
Year
Polisena,
2009a
Review
Objective
Costeffectiveness of
home telehealth
of various
complexities for
chronic diseases
compared to
usual care.
Studies
Included
22 studies (14
RCTs, 4 case
control
studies, 4 prepost studies)
Methods
Reported Results
CS;QA; IS
Most studies in our economic review found home telehealth to be cost
saving from health care system and insurance provider perspectives.
Conclusions must be qualified as the quality of the studies in terms of
economic evaluations was poor. The studies were also heterogeneous
possibly due to diverse study populations, interventions, and the health
care systems in which they are based, so it remains a challenge to make an
informed decision on resource allocation.
Together, the reviewed studies show a general trend towards
improvement associated with the use of most modalities; however,
inconsistent evidence between trials for the same
modality and differences between modalities makes a definitive
conclusion difficult. Telemonitoring appears to be an acceptable method
for monitoring of heart failure patients. Controlled, randomized studies
directly comparing different modalities and evaluating their success and
feasibility when used as part of routine clinical care, are now required.
92
Overall
conclusions
Cost/Resource
use: Positive
Quality of the Evidence Available
Most studies were considered to be of poor quality.
Some studies in the economic review had small sample
sizes and a lack of information on patient characteristics,
clinical outcomes, and study perspectives. There are no
published economic reviews specific to home telehealth
on which to make an informed policy decision. Past
systematic reviews on the cost-effectiveness of
telemedicine interventions found the existing evidence
on which to draw a conclusion to be very limited.
The studies were also heterogeneous possibly due to
diverse study populations, interventions, and the health
care systems in which they are based, so it remains a
challenge to make an informed decision on resource
allocation.
Polisana,
2009b
Home telehealth
(home
telemonitoring
(HTM) and/or
telephone
support (TS)
compared with
usual care (UC)
for patients with
diabetes on
health and cost
outcomes.
12 RCTs and 9
observational
studies
Ekeland,
2010
Impacts and
costs of
telemedicine
services (review
of reviews)
80
heterogeneous
systematic
reviews.
CS;QA; IS
In four studies, most patients thought that home telehealth was better
than UC and that the system was reliable, simple and user-friendly. Four
studies found no differences between groups in patient satisfaction or
health related QOL, and both groups expressed high satisfaction with their
overall diabetic care. Although patients in the TS group reported greater
self-efficacy, fewer symptoms of depression and fewer days in bed
compared with those in UC in one study, no intervention effect was
observed on diabetes-specific health related QOL. One study reported
fewer symptoms of poor glycaemic control (Hb1Ac) and had significantly
more satisfaction with home telehealth compared with UC. The home
telehealth interventions were similar or favourable in terms of health
related QOL or patient satisfaction compared with the UC arm. The study
results indicate that home telehealth interventions were similar or
favourable to UC in terms of QOL, patient satisfaction, adherence to
treatment or compliance compared with UC. Patient adverse events were
not discussed in any of the selected studies. Study results indicated that
home telehealth helps to reduce the number of patients hospitalized,
hospitalizations and bed days of care. Home telehealth was similar or
favourable to UC across studies for quality-of-life and patient satisfaction
outcomes. More studies of higher methodological quality are required to
give more precise insights into the potential clinical effectiveness of home
telehealth interventions.
Health, process
and cost
outcomes:
Positive
The number of studies in our systematic review and their
sample sizes were low for a number of outcomes
measured, and some studies failed to report
themeasures of variation for several continuous
outcomes. Patients with cognitive impairment, mental
illness, a language barrier, no telephone line or
computer to transmit data or a life expectancy of less
than 1 year were excluded from most studies, so the
generalizability of their findings may be limited. Also, it
was unclear in several studies what clinical services (e.g.
health-care providers involved in patient’s disease
management) were delivered by the home telehealth
interventions. Patients with cognitive impairment,
mental illness, a language barrier, no telephone line or
computer to transmit data or a life expectancy of less
than 1 year were excluded from most studies, so the
generalizability of their findings may be limited. Health
outcomes: The QOL and patient satisfaction outcomes
were summarized qualitatively because they were
measured with various instruments.
