# Innovative models of healthcare delivery: an umbrella review of reviews

Natalie Roberts, Ann Carrigan, Robyn Clay-Williams, Peter D Hibbert, Zeyad Mahmoud, Chiara Pomare, Diana Fajardo Pulido, Isabelle Meulenbroeks, Gilbert Thomas Knaggs, Elizabeth E Austin, et al.

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## To cite this version:

Natalie Roberts, Ann Carrigan, Robyn Clay-Williams, Peter D Hibbert, Zeyad Mahmoud, et al. "Innovative models of healthcare delivery: an umbrella review of reviews." BMJ Open, 2023, 13 (2), pp.e066270. 10.1136/bmjopen-2022-066270. hal-04256108

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# BMJ Open Innovative models of healthcare delivery: an umbrella review of reviews

Natalie Roberts¹,¹ Ann Carrigan ID,¹ Robyn Clay-Williams ID,¹
Peter D Hibbert ID,¹,² Zeyad Mahmoud ID,¹,³ Chiara Pomare ID,¹
Diana Fajardo Pulido,¹ Isabelle Meulenbroeks,¹ Gilbert Thomas Knaggs ID,¹
Elizabeth E Austin ID,¹ Kate Churruca ID,¹ Louise A Ellis ID,¹ Janet C Long ID,¹
Karen Hutchinson,¹ Stephanie Best,¹,⁴ Brona Nic Giolla Easpaig,¹
Mitchell N Sarkies ID,¹ Emilie Francis Auton,¹ Sarah Hatem,¹
Genevieve Dammery ID,¹ Mai-Tran Nguyen,¹ Hoa Mi Nguyen ID,¹
Gaston Arnolda ID,¹ Frances Rapport ID,¹ Yvonne Zurynski ID,¹ Katherine Maka,⁵
Jeffrey Braithwaite ID,¹

**To cite:** Roberts N, Carrigan A, Clay-Williams R, et al. Innovative models of healthcare delivery: an umbrella review of reviews. *BMJ Open* 2023;13:e066270. doi:10.1136/bmjopen-2022-066270

► Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (http://dx.doi.org/10.1136/bmjopen-2022-066270).

Received 05 July 2022
Accepted 13 February 2023

## ABSTRACT

**Objective** To undertake a synthesis of evidence-based research for seven innovative models of care to inform the development of new hospitals.

**Design** Umbrella review.

**Setting** Interventions delivered inside and outside of acute care settings.

**Participants** Children and adults with one or more identified acute or chronic health conditions.

**Data sources** PsycINFO, Ovid MEDLINE and CINAHL.

**Primary and secondary outcome measures** Clinical indicators and mortality, healthcare utilisation, quality of life, self-management and self-care and patient knowledge.

**Results** A total of 66 reviews were included, synthesising evidence from 1272 primary studies across the 7 models of care. Virtual care was the most common model studied, addressed by 47 (73%) of the reviews. Common outcomes evaluated across reviews were clinical indicators and mortality, healthcare utilisation, self-care and self-management, patient knowledge, quality of life and cost-effectiveness. The findings indicate that the innovative models of healthcare we identified in this review may be effective in managing patients with a range of acute and chronic conditions. Most of the included reviews reported evidence of comparable or improved care.

**Conclusions** A consideration of local infrastructure and individual patient characteristics, such as health literacy, may be critical in determining the suitability of models of care for patients and their implementation in local health systems.

**Trial registration number** 10.17605/OSF.IO/PS6ZU.

## STRENGTHS AND LIMITATIONS OF THIS STUDY

⇒ This review presents a broad array of evidence for the implementation of seven innovative models of care in managing several acute and chronic health conditions.

⇒ The search string and strategy was developed in consultation with a local health district and a research librarian to reflect current high prevalence conditions typically found in developed countries.

⇒ We assessed evidence of blended or hybrid model delivery, as well as model to model comparisons.

⇒ Evidence for the digital hospital model of care was limited due to the focus on review articles. As a result, cutting-edge developments that have currently evaded systematic review may not have been adequately captured.

⇒ Umbrella reviews present an overview of evidence, but do not permit in-depth discussion of primary studies. Individual systematic reviews may provide more detail on the outcomes of specific interventions within models of care.

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© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

For numbered affiliations see end of article.

