The effects of integrated care: a systematic review of UK and international evidence

BACKGROUND: Healthcare systems around the world have been responding to the demand for better integrated models of service delivery. However, there is a need for further clarity regarding the effects of these new models of integration, and exploration regarding whether models introduced in other care systems may achieve similar outcomes in a UK national health service context. METHODS: The study aimed to carry out a systematic review of the effects of integration or co-ordination between healthcare services, or between health and social care on service delivery outcomes including effectiveness, efficiency and quality of care. Electronic databases including MEDLINE; Embase; PsycINFO; CINAHL; Science and Social Science Citation Indices; and the Cochrane Library were searched for relevant literature published between 2006 to March 2017. Online sources were searched for UK grey literature, and citation searching, and manual reference list screening were also carried out. Quantitative primary studies and systematic reviews, reporting actual or perceived effects on service delivery following the introduction of models of integration or co-ordination, in healthcare or health and social care settings in developed countries were eligible for inclusion. Strength of evidence for each outcome reported was analysed and synthesised using a four point comparative rating system of stronger, weaker, inconsistent or limited evidence. RESULTS: One hundred sixty seven studies were eligible for inclusion. Analysis indicated evidence of perceived improved quality of care, evidence of increased patient satisfaction, and evidence of improved access to care. Evidence was rated as either inconsistent or limited regarding all other outcomes reported, including system-wide impacts on primary care, secondary care, and health care costs. There were limited differences between outcomes reported by UK and international studies, and overall the literature had a limited consideration of effects on service users. CONCLUSIONS: Models of integrated care may enhance patient satisfaction, increase perceived quality of care, and enable access to services, although the evidence for other outcomes including service costs remains unclear. Indications of improved access may have important implications for services struggling to cope with increasing demand. TRIAL REGISTRATION: Prospero registration number: 42016037725

Stratigraphy of Triassic-Jurassic boundary sequences from the Kawhia coast and Awakino gorge, Murihiku Terrane, New Zealand

We have examined the stable carbon isotope stratigraphy, bio- and litho-stratigraphy of the Upper Triassic (Otapirian) - Lower Jurassic (Aratauran) boundary strata from the Awakino gorge and Kawhia coast sections, Murihiku Terrane, North Island, New Zealand. Successive occurrences of species of the bivalve genus Otapiria, O. dissimilis, O. marshalli and O. aff. marshalli, and also of age diagnostic ammonites indicate that the Hettangian strata in both sections are very thin compared with the Rhaetian sequences. Lamination structures are well developed at the Tr-Jr (Rhaetian-Hettangian) boundary transition interval. The delta C-13 values of organic matter from siltstone and carbonate nodules in the sedimentary rocks range from -28.5 to -25.5 parts per thousand and there is no correlation between delta C-13(org) and C/N ratios. The excursion patterns of delta C-13(org) from both sections are similar, showing a negative spike at the uppermost Rhaetian and a positive spike immediately below the Tr-Jr boundary. A long-lived positive shift is also recognized in the Awakino gorge section, which coincides in pattern with those reported in Tr-Jr boundary successions from the Queen Charlotte Islands, British Columbia, Canada. These results suggest that although magnitude and absolute values are slightly different, the integrated pattern of stable carbon isotope signatures over the Tr-Jr boundary could be a valuable tool for correlation, at least between sedimentary rocks from similar depositional settings in the Panthalassa