Overall outcome: Despite large number of studies and systematic reviews
on the effects of telemedicine, high quality evidence to inform policy
decisions on how best to use telemedicine in health care is still lacking.
Large studies with rigorous designs are needed to get better evidence on
the effects of telemedicine interventions on health, satisfaction with care
and costs.
Health, process
and cost
outcomes:
Positive/Neutral
The study had to rely on the information in the included
reviews. The quality of the reviews may vary. The
reviews may have done a poor job in specifying their
inclusion/exclusion criteria, the searches may not be
comprehensive,, the review authors may not have
assessed or extracted data from primary studies
adequately, nor analysed and synthesised the finding
across the studies properly. Several reviews have similar
or overlapping topics, it may therefore be that evidence
is counted twice or that different interpretations of
effectiveness are given by review authors.
Data collection and assessment of each review done by
one external expert. Generalizability not discussed.
However, inclusion criteria stated that all e-health
interventions within the health care system were
included
GarciaLizana,
2010
Information and
communication
technology (ICT)
(Telepsychiatry any kind of
'information and
communication
technology'
(ICT); direct
patient-based
interventions
(preventive
treatments were
excluded
10 RCTs
CS;QA; IS
Evaluation of symptoms: 4/9 studies showed improved depression
symptoms; 5/9 no significant difference compared to control;
QOL: 4/4 showed no significant difference with control;
Patient satisfaction: 5/5 no difference (1/1 no difference with technology
and quality both)
There is insufficient scientific evidence regarding the effectiveness of ICT
use in the management of depression, and more research is needed to
further evaluate the efficiency. However, there is a strong hypothesis that
videoconference-based treatment obtains the same results as face-to-face
therapy, and that self-help Internet programs could improve symptoms
when traditional care is not available.
3/3studies showed no difference in resource use during 12 months followup.
93
Health
outcomes:
Positive/Neutral
Cost outcomes:
Neutral
The limitations of this study are due partly to the quality
of the included RCTs, the variability of the interventions,
the lack of control-group in many cases, and, in
particular, the heterogeneity of the follow-up periods,
including the loss of follow-up in several of the RCTs
analyzed.
Two studies reported results from a wide range of
patient demographics; Review included studies from US,
Canada, UK, Aus, Sweden considering populations of
different type/stages of depression.
Griffiths,
2010
Preventive and
treatment
Internet
interventions for
patients with
depression and
anxiety disorders
26 RCTs
CS;QA; IS
The findings of this review clearly demonstrate that the Internet can be an
effective medium for the delivery of interventions designed to reduce the
symptoms of depression and anxiety conditions. Moreover, the effect
sizes for the depression trials, both with and without therapist input, were
at least as large as the standardised effect sizes relative to controls
reported in recent meta analyses of psychological treatment in primary
care (0.31) and antidepressant treatment of depression (0.37). Similarly,
the anxiety effect sizes reported here are consistent with controlled effect
sizes reported for face-to-face treatment of panic disorder and social
phobia.
Health
outcomes:
Positive
Of the 26 trials, 19, 9 and 17 were rated low-risk for bias
in the sequence generation, allocation concealment and
incomplete data domains, respectively. Risk of bias was
greater in the anxiety trials, with four of the eight
depression trials but only one of the 16 anxiety trials
rated low-risk for all three domains.
The effect sizes for anxiety trials appear larger than
those for depression trials, but participants in the former
trials were more often self-selected volunteers and were
typically only included in the trial if they also satisfied
diagnostic criteria at screening.
Since GPs involved had received mental health training,
the result may not be generalizable to GPs without such
training.
Luxton,
2010
Safety of
unsupervised
telemental
health care
delivery for
patients with
mental health
issues.
