Methodological Investigation of Cochrane reviews of Complex Interventions (MICCI)
Version 1: Data-extraction template for describing complex interventions
Worked example 1
A reengineered hospital discharge program to decrease rehospitalisation: a randomised trial.
Jack et al 2009
Dimension 1: Discrete, active components included in the intervention compared with the
control (or usual care).
List each component. A component is defined as a discrete, active element
of the intervention that could be implemented independently of other
elements e.g. an educational booklet for consumers; clinical guidelines for
Level of
practitioners; a single drug intervention; a discrete surgical procedure.
complexity
Include dose, frequency, and duration of intervention if applicable. If the
intervention comprises usual care plus something else, list “usual care” as
one component.
Control
(or usual care)
Intervention
Usual care (discharge from hospital) not described. Assumed to be
an administrative process including supply of medication and/or
outpatient appointment if appropriate and minimal advice
Reengineered hospital discharge comprising in-hospital components
delivered by trained Discharge Advocate (DA):
1. Educate patient about diagnoses
2. Co-ordinate appointments for follow-up and post-discharge
testing at convenient times for patient; discuss importance of
follow-up, access to transport and other potential barriers
3. Discuss pending tests and nature of follow-up with results
4. Organise post-discharge services, ensure patient understands and
can access them
5. Confirm and explain medication plan, ensure patient understands
schedule, purpose, how to take correctly and side effects, and can
obtain further supplies
6. Reconcile discharge plan with national guidelines and critical
pathways
7. Instruct patient in appropriate actions if a problem arises
8. Transmit detailed discharge summary to physicians and services
responsible for on-going care
9. Assess patient’s understanding of the plan and contact family if
necessary
10. Give patient detailed a written discharge plan including follow-up
information and calendar
Simple
Complex
Post-discharge telephone call to the patient from a pharmacist to
reinforce discharge plan, review medications and solve problems
The above are not all discrete elements, there is some overlap. They
could be grouped as organisational, patient-education and follow-up.
i.e. 3 components.
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Methodological Investigation of Cochrane reviews of Complex Interventions (MICCI)
Dimension 2: Behaviours or actions of intervention recipients or participants to which
the intervention is directed.
List each behaviour or action. Behaviours or actions include taking a
medication, changing a particular practice, improving knowledge or
Level of
undergoing a surgical procedure. Consider whether behaviours are single, complexity
repeated, or linked.
Control
(or usual care)
Patient is discharged from hospital with a prescription / follow-up
appointment / advice as appropriate
Simple
Intervention
Targeted actions to reduce readmissions are:
 Patients attend follow-up appointments and understand the
importance of test results etc.
 Patients take medication correctly, know how to obtain more
when needed, recognise side-effects
 Patients seek appropriate help when problems arise
Complex
Dimension 3. Organisational levels targeted by the intervention
Indicate which level(s) are targeted. Level refers to whether the
intervention was directed at one of more of the following strata:
individuals (consumers, professionals, policy makers); groups or teams of
individuals (a clinic, patient support group etc.); systems (health systems,
communities, policy networks).
Level of
complexity
Control
(or usual care)
Patients
Simple
Intervention 1
Patients
Simple
Dimension 4. The degree of flexibility or tailoring permitted across sites or individuals
in intervention implementation / application.
Indicate the degree of flexibility. Flexibility includes variation in
implementation from site to site permitted and / or intervention designed to
Level of
tailor to individuals or specific implementation settings (there could be a
complexity
rigid protocol where no variation is permitted or a loose protocol i.e. most
components of the intervention are tailored / flexible).
Control
(or usual care)
Usual discharge procedure is not described but it is assumed to be a
standardised administrative protocol with scope for tailoring its
delivery (amount and type of advice given etc).
Simple
Intervention
The intervention comprises a detailed protocol that has to be adhered
to, though there is scope for tailoring patient-specific content
Simple
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Methodological Investigation of Cochrane reviews of Complex Interventions (MICCI)
Dimension 5. The level of skill (defined as the ability to do something, arising from
training, practice or experience) required by those delivering the intervention.
Indicate the level of skill required i.e. new skills in addition to expected
existing skills AND / OR the extension of existing skills to a highly
specialised area AND / OR skills requiring extensive additional training.
Level of
Indicate whether the required skills are multi-disciplinary,
complexity
interdisciplinary or single disciplinary. Note: there may be no new skills
required.
Control
(or usual care)
No new skills required
Simple
Intervention
Nurse Discharge Advocates were specially recruited and trained to
deliver the in-hospital intervention
Complex
Dimension 6. The skills required for the targeted behaviour when entering the study by
those receiving the intervention in order to meet the intervention’s objectives.
Describe or list the skills required (defined as the ability to do something,
arising from training, practice or experience) for the targeted behaviour
Level of
when entering the study by those receiving the intervention (consumers,
complexity
professionals, planners) in order to meet the intervention’s objectives.
Note: there may be no specialist skills required
Control
(or usual care)
No specialist skills required
Simple
Intervention
No specialist skills required
Simple
Dimension 7. The interaction between intervention components
Describe the interaction between intervention components. Note:
Interaction may not be reported or may be implicit or suggested in the
discussion; components may have an aggregative effect or be independent
Level of
complexity
Control
(or usual care)
No interaction
Simple
Intervention
There is some interaction in that the educational component equips
patients with knowledge and understanding that promotes the desired
behaviour, the organisational component facilitates that behaviour,
and the post-discharge follow-up reinforces it.
Complex
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Methodological Investigation of Cochrane reviews of Complex Interventions (MICCI)
Dimension 8. The interaction between the intervention and the context or setting in
which it is implemented
Indicate which (if any) effects of the intervention are dependent on context
or setting. E.g. would the same intervention have the same effects in
primary care clinics and tertiary level hospitals, or in one country
Level of
compared to another. Would the same intervention have the same effects
complexity
on different groups (e.g. issues of equity need to be explained)
Control
(or usual care)
Could be delivered in any hospital
Simple
Intervention
Could be delivered in any hospital
Simple
Dimension 9. The ways in which the effectiveness of an intervention is modified by
patient, provider and health care delivery factors
Indicate the ways in which the effectiveness of an intervention is modified
Level of
by patient, provider and health care delivery factors (e.g.
complexity
duration/intensity of the intervention, person who delivers the intervention
Control
(or usual care)
The effect of standard hospital discharge protocols on readmission
rates could be modified by the person who effects the discharge. i.e.
by giving advice about medication, appointments etc. informally in
addition to the official procedure.
Moderately
complex
Intervention
The protocol is very detailed and there is little chance of impact on
effectiveness
Simple
Dimension 10. The ‘causal pathway’ between the intervention and the outcome it is
intended to effect.
Describe the causal pathway between the intervention and the outcome it is
Level of
intended to effect. The pathway may or may not be linear and there may
complexity
be more than one causal pathway. It may be helpful to use diagrams.
Control
(or usual care)
Pathway is short and linear.
Health care professional completes discharge procedure → patient is
discharged
Simple
Intervention
The pathway is not a single straight line. Elements of the
intervention form an educational component and organisational
component that run parallel and are complementary (one informs the
other facilitates). Both impact on behaviour that is then reinforced by
the post-discharge component.
Ed →
Pos-dis → behaviour
Org →
Moderately
complex
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