Integrated Care Programs for Adults With Chronic Conditions
Integrated Care Programs for Adults With Chronic Conditions
Our searches of electronic databases and reference lists identified a total of 3610 unique citations; of whom, 3492 were excluded based on titles and abstracts. The full text of 118 articles were examined in detail. After excluding 90 articles (see Supplementary Appendix for bibliographic details), 27 reviews, reported in 28 publications, met inclusion criteria. Of those, 26 were published in English and one in German. Figure 1 shows the flow of study selection.
(Enlarge Image)
Figure 1.
Study selection process.
The 27 reviews were published from 1997 to 2012; the median year of publication was 2005 (Table 2). Nineteen reviews reported the total number of study participants; this number ranged from 669 to 35 484 patients. Chronic heart failure (CHF; n = 12) was the most common medical condition examined, followed by diabetes mellitus (DM; n = 7), chronic obstructive pulmonary disease (COPD; n = 7), asthma (n = 5), hypertension (n = 3), cancer (n = 2) and rheumatoid arthritis (n = 2). Seventeen reviews (63%) included both RCTs of integrated care interventions and studies where comparisons were not randomized; seven reviews (26%) exclusively focused on RCTs and three reviews did not report the type of studies they included. Eighteen reviews (68.0%) included a meta-analysis to statistically combine results of primary studies. A detailed description of the 27 reviews, with disease area, terms used to describe integrated care, specific aims and conclusions, is given in Supplementary Table S2.
'Disease management' was the most frequently used term for integrated care. Other terms included 'case management', 'shared care', 'managed care', 'comprehensive care', 'multidisciplinary care', 'organised and coordinated care', 'team care', 'managed care cooperation' and 'chronic care models' (Supplementary Table S2). Among the 10 key principles, comprehensive services across the care continuum, patient focus and standardized care delivery through inter-professional teams were assessed in most reviews, and performance management, information systems and physician integration in about half of reviews (Table 2). Fifteen reviews (56%) evaluated five or more of the principles. Only one review focused on organizational culture and leadership and governance structure. A description of the integrated care programmes and outcomes evaluated in the reviews is available in Supplementary Table S3. Unfortunately, the description of the programmes and interventions was often superficial and incomplete, hampering a detailed assessment of the different components and interventions. Supplementary Table S4 lists the key principles of integrated care assessed based on the information provided in the reviews.
The methodological and reporting quality of reviews varied widely. The median number of AMSTAR criteria met was 5. Reporting was very poor for one review; none of the criteria was clearly met. A Cochrane review met 10 of the 11 criteria. Six reviews scored on eight to nine criteria. The assessments of the methodological quality by AMSTAR item are shown in Fig. 2 and Table 3. Twenty-six reviews (96%) defined a priori research questions and inclusion criteria, 20 (74%) employed duplicate study selection and data extraction, 20 (74%) did a comprehensive literature search, 2 (7%) searched for grey or non-English literature, 3 (11%) provided a list of included and excluded studies, 6 (22%) described the characteristics of the included studies, 22 (82%) assessed and documented their quality and 21 (78%) used the data on the quality of primary studies appropriately when formulating conclusions. Seventeen of 18 meta-analyses (94%) used appropriate statistical methods and 10 (56%) assessed publication bias. Finally, two reviews (7%) considered potential conflicts of interest.
(Enlarge Image)
Figure 2.
Proportion of systematic reviews that addressed each of the methodological quality items of the AMSTAR tool; based on 27 included systematic reviews.
A total of 824 primary studies (range: 4–112 per review) had been included in the 27 reviews. The design of studies was reported in 24 reviews: of 637 studies, 480 (75%) were described as RCTs, and 157 (25%) were studies where comparisons had not been randomized (Table 1). All but four reviews reported the setting where the primary studies were conducted. Settings varied widely from inpatient to outpatient care, and included home care, nursing home, rehabilitation centre, community hospital and secondary and tertiary care settings. A detailed description of the primary studies by review is given in Supplementary Table S5, including the number and setting of studies, the study designs and the age and gender distribution of study populations.
The use of healthcare resources was the most frequently examined outcome, followed by patient-reported and functional outcomes, and costs to patients, payers or society. Process-related and clinical outcomes were assessed in less than half of reviews (Table 2). The effects of integrated care found in the 27 reviews are summarized in Table 4 for CHF, diabetes mellitus, COPD and asthma. For outcome assessed in at least two reviews, the table shows the number of reviews that assessed the outcome, and number of reviews that showed a statistically significant (P < 0.05) beneficial effect or trend in the direction of benefit. For CHF, the majority of relevant reviews reported that integrated care programmes reduced mortality and hospital admissions and readmissions, as well as visits to the emergency department. For diabetes mellitus, the majority of reviews showed that glycaemic control, adherence to treatment guidelines and quality of life were improved, and hospital admissions reduced. Similarly, for COPD, reviews showed an improvement in the adherence to treatment guidelines, a reduction in hospital readmissions and length of hospital stays, and a reduction in visits to the emergency department. For asthma, all relevant reviews indicated an improvement in the adherence to treatment guidelines and two of the three reviews showed a reduction in hospital admissions. Of note, few reviews found that costs were reduced and no review found any evidence of harm of integrated care programmes (Table 4).