9 studies:
including 6
RCTs.
CS; IS
Two of the nine studies reported events that required the researchers to
use safety procedures to effectively respond to concerns they had
regarding participant safety. In both of these studies, the issues were
resolved with prescribed safety procedures. Our review provides initial
evidence that tele-mental health services delivered to clinically
unsupervised settings can be safely managed. The limited data and low
count of peer-reviewed studies, however, limit our ability to make
generalized conclusions about the safety of these treatments.
Process
outcomes:
Positive
The limited data and low count of peer-reviewed studies,
however, limit our ability to make generalized
conclusions about the safety of these treatments.
Further, several of the studies did not have sufficient
detail regarding study methods necessary to adequately
assess safety plans or outcomes.
McLean,
2010
Telehealth care
interventions
used for the
treatment of
asthma (children
and/or adult)
21 studies: all
RCTs. The 21
trials included
in the final
review were
published
across 25
reports.
CS;QA; IS
Health
outcomes:
Neutral ( QOL)
Positive
(admission to
hospital)
The level of intervention may vary in telehealth care,
with tasks delegated to less senior, less expensive health
care professionals and to patients themselves for selfcare when their asthma is stable. This variation may lead
to more effectively tailored care. The benefits of
telehealth care are mediated by education, an enhanced
therapeutic relationship, more intensive monitoring of
the patient and feedback.
Swanepoel,
2010
Audiological
services with a
telehealth
component,
either
synchronus or
asynchronis ((1)
audiological
screening, (2)
audiological
diagnosis, (3)
audiological
intervention,
and (4) patientclinician
perceptions
26 articles
(majority
being case
reports)
CS; IS
Meta-analysis did not show a clinically important improvement in
patients’ QOL, and there was no significant change in the number of visits
to the ED over 12 months. There was a significant reduction in the number
of patients admitted to hospital once or more over 12 months.
We found no evidence of a clinically important impact on patients’ QOL.
Telehealth care is no worse than normal care in its ability to improve QOL
in carefully selected and triaged patients receiving primary and secondary
care. Telehealth care interventions do appear to have the potential to
reduce the risk of admission to hospital, particularly for patients with
severe asthma.
Studies with larger intervention and control groups are needed to confirm
these results with precision
Several screening applications for populations consisting of infants,
children, and adults have demonstrated the feasibility and reliability of
telehealth using both synchronous and asynchronous models. The
diagnostic procedures reported, including audiometry, video-otoscopy,
oto-acoustic emissions, and auditory brainstem response, confirm
clinically equivalent results for remote telehealth-enabled tests and
conventional face-to-face versions. Intervention studies, including hearing
aid verification, counseling, and Internet-based treatment for tinnitus,
demonstrate reliability and effectiveness of telehealth applications
compared to conventional methods. Tele-audiology holds significant
promise in extending services to the underserved communities but require
considerable empirical research to inform future implementation.
Process
outcomes:
Neutral
Potential bias or the use of quality assessment was not
discussed. The majority of these studies on audiological
diagnosis and intervention were conducted on adults,
and many audiological areas of practice have not been
applied through telehealth means. No protocols and
service delivery models are currently specified for
specific populations, and the current understanding of
patient and clinician perceptions is poor and incomplete.
Further, important issues such as financial costs and
resources for tele-audiology within existing health care
infrastructures and models remain to be addressed by
systematic investigations and cost-analysis studies.
94
Glossary of Selected Terms from the Report
Allied health professionals: “Allied Health professionals are involved with the delivery of health or related services
pertaining to the identification, evaluation and prevention of diseases and disorders; dietary and nutrition services;
rehabilitation and health systems management, among others”(129).
Ambulatory services: Health care services provided to patients on an ambulatory basis, rather than by admission to a
hospital or other health care facility. The services may be a part of a hospital, augmenting its inpatient services, or may
be provided at a free-standing facility (130).