**Correspondence to**
Dr Robyn Clay-Williams;
robyn.clay-Williams@mq.edu.au

## INTRODUCTION

The increasing demands of ageing populations and burgeoning rates of chronic illness have necessitated substantial changes in the delivery of acute care.¹² In response to these growing demands and challenges, hospitals and governments internationally have adopted innovative approaches to care

delivery. These include prioritising consumer engagement,¹ adopting cost-effective care alternatives that are positioned outside of conventional hospital settings,³ and making investments in digitised care services.⁴ For example, some hospitals have integrated emerging technologies (eg, artificial intelligence, robotics, big data analytics) into hospital workflows to provide more streamlined care to consumers.⁵⁻⁷ The COVID-19 pandemic accelerated the rollout of many of these innovative ways of delivering healthcare, termed models of care, including the adoption of telehealth and other virtual care methods.⁸⁻¹⁰ However, while these methods show promise, innovations in healthcare delivery have been adopted in an ad-hoc
manner, without adequately addressing the potential for larger-scale, systematic changes in the care delivery.¹¹⁻¹³

Models of care describe alternative methods of health-care delivery that differ in setting, type of care, provider, population or the patient experience.¹⁴ Applied models of care are often captured under broader categories of delivery, such as integrated care, outpatient care and tele-health. This review builds on the findings from a rapid review of grey literature that identified seven innovative models of care: consumer-focused care; ambulatory care and diagnostic hospitals; digital hospitals; hospital in the home (HITH); integrated care; virtual care; and specialist hospitals and population-specific care units.¹⁵ See online supplemental file for definitions of models.

## AIMS

The aim of this review is to evaluate the evidence-base regarding the efficacy of seven innovative models of care compared with usual care, in treating identified priority acute and chronic conditions. Results can inform the adoption of models for treating these conditions internationally.

## METHODS

The protocol for this umbrella review is registered on the Centre for Open Science protocol register (OSF; registration number 10.17605/OSF.IO/PS6ZU); methodology was developed in accordance with the Joanna Briggs Institute Methodology for JBI Umbrella Reviews.¹⁶ We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).¹⁷

## Patient and public involvement

There was no direct involvement of patients or members of the public in designing or conducting this review.

### Inclusion criteria

We included systematic reviews, meta-analyses, scoping reviews, integrated reviews and meta-ethnographies in the peer-reviewed literature that evaluated outcomes of innovative models of care compared with usual care in treating a number of acute and chronic conditions. Priority conditions were selected based on selected high impact conditions with consideration of a balance between chronic and acute conditions, covering various body systems. The publication date range was limited to 5 years to capture the most recent evidence. See table 1 for inclusion criteria.

### Data sources and search strategy

The search was designed in consultation with a research librarian and conducted across three databases: PsycINFO, Ovid MEDLINE and CINAHL. Online supplemental table 1 presents the search string for CINAHL used in the academic search.

The screening of the reviews was undertaken in two steps: title/abstract screen and full-text screen. At both

<table><caption>**Table 1** Academic literature search strategy</caption><thead><tr><th colspan="2">Inclusion criteria</th></tr></thead><tbody><tr><td>Publication date</td><td>2016–2022</td></tr><tr><td>Language</td><td>English</td></tr><tr><td>Document type</td><td>Peer-reviewed reviews</td></tr><tr><td>Population</td><td>Humans</td></tr><tr><td>Model of care</td><td>Describes one of the following seven innovative models of care: consumer-focused care; ambulatory care and diagnostic hospitals; digital hospitals; hospital in the home; integrated care; telehealth and virtual care; specialised hospitals and population-specific hospital care units</td></tr><tr><td>Priority condition</td><td>Describes one of the priority acute or chronic conditions/services: Acute: cardiac arrest, chest pain, myocardial infarction, fractures, knee replacement, hip replacement, joint replacement, abdominal pain, pelvic pain, gastrointestinal pain, pneumonia, postnatal depression Chronic: congestive heart failure, dialysis, kidney disease, end-stage kidney disease, abnormal gait, bone disease, osteoporosis, asthma, chronic obstructive pulmonary disease</td></tr></tbody></table>

stages, all articles were independently screened by blinded pairs of reviewers on Rayyan (https://www.rayyan.ai/), a web-based collaborative tool. A total of 16 reviewers were paired and each pair allocated 926 articles at the title/abstract stage (7412/8 pairs). One pair was assisted by a third reviewer as one reviewer was unable to complete the screening. Three reviewers independently conducted an interrater reliability assessment on 5% of the articles during full-text screening (κ=1, 95% CI 0.97 to 1.00, p<0.001). Prior to screening, a selection of 20 articles were pilot screened by all 17 reviewers for calibration purposes. The search was updated in January 2022 to identify suitable articles published within the 6 months following the initial search. See figure 1 for PRISMA flow diagram of initial and updated searches.

### Critical appraisal

The risk of bias and quality of methodological results for the included reviews were evaluated using the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews.¹⁸ This process was conducted in pairs and discrepancies were discussed to reduce the risk of interobserver bias.¹⁸ See online supplemental table 2 for ratings of included reviews. Although several studies were marked N or NA, they were still considered to meet the criteria the team had set, so all articles were included in the synthesis.

