title: Effectiveness of quality improvement strategies for coordination of care to reduce use of health care services: a systematic review and meta-analysis.
abstract: BACKGROUND
  Frequent users of health care services are a relatively small group of patients who account for a disproportionately large amount of health care utilization. We conducted a meta-analysis of the effectiveness of interventions to improve the coordination of care to reduce health care utilization in this patient group.
  
  
  METHODS
  We searched MEDLINE, Embase and the Cochrane Library from inception until May 2014 for randomized clinical trials (RCTs) assessing quality improvement strategies for the coordination of care of frequent users of the health care system. Articles were screened, and data abstracted and appraised for quality by 2 reviewers, independently. Random effects meta-analyses were conducted.
  
  
  RESULTS
  We identified 36 RCTs and 14 companion reports (total 7494 patients). Significantly fewer patients in the intervention group than in the control group were admitted to hospital (relative risk [RR] 0.81, 95% confidence interval [CI] 0.72-0.91). In subgroup analyses, a similar effect was observed among patients with chronic medical conditions other than mental illness, but not among patients with mental illness. In addition, significantly fewer patients 65 years and older in the intervention group than in the control group visited emergency departments (RR 0.69, 95% CI 0.54-0.89).
  
  
  CONCLUSIONS
  We found that quality improvement strategies for coordination of care reduced hospital admissions among patients with chronic conditions other than mental illness and reduced emergency department visits among older patients. Our results may help clinicians and policy-makers reduce utilization through the use of strategies that target the system (team changes, case management) and the patient (promotion of self-management).
authors.affiliation: Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont.
authors.forename: Andrea C
authors.initials: AC
authors.lastname: Tricco
authors.affiliation: Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont.
authors.forename: Jesmin
authors.initials: J
authors.lastname: Antony
authors.affiliation: Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont.
authors.forename: Noah M
authors.initials: NM
authors.lastname: Ivers
authors.affiliation: Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont.
authors.forename: Huda M
authors.initials: HM
authors.lastname: Ashoor
authors.affiliation: Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Khan
authors.affiliation: Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont.
authors.forename: Erik
authors.initials: E
authors.lastname: Blondal
authors.affiliation: Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont.
authors.forename: Marco
authors.initials: M
authors.lastname: Ghassemi
authors.affiliation: Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont.
authors.forename: Heather
authors.initials: H
authors.lastname: MacDonald
authors.affiliation: Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont.
authors.forename: Maggie H
authors.initials: MH
authors.lastname: Chen
authors.affiliation: Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont.
authors.forename: Lianne Kark
authors.initials: LK
authors.lastname: Ezer
authors.affiliation: Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont. sharon.straus@utoronto.ca.
authors.forename: Sharon E
authors.initials: SE
authors.lastname: Straus
mesh_terms: D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D006296:Health Services / Q000706:statistics & numerical data*; D006801:Humans; D058996:Quality Improvement