Living evidence synthesis about the intersections between primary care-based PHM approaches and specialty service lines
Creators: name: Kaelan Moatt
name: Velez, Marcela
name: Lavis, John
Publisher: name: Open Science Framework
Year: 2023
Subjects: subject: Public Health
subject: Health Services Research
subject: Medicine and Health Sciences

description: Background The prevention and management of chronic conditions represents one of the principal challenges for health systems today. Many patients who are at risk of developing a chronic condition are not proactively identified and engaged to either reduce their risk of developing an illness (when possible) or to intervene at an early stage in the hopes of minimizing the negative health outcomes associated with it. Furthermore, patients face a great degree of variability in care during the diagnosis and management of acute and chronic diseases, fragmentation of care that can result in inadequate communication and even an interruption of treatment, and a lack of attention paid to the prevention of the complications that can arise from suboptimal and fragmented care. One promising approach to addressing this challenge involves designing and implementing a population health management (PHM) approach, that aim to 1) identifying priority populations within the larger attributed population; 2) segmenting priority populations according to their needs, risks, and potential barriers; 3) co-designing person-centred care models and service mix with patients; 4) implementing and increasing the reach of models and service mix; and 5) monitoring and evaluating progress to inform learning and improvement efforts at macro, meso and micro levels (see Figure 1). Evidence-support systems can help to drive sector-specific learning and improvement across many decision-making levels, in this case as part of a ‘learning health system’ (ideally supported by a ‘general contractor’ who brings in the right ‘trades’) (see Figure 2). This ‘learning health system’ is a step forward in the evolution of the research paradigm, moving from separate and distinct enterprises of research and care delivery, toward knowledge translation and exchange, and even further to embedded evidence-support units and applied researchers (see Figure 3). PHM approaches are ideally integrated into the provision of a continuum of care with a strong grounding in primary care. There is also an opportunity to underline the intersections between primary care and specialty service lines, given many patients with long-standing chronic conditions will require care across both primary care and a variety of types of specialty care.(1) In the context of PHM approaches, specialty service lines can be conceptualized both as coordinated programs of care for individuals at the top of the PHM risk pyramid (i.e., those individuals with the most complex health risks and barriers to accessing care) and as offering support – via a primary care-grounded technical-support partner – to primary care-based providers working at other levels of the population-health risk pyramid, including those who have yet to develop a serious condition but who are at risk of doing so (see Figure 4). For instance, specialty service lines might work with the technical support partner on the development and implementation of patient self-management supports that operate across multiple chronic conditions and of prompts and reminders for primary-care providers in primary-care settings. Objective To regularly synthesize empirical and non-empirical evidence focused on optimizing the intersections between primary care-based PHM approaches and specialty service lines to achieve the quadruple aim. Rationale for our approach We will conduct a living evidence synthesis with four complementary evidence synthesis products. In the first product – a critical interpretative synthesis – we will develop a framework to clarify how primary-care-based PHM and specialty service lines may intersect. This framework will be used in the other three products. The second product – a scoping review – will describe the nature of the evidence available in this field. The third product – an evidence synthesis and meta-analysis – will assess the effects these approaches have on achieving quadruple-aim metrics. The last product will provide an understanding of whether, how and why these approaches work, and what stakeholders' views and experiences are with them. Design and methods Living evidence synthesis Rationale for the use of this method: 'Living' approaches to evidence synthesis have been a key innovation in evidence synthesis methods during the COVID-19 pandemic. They provide decision-makers with up-to-date, relevant and rigorous synthesized evidence.(2) Living evidence syntheses are also well poised to inform policy for topics such as intersections between primary care-based PHM approaches and specialty service lines, where evidence is emerging and where there is uncertainty about many interventions.