Collaborative Emergency Centres: A CEC-type centre focuses on the delivery of health care services including both
primary care and access to emergency care through a seamless collaborative team approach. Primary care encompasses
access to health promotion, wellness, chronic disease management, illness and injury prevention, and diagnosis and
treatment of illness and injury. Access to emergency care includes initial emergency stabilization of life-threatening
conditions, response to (including treatment or referral) the majority of urgent conditions and those conditions of lesser
urgency. A health care provider must be available on-site, and has a formal supportive relationship with other
professional(s) or institution(s) elsewhere through telephone or technological means.
Canadian Triage Acuity Scale (CTAS): A 5 level triage scale designed to classify the acuity of a patient's condition.
Clinical trials: Work that is the report of a pre-planned clinical study of the safety, efficacy, or optimum dosage schedule
of one or more diagnostic, therapeutic, or prophylactic drugs, devices, or techniques in humans selected according to
predetermined criteria of eligibility and observed for predefined evidence of favourable and unfavourable effects. While
most clinical trials concern humans, this publication type may be used for clinical veterinary articles meeting the
requisites for humans. Controlled clinical trials, and randomized clinical trials are specific types of clinical trials (131).
Cochrane Reviews are systematic reviews produced by The Cochrane Collaboration, and are published in The Cochrane
Library. The Cochrane Collaboration offers a handbook for systematic reviewers that “provides guidance to authors for
the preparation of Cochrane Intervention reviews" (132). The rigorous predefined guidelines demanded of a Cochrane
Review, in addition to the recommended update of all Cochrane Reviews every two years, increases the reliability of
these evidence syntheses.
Commentaries: Work consisting of a critical or explanatory note written to discuss, support, or dispute an article or
other presentation previously published. It may take the form of an article, letter, editorial, etc. They appear in
publications under a variety of names: comment, commentary, editorial comment, viewpoint, etc. (133).
Deputizing doctors: Commercial companies employing doctors to provide after-hours service. The use of deputizing
services after hours is widespread in urban areas of the United Kingdom and Australia (2).
Evidence synthesis: There are many common types of evidence synthesis, see: narrative reviews, jurisdictional reviews,
scoping reviews, systematic reviews, meta-analyses, and Cochrane Reviews.
Grey literature: "Grey literature stands for manifold document types produced on all levels of government, academics,
business and industry in print and electronic formats that are protected by intellectual property rights, of sufficient
quality to be collected and preserved by library holdings or institutional repositories, but not controlled by commercial
publishers i.e., where publishing is not the primary activity of the producing body" (134).
Jurisdictional reviews: Reviews that seek to provide an overview of policies, practices, legislations or regulations as
observed through a range of jurisdictions. There are no guidelines available for the conduct of jurisdictional reviews.
While jurisdictional reviews can answer the question, “what are others doing”, they usually do not consider the
effectiveness of interventions.
Knowledge translation: Defined by the Canadian Institutes of Health Research (CIHR) as a “dynamic and iterative
process that includes the synthesis, dissemination, exchange and ethically sound application of knowledge to improve
health, provide more effective health services and products, and strengthen the health care system” (83).The use of
evidence from research to make informed decisions in health care is often lacking; increasing recognition of these gaps
95
in translating knowledge into action have led to greater efforts in involving decision-makers in knowledge creation,
distillation, and dissemination of evidence (135). The process of knowledge translation takes place within a complex
system of interactions between researchers and knowledge users. The process can vary in intensity, complexity and level
of engagement (136).
Mental health workers: Mental Health Workers described in a systematic review by Harkness (2006) included
counsellors, psychologists, psychiatrists, community psychiatric nurses, nurse therapists, practice nurses, and social
workers (16).
Meta-analyses are quantitative syntheses often included within systematic reviews. Meta-analyses use “statistical
methods to summarize the results of independent studies” (137), with the advantage that more precise estimates of, for
example, the effect of an intervention, result from pooling information from all relevant studies (132).