### Data collection and extraction

Data was extracted using a purpose-built Microsoft Excel data extraction sheet developed for the study and piloted before use. Reviews that did not meet criteria were
<figure><img src="image_4.png" /><figcaption>**Figure 1** Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram for initial and updated search. Black text: original search; blue text: updated search. \*Some reports were excluded for multiple reasons.</figcaption></figure>

excluded at the full-text review stage. Data were extracted during the full-text review stage and included details on the model of care, setting, providers, consumers, conditions/service specificities, broader applicability to other conditions and outcome measures (ie, clinical indicators, mortality, quality of life). Models of care were coded to capture blended models or comparisons between models within reviews. During extraction, separate spreadsheets were created to evaluate the evidence for each model.

## RESULTS

Following the initial and updated screening, a total of 66 reviews published between 2016 and 2021 met the inclusion criteria. Sixty-one reviews were identified during the initial search, and a further five reviews identified during an updated search. Of these, most reviews were published in 2018 (n=17, 59%), followed by 2016 (n=13, 20%), 2017 (n=11, 17%), 2020 (n=8, 12%) and 2019 (n=6, 9%). Overall, 6 articles from the initial search and a further 5 articles from the updated search were published in 2021 (n=11). Overall, 54 reviews (82%)

discussed a single model of care and 12 reviews (18%) evaluated multiple models of care (ie, comparing or blending models).

## Overlap of evidence

A total of 1272 primary studies were captured within the 66 reviews. Of these, 523 studies were included in multiple reviews, representing a 41% overlap of primary evidence. The overlap was most frequently found for reviews that assessed evidence for singular conditions. For example, chronic kidney disease (CKD),¹⁹⁻²¹ heart failure²² ²³ and chronic obstructive pulmonary disease (COPD).²⁴⁻²⁷

## Population

The included reviews assessed evidence for care across a diverse age range. Participants ranged between 6 and 93 years of age, varying by condition. For example, younger participants (<18) were more frequently represented within asthma reviews, while older participants (>65) were most frequently captured within fracture and COPD reviews.
<table><caption>**Table 2** Definitions of included models of care</caption><thead><tr><td>Model of care</td><td>Definition</td><td>Example</td></tr></thead><tbody><tr><td>Consumer-focused care</td><td>During planning, delivery and evaluation, consumers, carers and families are placed at the centre of care.<sup>84 85</sup></td><td>Individualised self-management support in early chronic kidney disease transition of the care plan.</td></tr><tr><td>Ambulatory care and diagnostic hospitals</td><td>Outpatient or non-admitted services, where patient care does not involve an overnight stay and usually involves diagnosis and treatment on the same day.<sup>86</sup></td><td>Outpatient renal dialysis.</td></tr><tr><td>Hospital in the home</td><td>Patient care and consultation that are typically delivered in the hospital settings are delivered to patients in their own home.<sup>87 88</sup></td><td>Early discharge hospital at home care for chronic obstructive airways disease managed by a community service.</td></tr><tr><td>Integrated care</td><td>Multidimensional needs of the patient are delivered in a coordinated manner by an interdisciplinary team or network of healthcare professionals.<sup>89 90</sup></td><td>Orthogeriatric fracture service.</td></tr><tr><td>Virtual care</td><td>Patient care and consultation are delivered through telephone or video communication.<sup>91</sup></td><td>Telehealth management in patients with heart failure.</td></tr><tr><td>Specialist hospitals and population-specific care units</td><td>Specialist hospitals provide selective care services for targeted patient groups. Population-specific care units are pathways within general hospitals dedicated to the treatment of specific conditions.<sup>92 93</sup></td><td>Comprehensive cancer centres.</td></tr></tbody></table>

## Models of care

The included reviews covered evidence for virtual care (n=47, 71%), integrated care (n=11, 17%), HITH (n=10, 15%), ambulatory care and diagnostic hospitals (n=10, 15%), specialist hospitals and population-specific care units (n=6, 9%) and consumer-focused care (n=3, 5%). No reviews were retained that evaluated the digital hospital model; evidence for this model was solely found in primary studies and thus excluded. See **table 2** for definitions of models of care and **figure 2** for the relationships among models across reviews.

## Conditions and outcomes

The reviews presented evidence for the outcomes of models of care in treating and managing several health conditions. See **table 3** for a summary of included conditions and outcomes. Additional details are presented descriptively for the top 4 outcomes, which were reported in 64 out of 66 (96.7%) reviews. See online supplemental table 3 for a summary of outcomes across models of care, and online supplemental table 4 for descriptions of included studies.

### Clinical indicators and mortality

#### Virtual care

A total of 31 (47%) reviews assessed the impact of virtual care interventions on clinical indicators and mortality.<sup>22 23 25–53</sup> Of these, four reviews reported positive effects of virtual care on clinical indicators<sup>47</sup> and mortality<sup>38 42 47 52</sup> for patients with chronic heart failure. Two reviews presented mixed evidence on mortality<sup>29</sup> and clinical indicators,<sup>29 32</sup> while four reviews found no significant effect of virtual care interventions on clinical indicators<sup>49</sup> or mortality<sup>23 30 32</sup> for heart failure patients.