Results
Identification of Eligible Reviews
Our searches of electronic databases and reference lists identified a total of 3610 unique citations; of whom, 3492 were excluded based on titles and abstracts. The full text of 118 articles were examined in detail. After excluding 90 articles (see Supplementary Appendix for bibliographic details), 27 reviews, reported in 28 publications, met inclusion criteria. Of those, 26 were published in English and one in German. Figure 1 shows the flow of study selection.
(Enlarge Image)
Figure 1.
Study selection process.
Characteristics of Reviews
The 27 reviews were published from 1997 to 2012; the median year of publication was 2005 (Table 2). Nineteen reviews reported the total number of study participants; this number ranged from 669 to 35 484 patients. Chronic heart failure (CHF; n = 12) was the most common medical condition examined, followed by diabetes mellitus (DM; n = 7), chronic obstructive pulmonary disease (COPD; n = 7), asthma (n = 5), hypertension (n = 3), cancer (n = 2) and rheumatoid arthritis (n = 2). Seventeen reviews (63%) included both RCTs of integrated care interventions and studies where comparisons were not randomized; seven reviews (26%) exclusively focused on RCTs and three reviews did not report the type of studies they included. Eighteen reviews (68.0%) included a meta-analysis to statistically combine results of primary studies. A detailed description of the 27 reviews, with disease area, terms used to describe integrated care, specific aims and conclusions, is given in Supplementary Table S2.
'Disease management' was the most frequently used term for integrated care. Other terms included 'case management', 'shared care', 'managed care', 'comprehensive care', 'multidisciplinary care', 'organised and coordinated care', 'team care', 'managed care cooperation' and 'chronic care models' (Supplementary Table S2). Among the 10 key principles, comprehensive services across the care continuum, patient focus and standardized care delivery through inter-professional teams were assessed in most reviews, and performance management, information systems and physician integration in about half of reviews (Table 2). Fifteen reviews (56%) evaluated five or more of the principles. Only one review focused on organizational culture and leadership and governance structure. A description of the integrated care programmes and outcomes evaluated in the reviews is available in Supplementary Table S3. Unfortunately, the description of the programmes and interventions was often superficial and incomplete, hampering a detailed assessment of the different components and interventions. Supplementary Table S4 lists the key principles of integrated care assessed based on the information provided in the reviews.
The methodological and reporting quality of reviews varied widely. The median number of AMSTAR criteria met was 5. Reporting was very poor for one review; none of the criteria was clearly met. A Cochrane review met 10 of the 11 criteria. Six reviews scored on eight to nine criteria. The assessments of the methodological quality by AMSTAR item are shown in Fig. 2 and Table 3. Twenty-six reviews (96%) defined a priori research questions and inclusion criteria, 20 (74%) employed duplicate study selection and data extraction, 20 (74%) did a comprehensive literature search, 2 (7%) searched for grey or non-English literature, 3 (11%) provided a list of included and excluded studies, 6 (22%) described the characteristics of the included studies, 22 (82%) assessed and documented their quality and 21 (78%) used the data on the quality of primary studies appropriately when formulating conclusions. Seventeen of 18 meta-analyses (94%) used appropriate statistical methods and 10 (56%) assessed publication bias. Finally, two reviews (7%) considered potential conflicts of interest.
(Enlarge Image)
Figure 2.
Proportion of systematic reviews that addressed each of the methodological quality items of the AMSTAR tool; based on 27 included systematic reviews.
Characteristics of Primary Studies Included in Reviews
A total of 824 primary studies (range: 4–112 per review) had been included in the 27 reviews. The design of studies was reported in 24 reviews: of 637 studies, 480 (75%) were described as RCTs, and 157 (25%) were studies where comparisons had not been randomized (Table 1). All but four reviews reported the setting where the primary studies were conducted. Settings varied widely from inpatient to outpatient care, and included home care, nursing home, rehabilitation centre, community hospital and secondary and tertiary care settings. A detailed description of the primary studies by review is given in Supplementary Table S5, including the number and setting of studies, the study designs and the age and gender distribution of study populations.
Outcomes
The use of healthcare resources was the most frequently examined outcome, followed by patient-reported and functional outcomes, and costs to patients, payers or society. Process-related and clinical outcomes were assessed in less than half of reviews (Table 2). The effects of integrated care found in the 27 reviews are summarized in Table 4 for CHF, diabetes mellitus, COPD and asthma. For outcome assessed in at least two reviews, the table shows the number of reviews that assessed the outcome, and number of reviews that showed a statistically significant (P < 0.05) beneficial effect or trend in the direction of benefit. For CHF, the majority of relevant reviews reported that integrated care programmes reduced mortality and hospital admissions and readmissions, as well as visits to the emergency department. For diabetes mellitus, the majority of reviews showed that glycaemic control, adherence to treatment guidelines and quality of life were improved, and hospital admissions reduced. Similarly, for COPD, reviews showed an improvement in the adherence to treatment guidelines, a reduction in hospital readmissions and length of hospital stays, and a reduction in visits to the emergency department. For asthma, all relevant reviews indicated an improvement in the adherence to treatment guidelines and two of the three reviews showed a reduction in hospital admissions. Of note, few reviews found that costs were reduced and no review found any evidence of harm of integrated care programmes (Table 4).