Narrative reviews report knowledge on a topic based on previously published research (138). They are often labelled as
editorials, commentaries or narrative overviews (138). Although they may have been written by a recognized expert,
narrative reviews often lack systematic research methods as they may not identify all relevant studies. Furthermore,
narrative reviews may be more likely to support opinions, prejudices or commercial interests (84).
Paraprofessionals: A whole category of mental health personnel who are not qualified as psychiatrists, psychologists,
social workers or nurses, and who are below a master’s degree level of education. Alternatively, paraprofessionals may
be experienced patients, residents from local catchment areas or college students (11).
Physician assistants: Physician assistants are fully licensed medical practitioners who are trained to provide care under
the direction and supervision of a doctor. Although the doctor is ultimately responsible for the patient and establishes
the degree of physician assistant’s supervision, physician assistants exercise autonomy in medical decision making.
Typical duties include taking a history, performing a physical examination, evaluating laboratory data, instituting
treatment, performing procedures, screening ED patients with ‘routine’ problems, admitting certain patients and
communicating with consultant services (6).
Qualitative studies: Research that derives data from observation, interviews, or verbal interactions and focuses on the
meanings and interpretations of the participants (139).
Rapid reviews are literature reviews using accelerated or streamlined traditional systematic review methods (140, 141).
Rapid reviews strive to produce evidence synthesis with the most rigorous and transparent methods possible within a
restricted timeline. They can benefit policy and clinical decision making by providing rapid access to high quality
evidence. Rapid reviews are a new concept and are increasing in use. Varieties in nomenclature (rapid review, rapid
health technology assessment (HTA), rapid evidence assessment), time frames (1-9 months, or no reported time) and
streamlining methods (restricted searching, restricted screening, restricted quality appraisal, restricted data extraction)
demonstrate the lack of a universally accepted definition or methodological protocol for rapid reviews (140, 141).
Although rapid reviews are increasingly used, the lack of predefined methods may result in poor methodological
transparency and limited understanding of the implications of streamlining (141).
Residents: Graduates of medicine in programs of training in medicine and medical specialties offered by hospitals.
Graduates train to meet the requirements established by accrediting authorities (142).
Scoping reviews “map rapidly the key concepts underpinning a research area and the main sources and types of
evidence available”(143). Scoping reviews can be undertaken as a stand-alone project, or as part of a greater project.
They can vary in breadth and depth and can examine the range of research evidence on a select topic, determine the
value of undertaking a full review, summarise and disseminate research findings, or identify gaps in existing literature
(143). Scoping reviews often take a descriptive or narrative perspective towards summarising evidence. Limitations of
scoping reviews include a lack of quality appraisal of primary research, and a lack of evidence synthesis; they often deal
with quantity, rather than quality of evidence (143).
Systematic reviews: Reviews that comprehensively and systematically identify, select, assess, synthesize and report
research evidence for a clearly defined question(84). While any review’s methods are subject to bias, a systematic
96
review’s pre-specified, transparent approach reduces the risk of being misled by chance or biased selection and
appraisal of evidence (144). Systematic reviews can be limited due to the variation in reliability and quality of included
studies, and the need for the review itself to be updated with the production of new primary studies (145, 146). In
addition, the length of time it takes to produce a thorough systematic review is not always conducive to decision
making, where research is often desired sooner rather than later (143).
Telemedicine Intensive Care Unit (ICU): The application of telemedicine to hospital critical care units; this includes any
telecommunication system installed in the ICU to facilitate real-time access to critical care specialists located elsewhere
(55).
Triage liaison physician: “Physicians working with triage (a system of sorting patients based on acuity and risk) staff to
expedite the care of patients, based on medical need, who are subject to unpredictable wait times due to lack of
available ED treatment spaces” (9).
Web presence: The collection of websites and web-resources associated with a company, organization or individual.
97
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