The effects of virtual care on clinical indicators and mortality among asthma patients were explored in

seven reviews.<sup>31 34 36 37 40 44 51</sup> Of these, four reviews found mixed evidence for the impact of interactive digital interventions and remote check-ups on clinical indicators<sup>31 36 51</sup> and exacerbations.<sup>44</sup> Three reviews found no significant effect of interventions on asthma exacerbations.<sup>34 37 40</sup>

Four reviews evaluated the evidence for virtual care on clinical indicators and mortality for COPD.<sup>25–28</sup> One review found mixed evidence for the effect of mobile health applications on lung function,<sup>26</sup> while three reviews found no significant effect of telemonitoring-based interventions on mortality<sup>25 27</sup> and exercise capacity.<sup>28</sup>

The effects of eHealth and Information Technology (IT)-based interventions on proximal clinical indicators for CKD were assessed in two reviews.<sup>35 46</sup> Mixed evidence was found for the effects of interventions on clinical indicators, including blood pressure.<sup>35 46</sup> Similarly, mixed effects were found for the effect of tele-based interventions on myocardial infarction outcomes, with one review finding significant reductions in mortality,<sup>39</sup> and one review indicating no effect of intervention on cardiovascular disease-related mortality outcomes,<sup>50</sup> when compared with usual care.

Evidence for virtual interventions on multiple chronic conditions was evaluated in four reviews.<sup>41 43 45 48</sup> Two reviews found no significant effect of virtual care, including telerehabilitation, on functional outcomes,<sup>48</sup> mortality or adverse events such as COPD exacerbations.<sup>43</sup> However, two reviews found positive effects of clinical pharmacist telemedicine interventions<sup>41</sup> and virtual education<sup>45</sup> on pulmonary function and inhaler use,<sup>45</sup> and chronic disease management.<sup>41</sup>

Two reviews found a significant improvement in postpartum depression<sup>33 53</sup> and anxiety<sup>53</sup> scores among women who received telemedicine interventions, when
<figure><img src="image_5.png" /><figcaption>**Figure 2** Relationships among models across reviews.</figcaption></figure>

compared with usual care. This effect was most significant for telephone-based interventions.⁵³

### Ambulatory care and diagnostic hospitals

A total of 10 reviews (15%) investigated the effects of ambulatory care interventions on clinical indicators and mortality,⁵⁰⁵⁴⁻⁶² with 3 reviews demonstrating positive effects. One review found that total ankle arthroplasty patients reported five times fewer complications when performed in ambulatory settings in contrast with usual care.⁵⁴ Outpatient total hip arthroplasty (THA) was similarly associated with improvements in pain and functional outcomes.⁵⁹ Among patients with myocardial infarction, significant reductions in cardiovascular and all-cause mortality were recorded among patients receiving centre-based cardiac rehabilitation, when compared with usual care.⁵⁰

Mixed-effects of ambulatory interventions on mortality and functional status were reported in two reviews.⁵⁷,⁵⁸ For example, ambulatory management of chronic heart failure,⁵⁷ and nocturnal haemodialysis,⁵⁸ produced mixed effects on mortality. However, improved mortality rates were found among patients receiving haemodialysis in satellite clinics and community houses.⁵⁸ In addition, five reviews reported non-significant effects of ambulatory

care on functional outcomes, when compared with usual care.⁵⁵,⁵⁶,⁶⁰⁻⁶²

### Hospital in the home

The impact of HITH interventions on clinical indicators such as blood pressure, functional capacity and exercise duration was assessed in 8 reviews (12%).²³ ²⁷ ⁴⁹ ⁵⁰ ⁵⁸ ⁶³⁻⁶⁵ Of these, seven reviews found no significant effect of HITH interventions on mortality, and one review found significant reductions in mortality among heart failure patients receiving nurse home visits, when compared with usual care.²³

