Integrated care programmes for adults with chronic conditions: a meta-review

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Abstract

Objective

To review systematic reviews and meta-analyses of integrated care programmes in chronically ill patients, with a focus on methodological quality, elements of integration assessed and effects reported.

Design

Meta-review of systematic reviews and meta-analyses identified in Medline (1946–March 2012), Embase (1980–March 2012), CINHAL (1981–March 2012) and the Cochrane Library of Systematic Reviews (issue 1, 2012).

Main Outcome Measures

Methodological quality assessed by the 11-item Assessment of Multiple Systematic Reviews (AMSTAR) checklist; elements of integration assessed using a published list of 10 key principles of integration; effects on patient-centred outcomes, process quality, use of healthcare and costs.

Results

Twenty-seven systematic reviews were identified; conditions included chronic heart failure (CHF; 12 reviews), diabetes mellitus (DM; seven reviews), chronic obstructive pulmonary disease (COPD; seven reviews) and asthma (five reviews). The median number of AMSTAR checklist items met was five: few reviewers searched for unpublished literature or described the primary studies and interventions in detail. Most reviews covered comprehensive services across the care continuum or standardization of care through inter-professional teams, but organizational culture, governance structure or financial management were rarely assessed. A majority of reviews found beneficial effects of integration, including reduced hospital admissions and re-admissions (in CHF and DM), improved adherence to treatment guidelines (DM, COPD and asthma) or quality of life (DM). Few reviews showed reductions in costs.

Conclusions

Systematic reviews of integrated care programmes were of mixed quality, assessed only some components of integration of care, and showed consistent benefits for some outcomes but not others.

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Most cited references 46

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The hazards of scoring the quality of clinical trials for meta-analysis.

Peter Jüni (1999)

Although it is widely recommended that clinical trials undergo some type of quality review, the number and variety of quality assessment scales that exist make it unclear how to achieve the best assessment. To determine whether the type of quality assessment scale used affects the conclusions of meta-analytic studies. Meta-analysis of 17 trials comparing low-molecular-weight heparin (LMWH) with standard heparin for prevention of postoperative thrombosis using 25 different scales to identify high-quality trials. The association between treatment effect and summary scores and the association with 3 key domains (concealment of treatment allocation, blinding of outcome assessment, and handling of withdrawals) were examined in regression models. Pooled relative risks of deep vein thrombosis with LMWH vs standard heparin in high-quality vs low-quality trials as determined by 25 quality scales. Pooled relative risks from high-quality trials ranged from 0.63 (95% confidence interval [CI], 0.44-0.90) to 0.90 (95% CI, 0.67-1.21) vs 0.52 (95% CI, 0.24-1.09) to 1.13 (95% CI, 0.70-1.82) for low-quality trials. For 6 scales, relative risks of high-quality trials were close to unity, indicating that LMWH was not significantly superior to standard heparin, whereas low-quality trials showed better protection with LMWH (P<.05). Seven scales showed the opposite: high quality trials showed an effect whereas low quality trials did not. For the remaining 12 scales, effect estimates were similar in the 2 quality strata. In regression analysis, summary quality scores were not significantly associated with treatment effects. There was no significant association of treatment effects with allocation concealment and handling of withdrawals. Open outcome assessment, however, influenced effect size with the effect of LMWH, on average, being exaggerated by 35% (95% CI, 1%-57%; P= .046). Our data indicate that the use of summary scores to identify trials of high quality is problematic. Relevant methodological aspects should be assessed individually and their influence on effect sizes explored.

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Integrated care programmes for chronically ill patients: a review of systematic reviews.