(3) Approach: In preparing the first product will perform a critical interpretative synthesis (CIS) using the evidence to generate a novel framework explaining the factors, mechanisms and intersections between primary care-based PHM approaches and specialty service lines. The second product will be a scoping review that will identify the nature of the evidence about the factors, mechanisms and intersections between primary-care-based PHM approaches and specialty service lines, the diseases and conditions that have been managed through these approaches, the outcomes associated with these initiatives, as well as what jurisdictions have experienced planning and implementing these approaches. The third product will use the evidence on effects identified in the second product (with updated searchers to ensure any newly published studies are identified) and conduct a meta-analysis that generates evidence about the effects of approaches related to intersections between primary-care-based PHM approaches and specialty service lines (e.g., on the quadruple-aim metrics). Lastly, the fourth product will perform a qualitative evidence synthesis. This product will provide insights about how and why particular approaches have been placed to facilitate the intersections between primary-care-based PHM approaches and specialty service lines, as well as the views and experiences of government decision-makers, health professionals, and patients and caregivers, with these approaches (see Figure 5 for a representation of the methods). Search strategy: We will conduct comprehensive searches for published and grey literature in collaboration with an experienced library scientist. We will search ten databases (from inception onwards): MEDLINE, EMBASE, the Cochrane Library, CINAHL, PsycINFO, ACCESSSS, HealthEvidence, Health Systems Evidence, Epistemonikos, and medRxiv. Grey literature will be identified using Google Scholar, Open Science Framework, and governmental websites. Inclusion assessment and mapping of titles and abstracts: Two independent reviewers will assess all search results and include all types of articles and documents that provide insights about intersections between primary care-based PHM approaches and specialty service lines. Those included will be mapped as potentially relevant for one or more of the four products in this living evidence synthesis. Discrepancies in inclusion will be solved by consensus. Update process: We plan to run four iterations of the search, inclusion assessment and mapping of relevant articles. After the first iteration, we will perform the CIS and develop the framework that will be used to organize the evidence in the upcoming stages. After the second iteration, we will modify the framework in light of any new evidence, and proceed with the scoping review to understand the nature of the evidence available on the topic. After the third iteration, we will again update the framework as well as the scoping review in light of new evidence, and proceed with an evidence synthesis of effects and meta-analysis (assuming we identify quantitative studies that evaluate the effects of interventions and that it is statistically appropriate to pool the data from one or more of these studies). The fourth iteration will update insights from the previous three products as appropriate (i.e., the framework, the scoping review and the evidence synthesis of effects in light of new evidence). In this final iteration, we will focus on analyzing and synthesizing the insights from qualitative studies to gather insights about how and why particular approaches have been placed to facilitate intersections between primary care-based PHM approaches and specialty service lines, as well as stakeholders' views and experiences, allowing us to propose a list of implications for implementing these approaches. Critical interpretative synthesis (CIS) Rationale for the use of this method: The CIS is a methodology used for theory building that combines conducting an evidence synthesis with qualitative research inquiry. The CIS was selected for the first stage of this research given its appropriateness to answer research questions that need to draw on a heterogeneous body of literature that is not particularly well developed or focused,(4,5) which is the case with the literature related to factors, mechanisms and intersections between primary care-based PHM approaches and specialty service lines.(6) the key population segments requiring specialty service lines (i.e., the ‘buckets’ of populations and conditions for which unique health-systems arrangements are adopted to support specialty service lines), as well as the levels at which they can be planned and considerations that may affect the level at which they are provided Inclusion assessment: After the first iteration of search, inclusion assessment and mapping of titles and abstracts, we will retrieve the full text of all potentially relevant articles for the CIS. Two researchers will independently review them to make a final inclusion assessment. Any disagreement at this stage will be solved by consensus. Conceptual mapping and data extraction: We will conceptually map the included papers using a structured form. This form contains but is not limited to bibliographic information (e.g., title, authors, year of publication), study characteristics (e.g., publication type, study design in case of an empirical article, population targeted, specialty service lines, diseases and conditions addressed, jurisdictions involved, and outcomes assessed). After conceptually mapping, we will extract key insights from all included full-text articles by developing a summary of key findings and conclusions. We will use the mapping exercise to identify areas that are conceptually rich and areas where there appear to be conceptual gaps. Purposive sampling: We will then conduct purposive searching and sampling to fill conceptual gaps. In this process, we aim to identify additional articles (if needed) that are conceptually rich (i.e., those that address and highlight intersections between several factors included in the conceptual mapping