### Integrated care

Eight reviews assessed the impact of integrated care interventions on clinical indicators and mortality.²¹ ²³ ²⁵ ⁶² ⁶⁶⁻⁶⁹ Four reviews recorded positive effects of integrated care interventions on physical⁶²,⁶⁸ and mental health outcomes,⁶⁸ mobility⁶⁶ and osteoporosis treatment⁶⁹ for hip fracture patients. Similarly, improvements in blood pressure,²¹ heart rate and oxygen saturation²⁵ were reported for patients with CKD²¹ and COPD²⁵. No effects on mortality were found for patients with CKD²¹ and COPD.²⁵ One review found mixed evidence for reductions in mortality among hip fracture patients.⁶² One review found no effect
<table><caption>**Table 3** Number of reviews assessing conditions and outcomes</caption><thead><tr><th></th><th>Type</th><th>Reviews, n, (%)</th></tr></thead><tbody><tr><td rowspan="8">Condition</td><td>Heart failure</td><td>34 (52%)</td></tr><tr><td>Chronic obstructive pulmonary disease</td><td>20 (30%)</td></tr><tr><td>Asthma</td><td>13 (20%)</td></tr><tr><td>Chronic kidney disease</td><td>13 (20%)</td></tr><tr><td>Joint replacement</td><td>8 (12%)</td></tr><tr><td>Fractures</td><td>7 (11%)</td></tr><tr><td>Myocardial infarction</td><td>2 (3%)</td></tr><tr><td>Postnatal depression</td><td>2 (3%)</td></tr><tr><td>Chest pain</td><td>1 (2%)</td></tr><tr><td rowspan="10">Outcome</td><td>Clinical indicators and mortality</td><td>32 (48%)</td></tr><tr><td>Healthcare utilisation</td><td>30 (45%)</td></tr><tr><td>Quality of life</td><td>25 (38%)</td></tr><tr><td>Self-management and self-care</td><td>21 (32%)</td></tr><tr><td>Patient knowledge</td><td>8 (12%)</td></tr><tr><td>Cost-effectiveness</td><td>7 (11%)</td></tr><tr><td>Patient satisfaction</td><td>2 (3%)</td></tr><tr><td>Feelings of belonging</td><td>1 (2%)</td></tr><tr><td>User experience</td><td>1 (2%)</td></tr><tr><td>Social support</td><td>1 (2%)</td></tr><tr><td>Loneliness</td><td>1 (2%)</td></tr><tr><td>Self-efficacy</td><td>1 (2%)</td></tr><tr><td>Staff perspectives</td><td>1 (2%)</td></tr></tbody></table>

of multidisciplinary care on mortality among heart failure patients,⁶⁷ while another review found that nurse home visits and nurse case management significantly decreased all-cause mortality for heart failure patients.²³

### Specialist hospitals

The effect of specialist hospital care on clinical indicators and mortality were assessed in four reviews.¹⁹ ²⁰ ²³ ⁷⁰ Of the three reviews that evaluated a blended integrated-specialist model for the treatment of CKD, two reviews found that multidisciplinary specialist care was associated with improved estimated glomerular filtration rate and reductions in mortality.¹⁹ ²⁰ One review found that nurse-coordinated care produced improvements in blood pressure, markers of kidney function and reduced the risk of ischaemic stroke and cardiovascular death.⁷⁰ One review found significant decreases in all-cause mortality for heart failure patients receiving nurse case management.²³

### Consumer-focused care

One review assessed the impact of consumer-focused care on clinical indicators among patients with CKD, including mortality, blood pressure control and risk of kidney transplant.²¹ Mixed evidence was reported for the effect of interventions on all-cause or cardiovascular mortality, when compared with usual care.²¹ No

significant difference in CKD outcomes or blood pressure control were observed between intervention patients and those receiving usual care.²¹

### Healthcare utilisation

#### Virtual care

A total of 29 reviews (44%) recorded the impact of virtual care interventions on healthcare utilisation.²² ²³ ²⁵⁻³² ³⁶ ³⁸⁻⁴⁰ ⁴²⁻⁴⁵ ⁴⁷ ⁵⁰ ⁵² ⁵⁸ ⁷¹⁻⁷⁷ Of these, eight reviews reported positive effects of virtual care interventions such as health education and telemonitoring on healthcare utilisation, in managing fractures,⁷⁵ CKD,⁵⁸ myocardial infarction,³⁹ asthma,⁴⁴ COPD²⁵ ²⁶ and heart failure.⁷² ⁷⁴

A total of 10 reviews reported mixed evidence²² ²⁹ ³¹ ³² ⁴⁰ ⁴³ ⁴⁷ ⁷¹ ⁷³ ⁷⁷ and 11 studies (17%) found no significant effect of virtual care on healthcare utilisation.²³ ²⁷ ²⁸ ³⁰ ³⁶ ³⁸ ⁴² ⁴⁵ ⁵⁰ ⁵² ⁷⁶ Three reviews reported negative effects of virtual care, including increased non-emergency or outpatient clinic contacts and visits,³² ⁷⁷ and some evidence of increased admissions for patients with COPD when compared with usual care.⁷⁶

### Hospital in the home

A total of 9 reviews (14%) assessed the impact of HITH interventions on readmission rates.²³ ²⁷ ⁵⁰ ⁵⁸ ⁶³⁻⁶⁵ ⁷⁴ ⁷⁸ Of these, three reviews reported a significant reduction in COPD readmissions²⁷ ⁶⁴ ⁶⁵ and length of stay⁶⁵ following interventions, including early supported discharge and continuity of care.²⁷ ⁶⁴ ⁶⁵

Positive effects of transitional care interventions⁷⁴ and nurse home visits²³ on all-cause²³ ⁷⁴ and heart failure-specific⁷⁴ readmission rates for patients with heart failure were found in two reviews. Similarly, in one review that assessed the impact of blended integrated, HITH and virtual care for heart failure patients, interventions that used home visits, telemedicine and telemonitoring demonstrated some positive effect on admission rates.⁷⁸ One review found that home dialysis and blended home dialysis with telemedicine produced superior outcomes for patients with CKD, when compared with centre-based and satellite clinic dialysis.⁵⁸

Conversely, in two reviews that assessed the impact of home-based cardiac rehabilitation on readmission for cardiac conditions including myocardial infarction,⁵⁰ ⁶³ heart failure⁶³ and chest pain,⁶³ no significant effects of interventions were observed when compared with usual care.