Marielle MTJ Ouwens, Hub Wollersheim, Rosella Hermens … (2005)

To investigate effectiveness, definitions, and components of integrated care programmes for chronically ill patients on the basis of systematic reviews. Literature review from January 1996 to May 2004. Definitions and components of integrated care programmes and all effects reported on the quality of care. Searches in the Medline and Cochrane databases identified 13 systematic reviews of integrated care programmes for chronically ill patients. Despite considerable heterogeneity in interventions, patient populations, and processes and outcomes of care, integrated care programmes seemed to have positive effects on the quality of patient care. No consistent definitions were present for the management of patients with chronic illnesses. In all the reviews the aims of integrated care programmes were very similar, namely reducing fragmentation and improving continuity and coordination of care, but the focus and content of the programmes differed widely. The most common components of integrated care programmes were self-management support and patient education, often combined with structured clinical follow-up and case management; a multidisciplinary patient care team; multidisciplinary clinical pathways and feedback, reminders, and education for professionals. Integrated care programmes seemed to have positive effects on the quality of care. However, integrated care programmes have widely varying definitions and components and failure to recognize these variations leads to inappropriate conclusions about the effectiveness of these programmes and to inappropriate application of research results. To compare programmes and better understand the (cost) effectiveness of the programmes, consistent definitions must be used and component interventions must be well described.

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Interventions used in disease management programmes for patients with chronic illness-which ones work? Meta-analysis of published reports.

Joshua Ofman, V Hasselblad, Kevin Knight … (2002)

To systematically evaluate the published evidence regarding the characteristics and effectiveness of disease management programmes. Meta-analysis. Computerised databases for English language articles during 1987-2001. 102 articles evaluating 118 disease management programmes. Pooled effect sizes calculated with a random effects model. Patient education was the most commonly used intervention (92/118 programmes), followed by education of healthcare providers (47/118) and provider feedback (32/118). Most programmes (70/118) used more than one intervention. Provider education, feedback, and reminders were associated with significant improvements in provider adherence to guidelines (effect sizes (95% confidence intervals) 0.44 (0.19 to 0.68), 0.61 (0.28 to 0.93), and 0.52 (0.35 to 0.69) respectively) and with significant improvements in patient disease control (effect sizes 0.35 (0.19 to 0.51), 0.17 (0.10 to 0.25), and 0.22 (0.1 to 0.37) respectively). Patient education, reminders, and financial incentives were all associated with improvements in patient disease control (effect sizes 0.24 (0.07 to 0.40), 0.27 (0.17 to 0.36), and 0.40 (0.26 to 0.54) respectively). All studied interventions were associated with improvements in provider adherence to practice guidelines and disease control. The type and number of interventions varied greatly, and future studies should directly compare different types of intervention to find the most effective.

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Author and article information

Journal

Journal ID (nlm-ta): Int J Qual Health Care

Journal ID (iso-abbrev): Int J Qual Health Care

Journal ID (publisher-id): intqhc

Journal ID (hwp): intqhc

Title: International Journal for Quality in Health Care

Publisher: Oxford University Press

ISSN (Print): 1353-4505

ISSN (Electronic): 1464-3677

Publication date (Print): October 2014

Publication date (Electronic): 09 August 2014

Publication date PMC-release: 09 August 2014

Volume: 26

Issue: 5

Pages: 561-570

Affiliations

[1 ]Institute of Social and Preventive Medicine (ISPM), University of Bern , CH-3012 Bern, Switzerland

[2 ]Institute of General Practice and Health Services Research, University of Zurich , CH-8091 Zurich, Switzerland

[3 ]College M, College for Management in Health Care , CH-3010 Bern, Switzerland

Author notes

Address reprint requests to: Peter Berchtold, College M, College for Management in Health Care, Freiburgstrasse 41, CH-3010 Bern, Switzerland, Tel: +41-31-632-30-70; Fax: +41-31-632-30-25; E-mail: peter.berchtold@ 123456college-m.ch .

Article

Publisher ID: mzu071

DOI: 10.1093/intqhc/mzu071

PMC ID: 4195469

PubMed ID: 25108537

SO-VID: 68d31842-ed79-4be5-ad06-b41510e04ab4

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence ( http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

Integrated care programmes for adults with chronic conditions: a meta-review

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Abstract

Objective

Design

Main Outcome Measures

Results

Conclusions

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The Physician

Most cited references 46

The hazards of scoring the quality of clinical trials for meta-analysis.

Integrated care programmes for chronically ill patients: a review of systematic reviews.

Interventions used in disease management programmes for patients with chronic illness-which ones work? Meta-analysis of published reports.

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