and which describe and provide in-depth analysis or discussion about intersections between primary care-based PHM approaches and specialty service lines). Data synthesis and framework development: We will use qualitative methods to analyze and synthesize data from a purposively selected set of included studies to allow for an interpretive synthesis. To do this, we will use a constant comparative method throughout our analysis to develop an explanatory framework of factors, mechanisms, and intersections between primary care-based PHM approaches and specialty service lines. Scoping review Rationale for the use of this method: Scoping reviews are an ideal methodology to establish the scope or coverage of a body of literature on a given topic. Scoping reviews can provide transparent information about studies available, the volume of literature and an overview of its focus.(7) The general purposes for conducting scoping reviews are identifying and mapping the available evidence, examining how research is performed on a particular topic or field, and identifying and analyzing knowledge gaps.(7) Given theses purposes, scoping reviews are suitable precursors to an evidence synthesis. Inclusion assessment: After the second iteration of search, inclusion assessment and mapping, we will retrieve the full text of all empirical and non-empirical potentially relevant articles for the scoping review. Two researchers will independently review the articles and include those describing 1) specialty lines that have been integrated with primary care-based PHM approaches, 2) diseases and conditions that have been managed through these approaches, 3) jurisdictions with experience in planning and implementing these approaches, and 4) outcomes assessed and strategies to measure the outcomes. Any disagreement in the full-text inclusion assessment will be solved by consensus. Data extraction: We will develop a data collection instrument using the framework created in the CIS, plus other variables related to bibliographic information (e.g., title, authors, year of publication), study characteristics (e.g., publication type, study design in case of an empirical article, population targeted, specialty service lines, diseases and conditions addressed, jurisdictions involved, and outcomes assessed). Data extraction will be conducted by one researcher and reviewed by a second researcher. Data synthesis: Data analysis and synthesis will focus on describing the main sources and types of evidence available; the aggregated findings will provide an overview of the research rather than an assessment of the quality of individual studies. An evidence synthesis of effects and meta-analysis Rationale for the use of this method: An evidence synthesis uses straightforward methods to minimize bias and therefore provide more reliable and meaningful findings useful to make decisions.(8) An evidence synthesis may be performed to prove or disprove if current practice is based on relevant evidence, to establish the quality of that evidence, and to address any uncertainty or variation in practice that may be occurring.(9) Such variations in practice may be due to conflicting evidence and undertaking an evidence synthesis might contribute to solving such conflicts. An evidence synthesis also can identify gaps, deficiencies, and trends in the current evidence. In cases of low heterogeneity among studies included in an evidence synthesis, it is possible to conduct a meta-analysis. Meta-analysis aims to establish statistical significance with studies that have conflicting results, develop a correct estimate of effect magnitude, provide a more complex analysis of harms, safety data, and benefits, and examine subgroups with individual numbers that are not statistically significant.(10) Inclusion assessment: After the third iteration of search, inclusion assessment and mapping, we will retrieve the full text of all quantitative empirical articles for the evidence synthesis and meta-analysis. Two researchers will independently review the articles and include those reporting quantitative empirical findings on the association between primary care-based PHM approaches and specialty service lines and a population outcome (i.e., benefits and harms) or cost outcome. We will include experimental and primary observational studies (e.g., cohorts, case-control, and cross-sectional studies). To be included in the meta-analytic part of the study, studies should provide effect sizes for the association between primary care-based PHM approaches and specialty service lines and a population or cost outcome. Studies lacking this information or reporting effect sizes that could not be transformed into odds ratios will be excluded from the meta-analysis. To avoid overlapping data, we will include the study with the largest sample when a data set has been used in more than one study. Data extraction: Two reviewers will independently extract findings from each included study using a data collection instrument developed based on the framework created in the CIS and the scoping review findings. We will also extract information about bibliographic information (e.g., title, authors, year of publication); and study characteristics (e.g., study design, population addressed, specialty service lines, diseases and conditions addressed, jurisdictions involved, and outcomes assessed). Discrepancies will be solved by consensus. Risk of bias assessment: All included studies will be assessed for risk of bias using the Cochrane risk of bias tool (ROB-2) for any experimental studies and an adapted version of ROBINS-I for observational study designs. Two reviewers will independently conduct the assessments, with discrepancies solved through consensus (detailed approach provided in Appendix 1). Data analysis: Data analysis will include meta-analysis if heterogeneity (assessed with I2) is ≤50%. We anticipate that individual studies will vary in effects observed; therefore, we will estimate the pooled mean effect size using the random effects model. We will use two indicators of publication bias (Rosenthal's Fail-Safe N and Duval and Tweedie's trim and fill procedure).