### Ambulatory care

A total of 8 reviews (12%) examined the impact of ambulatory care on healthcare utilisation.⁵⁰ ⁵⁴⁻⁵⁹ ⁶¹ Three reviews found significant reductions in hospitalisations and length of stay for patients receiving dialysis in alternate settings⁵⁸ and ambulatory THA.⁵⁶ ⁵⁹ One review found mixed evidence for a reduction in readmission rates, as well as emergency department (ED), physician and nurse visits among patients with heart failure who received ambulatory joint replacement.⁵⁷
No evidence of reduced reoperation or readmission rates following ambulatory total joint replacement were found in two reviews, when compared with usual care.<sup>54 61</sup> Similarly, 2 reviews (2%) found no significant difference in readmissions between ambulatory interventions and other models of care, including tele-based, home-based or centre-based cardiac rehabilitation for myocardial infarction,<sup>50</sup> and outpatient versus home-based exercise therapy for total knee arthroplasty and THA.<sup>55</sup>

### Integrated care

A total of 6 reviews (9%) assessed the effects of integrated care on readmission rates.<sup>21 23 25 67 74 79</sup> Four reviews found evidence of reduced all cause hospitalisations<sup>67</sup> and readmissions<sup>23 74 79</sup> and heart failure-specific hospitalisations<sup>67</sup> and readmissions<sup>74</sup> for heart failure patients. No effect of interventions on ED utilisation was found for heart failure.<sup>74 79</sup> One review found low-quality evidence for reduced all cause hospitalisation for CKD,<sup>21</sup> and one review found a significant reduction in ED visits for COPD following integrated telemonitoring.<sup>25</sup> No effect was reported for hospitalisations and length of stay.<sup>25</sup>

### Specialist hospitals

The impact of blended integrated and specialist hospital interventions, including transitional care,<sup>74</sup> disease management clinics<sup>23</sup> and multidisciplinary specialist care, was assessed in 3 reviews (5%).<sup>19</sup> Two reviews reported evidence for reduced rates of all-cause readmissions<sup>23 74</sup> for heart failure and heart failure-specific readmissions.<sup>74</sup> One review found evidence of lower hospitalisation rates for end-stage kidney disease.<sup>19</sup>

### Consumer-focused care

One review (2%) found evidence for reduced all-cause hospitalisation rates among patients with CKD receiving person-centred integrated care.<sup>21</sup>

### Quality of life

#### Virtual care

A total of 21 reviews (32%) examined the impact of virtual care on patient quality of life.<sup>24 25 27–29 32 34 36 37 40 43 45–49 52 72 80–82</sup> Five reviews reported a positive effect of virtual care interventions, including telemedicine and videoconferencing on quality-of-life outcomes.<sup>32 36 49 72 81</sup>

In total, 5 reviews found no significant effect of interventions on quality of life,<sup>27 37 43 47 80</sup> and 11 reviews presented mixed evidence for the impact of interventions on quality of life.<sup>24 25 28 29 34 40 45 46 48 52 82</sup>

### Hospital in the home

The effect of HITH interventions on quality of life were assessed in four reviews (6%).<sup>27 49 60 63</sup> One review found mixed effects of home-based care on quality of life for patients with COPD,<sup>60</sup> and three reviews found no significant difference in quality of life between interventions and other forms of care.<sup>27 49 63</sup>

### Integrated care

A total of 4 reviews (6%) assessed the effect of integrated care on quality of life.<sup>21 25 67 68</sup> One review found a moderate improvement in quality of life for patients with fragility fractures,<sup>68</sup> one review found mixed effects on quality of life<sup>25</sup> and two reviews found no significant effect of interventions on quality of life.<sup>21 25 67</sup>

### Ambulatory care

The impact of ambulatory care interventions on quality of life was assessed in 3 reviews (5%).<sup>57 59 60</sup> One review reported a moderate-to-large positive effect of THA on quality of life.<sup>59</sup> One review found mixed evidence of interventions on quality of life among heart failure<sup>57</sup> patients and one review found no significant difference in quality-of-life outcomes among patients with COPD<sup>60</sup> when interventions were delivered in outpatient or community settings.

