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Aspects of Multicomponent Integrated Care Promote Sustained Improvement in Surrogate Clinical Outcomes: A Systematic Review and Meta-analysis

Lim LL 1 , Lau ESH 1 , Kong APS 1 , Davies MJ 2 , Levitt NS 3 , Eliasson B 4 Show all authors , Aguilar-Salinas CA 5 , Ning G 6 , Seino Y 7 , So WY 1 , McGill M 8 , Ogle GD 9 , Orchard TJ 10 , Clarke P 11 , Holman RR 12 , Gregg EW 13 , Gagliardino JJ 14 , Chan JCN 15

Affiliations 

  • 1 Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region, China
  • 2 Diabetes Research Centre, University of Leicester, Leicester, U.K
  • 3 Department of Medicine, University of Cape Town, Cape Town, South Africa
  • 4 Institute of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
  • 5 Department of Endocrinology and Metabolism, National Institute of Medical Sciences and Nutrition, Mexico City, Mexico
  • 6 Shanghai Clinical Center for Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
  • 7 Center for Diabetes, Endocrinology and Metabolism, Kansai Electric Power Hospital, Osaka, Japan
  • 8 Diabetes Centre, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
  • 9 International Diabetes Federation Life for a Child Programme, Sydney, Australia
  • 10 Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
  • 11 Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
  • 12 Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, U.K
  • 13 Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
  • 14 Center of Experimental and Applied Endocrinology, National Scientific and Technical Research Council, National University of La Plata, La Plata, Argentina
  • 15 Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region, China [email protected]
Diabetes Care, 2018 06;41(6):1312-1320.
PMID: 29784698 DOI: 10.2337/dc17-2010

Abstract

OBJECTIVE: The implementation of the Chronic Care Model (CCM) improves health care quality. We examined the sustained effectiveness of multicomponent integrated care in type 2 diabetes.

RESEARCH DESIGN AND METHODS: We searched PubMed and Ovid MEDLINE (January 2000-August 2016) and identified randomized controlled trials comprising two or more quality improvement strategies from two or more domains (health system, health care providers, or patients) lasting ≥12 months with one or more clinical outcomes. Two reviewers extracted data and appraised the reporting quality.

RESULTS: In a meta-analysis of 181 trials (N = 135,112), random-effects modeling revealed pooled mean differences in HbA1c of -0.28% (95% CI -0.35 to -0.21) (-3.1 mmol/mol [-3.9 to -2.3]), in systolic blood pressure (SBP) of -2.3 mmHg (-3.1 to -1.4), in diastolic blood pressure (DBP) of -1.1 mmHg (-1.5 to -0.6), and in LDL cholesterol (LDL-C) of -0.14 mmol/L (-0.21 to -0.07), with greater effects in patients with LDL-C ≥3.4 mmol/L (-0.31 vs. -0.10 mmol/L for <3.4 mmol/L; Pdifference = 0.013), studies from Asia (HbA1c -0.51% vs. -0.23% for North America [-5.5 vs. -2.5 mmol/mol]; Pdifference = 0.046), and studies lasting >12 months (SBP -3.4 vs. -1.4 mmHg, Pdifference = 0.034; DBP -1.7 vs. -0.7 mmHg, Pdifference = 0.047; LDL-C -0.21 vs. -0.07 mmol/L for 12-month studies, Pdifference = 0.049). Patients with median age <60 years had greater HbA1c reduction (-0.35% vs. -0.18% for ≥60 years [-3.8 vs. -2.0 mmol/mol]; Pdifference = 0.029). Team change, patient education/self-management, and improved patient-provider communication had the largest effect sizes (0.28-0.36% [3.0-3.9 mmol/mol]).

CONCLUSIONS: Despite the small effect size of multicomponent integrated care (in part attenuated by good background care), team-based care with better information flow may improve patient-provider communication and self-management in patients who are young, with suboptimal control, and in low-resource settings.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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