(10) For interpretation and imprecision assessment, we will use a minimally contextualized approach that considers whether the 95% CI includes the null effect, or when the point estimate is close to the null effect. We will present sub-group estimates of effect and certainty of the evidence if we observe significant differences between subgroups. If meta-analysis is not possible, we will synthesize quantitative data according to outcomes and interventions addressed. We will present a narrative summary of findings using tables and charts and disaggregating by diseases/conditions and settings. Assessment of certainty of evidence with GRADE: We will assess the certainty of the body of evidence using the GRADE approach (this approach assesses the methodological limitations of the body of evidence, and its inconsistency, indirectness, imprecision, and publication bias).(11) Two reviewers will independently conduct the assessments, with discrepancies solved through consensus (detailed approach provided in Appendix 1). Qualitative evidence synthesis Rationale for the use of this method: Qualitative evidence synthesis (QES) is a methodology to summarize qualitative empirical research. QES can be developed as a stand-alone review or as a part of a review of complex interventions, or for supporting guideline development.(12,13) QES aimed to bring together the findings from qualitative research to establish a greater understanding of the impact of a condition, intervention or policy on the lived experiences and feelings of those involved.(13) Inclusion assessment: After the fourth iteration of search, inclusion assessment and mapping, we will retrieve the full text of all qualitative empirical articles for the QES. Two researchers will independently review the articles and include those primary studies that explored patients, caregivers, healthcare providers and other stakeholders' experiences, perceptions, and behaviours about intersections between primary care-based PHM approaches and specialty service lines. Those studies must apply qualitative designs (e.g., ethnography, phenomenology, case studies, grounded theory studies and qualitative process evaluations), qualitative methods for data collection (e.g., focus group discussions, individual interviews, observation, diaries, document analysis), or qualitative methods for data analysis (e.g. thematic analysis, framework analysis, grounded theory). In case the same study, using the same sample and methods, is presented in different reports, we will collate these reports so that each study (rather than each report) will be the unit of analysis. Data extraction: Two independent researchers will extract findings from each included study using a data collection instrument developed based on the framework created in the CIS and the scoping review findings. We will also extract bibliographic information (e.g., title, authors, year of publication); study characteristics (e.g., study design, method for data collection, method for data analysis, population addressed, specialty service lines addressed, diseases and conditions addressed, and jurisdictions involved); and type of participant involved (i.e., patient, caregiver, healthcare provider, other stakeholders). We will solve any discrepancy by consensus. Assessment of methodological limitations of included studies: The Critical Appraisal Skills Programme (CASP) tool will assess all included studies for methodological limitations. Two reviewers will independently conduct the assessments, with discrepancies solved through consensus (detailed approach provided in Appendix 2). Data synthesis: We will include data in the form of quotes or fieldnote extracts, as well as authors' interpretations which could be presented in either the results or discussion sections of the articles. We will use content analysis to synthesize the data and draw the findings. Assessment of confidence in the evidence with GRADE-CERQual: We will use the GRADE-CERQual approach for assessing the confidence in the review findings (this approach considers the methodological limitations of the body of evidence, and its coherence, adequacy, and relevance).(14) Two reviewers will independently conduct the assessments, with discrepancies solved through consensus (detailed approach provided in Appendix 2). Developing implications for implementation: Once we finalize preparing the review findings, we will identify factors that could influence the implementation of intersections between primary care-based PHM approaches and specialty service lines, and we will develop prompts for future implementers. These prompts will not be intended to be recommendations but will be phrased as questions to help implementers consider the implications of the review findings within their context. We will send these prompts to a selection of stakeholders to gather their feedback about their relevance and how they are phrased and presented, and then we will revise the prompts accordingly.