### Consumer-focused care

Overall, 2 reviews (3%) evaluated the effect of blended integrated and consumer-focused care on patient quality of life.<sup>21 69</sup> One review reported an improvement in quality of life, depression and anxiety scores among hip fracture patients,<sup>69</sup> and one review found no significant difference between patients with CKD receiving interventions,<sup>21</sup> compared with usual care.

### Self-management and self-care

#### Virtual care

A total of 17 reviews (26%) assessed the impact of virtual care on consumer-management outcomes, including medication, diet and inhaler adherence.<sup>26 29 31 32 34–37 40 41 44–47 51 72 83</sup> Six reviews found evidence for a positive effect of virtual care interventions on self-management behaviours for chronic illnesses such as asthma, COPD and heart failure.<sup>26 31 34 41 47 51</sup> A total of 10 reviews found mixed evidence,<sup>29 31 32 35 40 44–46 72 83</sup> and 2 reviews (3%) recorded no effect of virtual care on self-management outcomes.<sup>36 37</sup>

### Consumer-focused care

In total, 1 review (2%) assessed the impact of blended integrated and consumer-focused care interventions on self-management outcomes in hip fracture patients.<sup>69</sup> The review found mixed evidence for improvements in commitment to physical activity and osteoporosis treatment.<sup>69</sup>

### Ambulatory care

The effect of ambulatory care on patient self-management of heart failure was assessed in 1 review (2%).<sup>57</sup> The review found a positive effect of ambulatory management on diet and medication adherence.<sup>57</sup>

### Hospital in the home

In total, 1 review (2%) examined the effect of home-based models of cardiac rehabilitation on adherence to care.<sup>63</sup> The review found mixed evidence for HITH
rehabilitation on adherence to rehabilitation for patients with heart failure, myocardial infarction and chest pain, when compared with centre-based care.⁶³

### Integrated care

In total, 1 review (2%) examined the impact of pharmacist involvement in multidisciplinary management on consumer management of their care for patients with heart failure.⁶⁷ No significant improvements in patient management were observed following interventions.⁶⁷

### Patient knowledge

#### Virtual care

A total of 5 reviews (8%) assessed the impact of virtual care interventions on patient knowledge.³³ ³⁵ ⁴⁰ ⁴⁵ ⁶⁹ Three reviews found that virtual care interventions produced positive effects on knowledge for patients with osteoporosis,⁶⁹ CKD³⁵ and postnatal depression.³³ One review found mixed results for patients with asthma or heart failure,⁴⁵ and one found no significant difference among asthma patients when compared with usual care.⁴⁰

### Integrated care

The impact of integrated care interventions, including multidisciplinary educative sessions,⁶⁹ on patient knowledge was examined in 2 reviews (3%).⁶⁷ ⁶⁹ Among patients with osteoporosis⁶⁹ and heart failure,⁶⁷ knowledge of their disease significantly improved following the intervention.

### Ambulatory care

In total, 1 review (2%)⁵⁷ found a significant improvement in disease-specific and nutritional knowledge among heart failure patients receiving ambulatory educational and self-management interventions.

## DISCUSSION

This umbrella review of reviews presents an overview of evidence for innovative models of healthcare in and outside of hospital settings in treating and managing common acute and chronic conditions. Informed by a grey literature search,¹⁵ seven models of care were identified in the academic literature. Evidence in support of the models of care was mixed; however, all models of care demonstrated positive or equivalent healthcare outcomes for patients in treating several conditions, when compared with usual care. Importantly, non-significant effects of interventions indicated that the outcomes did not substantially differ from those seen with usual care. That is, non-significant results demonstrate a comparable intervention, rather than an ineffective intervention in absolute terms. Models of care that demonstrate similar effects to usual care on outcomes, such as clinical indicators, mortality or readmission, may produce additional benefits such as patient knowledge, quality of life and reduced cost.²¹ ²³ ²⁵ ⁵⁷ As a result, when implementing models of care in healthcare settings, a broader consideration of patient needs and health system factors may be

critical when evaluating the suitability of models of care that produce similar outcomes to usual care.

Virtual care was the most frequently evaluated model in the literature, represented in 47 out of 66 included reviews. This may be partially attributable to recent innovations seen in response to the COVID-19 pandemic and resultant adaptations in healthcare delivery. For example, virtual care interventions were frequently blended or implemented in conjunction with other models, including HITH⁵⁰ ⁵⁸ and integrated care,²³ ²⁵ ⁶⁹ to increase the reach and timeliness of care in the community. Blended or hybrid models were similarly seen outside of the virtual care model, including specialist-integrated care,¹⁹ ²⁰ ⁷⁰ consumer-focused-integrated care²¹ and ambulatory-HITH care.⁵⁰ While blended interventions appeared to produce superior outcomes in some reviews,²¹ ²⁵ it may be critical to examine whether they increase, decrease or shift resource requirements to other areas within the health system, for example, non-urgent visits, as well as nurse and General Practitioner (GP) contacts.³² ⁷⁷

## Strengths and limitations

A noted strength of this study is that it presents a comprehensive overview of evidence for innovative models of care and was guided by a research librarian with expertise in search string development. However, given the scope of the literature, primary studies were omitted to capture the maximum amount of high-level evidence across diverse interventions and cohorts. As a result, cutting-edge developments that have evaded systematic review may not have been adequately captured. This limitation was most pertinent for the digital hospital model. Finally, the evidence provided by the reviews was sufficiently heterogeneous that data were unable to be pooled for statistical analyses.

## Conclusions

This review identified seven innovative models of healthcare that may be effective in managing patients across a wide range of acute and chronic conditions. While most of the included reviews found evidence of comparable or improved care relative to usual practice, a consideration of local infrastructure, specific health system contexts and individual patient characteristics, such as health literacy, cultural background and age, may be critical in determining the suitability of models for patients. Structured approaches to identifying patient and provider expectations should be incorporated into planning and implementing innovative models of care into the hospitals of the future.

## Author affiliations

<footnote n="1">¹Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia</footnote>

<footnote n="2">²Division of Health Sciences, University of South Australia, Adelaide, South Australia, Australia</footnote>

<footnote n="3">³LEMNA, F-44000, Université de Nantes, Nantes, France</footnote>

<footnote n="4">⁴Australian Genomics, Murdoch Children's Research Institute, Parkville, Victoria, Australia</footnote>

<footnote n="5">⁵Western Sydney Local Health District, Wentworthville, New South Wales, Australia</footnote>
**Twitter** Ann Carrigan @annjcar, Robyn Clay-Williams @RClaywilliams, Zeyad Mahmoud @zeyadmahmoud, Louise A Ellis @LouiseAEllis, Janet C Long @JanetCLong and Yvonne Zurynski @YvonneZurynski

**Contributors** All authors (NR, AC, RC-W, PDH, ZM, CP, DFP, IM, GTK, EEA, KC, LAE, JCL, KH, SB, BNGE, MNS, EFA, SH, GD, M-TN, HMN, GA, FR, YZ, KM and JB) helped to shape and produce this review. NR, CP, AC, FR, YZ and JCL helped to design and refine the search string, and AC, NR, IM, GD, KC, SB, KH, EEA, JCL, SH, BNGE, DFP, MNS, EFA, LAE, M-TN and HMN assisted with screening and extracting the data at the title/abstract and full-text stages. NR and AC developed the initial search string and NR led the review team. JCL assisted with the transition from systematic to umbrella review. NR synthesised the findings and NR, AC and DFP completed the initial drafts of the manuscript. RC-W, PDH and JB supervised the review and provided guidance on the design, data collection, synthesis and write-up. AC, RC-W, PDH, MNS, JCL, SB, KH, KC, EEA, LAE, EFA, GD, YZ, GA, KM, IM, FR and JB provided feedback on the final manuscript. RC-W is the guarantor for the study.

**Funding** This project was funded by Health Infrastructure NSW under the grant HI20314.

**Competing interests** There are no competing interests to declare between the authors and Health Infrastructure. The project was commissioned by Health Infrastructure NSW and Western Sydney LHD (WSLHD). KM works for WSLHD; however, this did not inform the evaluation of evidence or conclusions of the review.

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

**Patient consent for publication** Not applicable.

**Provenance and peer review** Not commissioned; externally peer reviewed.

**Data availability statement** All data relevant to the study are included in the article or uploaded as an online supplemental information. All relevant data for the study are available in online supplemental files. Additional data are available on reasonable request.

**Supplemental material** This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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

## ORCID iDs

Natalie Roberts http://orcid.org/0000-0003-0939-5777
Ann Carrigan http://orcid.org/0000-0002-2525-9241
Robyn Clay-Williams http://orcid.org/0000-0002-6107-7445
Peter D Hibbert http://orcid.org/0000-0001-7865-343X
Zeyad Mahmoud http://orcid.org/0000-0003-3331-8093
Chiara Pomare http://orcid.org/0000-0002-9118-7207
Gilbert Thomas Knaggs http://orcid.org/0000-0003-4710-6104
Elizabeth E Austin http://orcid.org/0000-0002-8438-2362
Kate Churruca http://orcid.org/0000-0002-9923-3116
Louise A Ellis http://orcid.org/0000-0001-6902-4578
Janet C Long http://orcid.org/0000-0002-0553-682X
Mitchell N Sarkies http://orcid.org/0000-0001-7318-3598
Genevieve Dammery http://orcid.org/0000-0002-8188-712X
Hoa Mi Nguyen http://orcid.org/0000-0002-8431-9160
Gaston Arnolda http://orcid.org/0000-0003-4948-7633
Frances Rapport http://orcid.org/0000-0002-4428-2826
Yvonne Zurynski http://orcid.org/0000-0001-7744-8717
Jeffrey Braithwaite http://orcid.org/0000-0003-0296-4957

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