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Effectiveness of Chronic Care Models for the Management of Type 2 Diabetes Mellitus in Europe: a Systematic Review and Meta-Analysis

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Effectiveness of Chronic Care Models for the Management of Type 2 Diabetes Mellitus in Europe: a Systematic Review and Meta-Analysis Open Access Research BMJ Open: first published as 10.1136/bmjopen-2016-013076 on 20 March 2017. Downloaded from Effectiveness of chronic care models for the management of type 2 diabetes mellitus in Europe: a systematic review and meta-analysis Brenda W C Bongaerts,1,2 Karsten Müssig,2,3,4 Johan Wens,5 Caroline Lang,6 Peter Schwarz,6 Michael Roden,2,3,4 Wolfgang Rathmann1,2 To cite: Bongaerts BWC, ABSTRACT et al Strengths and limitations of this study Müssig K, Wens J, . Objectives: We evaluated the effectiveness of Effectiveness of chronic care European chronic care programmes for type 2 diabetes ▪ models for the management This is the first systematic review providing a mellitus (characterised by integrative care and a of type 2 diabetes mellitus in comprehensive overview of studies that have Europe: a systematic review multicomponent framework for enhancing healthcare evaluated the effectiveness of multifaceted dia- and meta-analysis. BMJ Open delivery), compared with usual diabetes care. betes care programmes addressing all their com- 2017;7:e013076. Design: Systematic review and meta-analysis. ponents together, rather than separately. doi:10.1136/bmjopen-2016- Data sources: MEDLINE, Embase, CENTRAL and ▪ The focus in this systematic review was on 013076 CINAHL from January 2000 to July 2015. European multifaceted diabetes care programmes Eligibility criteria: Randomised controlled trials only, to meet the need for efficient and estab- ▸ Prepublication history and focussing on (1) adults with type 2 diabetes, (2) lished programmes to providing optimal chronic additional material is multifaceted diabetes care interventions specifically care due to the burden of increasing diabetes available. To view please visit designed for type 2 diabetes and delivered in primary prevalence in Europe. the journal (http://dx.doi.org/ or secondary care, targeting patient, physician and ▪ There is an important lack of studies which 10.1136/bmjopen-2016- healthcare organisation and (3) usual diabetes care as evaluate the effectiveness of implementing all 013076). the control intervention. chronic care model-components simultaneously. Data extraction: Study characteristics, characteristics ▪ Overall, the studies included in this systematic review provided insufficient details to fully under- http://bmjopen.bmj.com/ Received 18 June 2016 of the intervention, data on baseline demographics and Revised 20 December 2016 changes in patient outcomes. stand the intensity of the intervention, and there Accepted 23 January 2017 Data analysis: Weighted mean differences in change was only little overlap in the wide range of in HbA1c and total cholesterol levels between outcome measures evaluated. intervention and control patients (95% CI) were estimated using a random-effects model. Results: Eight cluster randomised controlled trials and newly diagnosed diabetes patients than for were identified for inclusion (9529 patients). One year patients with prevalent diabetes. of multifaceted care improved HbA1c levels in on September 27, 2021 by guest. Protected copyright. patients with screen-detected and newly diagnosed diabetes, but not in patients with prevalent diabetes, compared to usual diabetes care. Across all seven included trials, the weighted mean difference in INTRODUCTION HbA1c change was −0.07% (95% CI −0.10 to Chronic disease management relies on the −0.04) (−0.8 mmol/mol (95% CI −1.1 to −0.4)); assumption that providing optimal chronic I2=21%. The findings for total cholesterol, LDL- care requires changes of patients and profes- cholesterol and blood pressure were similar to sionals with regard to behaviour, culture, and HbA1c, albeit statistical heterogeneity between studies communication.12Indeed, with ageing of was considerably larger. Compared to usual care, the population and the growing prevalence multifaceted care did not significantly change quality of chronic diseases, initiatives to improving of life of the diabetes patient. Finally, measured for quality of chronic care require more than For numbered affiliations see screen-detected diabetes only, the risk of end of article. macrovascular and mircovascular complications at evidence about effective diagnostic proce- follow-up was not significantly different between dures and treatments in comparison to acute disorders.3 Aimed at describing essential ele- Correspondence to intervention and control patients. Dr Brenda Bongaerts; Conclusions: Effects of European multifaceted ments for improving outcomes in care of brenda.bongaerts@ diabetes care patient outcomes are only small. chronic diseases, the chronic care model ddz.uni-duesseldorf.de Improvements are somewhat larger for screen-detected (CCM) was developed in the mid-1990s and Bongaerts BWC, et al. BMJ Open 2017;7:e013076. doi:10.1136/bmjopen-2016-013076 1 Open Access BMJ Open: first published as 10.1136/bmjopen-2016-013076 on 20 March 2017. Downloaded from was further refined in 1997.245This primary care-based according to the PRISMA-P guidelines (see online model is based on the assumption that improvements in supplementary file S1).28 care require an approach that incorporates patients, healthcare providers and system level interventions.46 Data sources and searches The CCM comprises six interrelated components We identified studies by searching MEDLINE, Embase, deemed essential for providing high-quality care to CINAHL and CENTRAL from January 2000 until July patients with chronic disease: (1) healthcare organisa- 2015. Search syntaxes were developed in consultation tion (ie, providing leadership for securing resources and with the Cochrane Metabolic and Endocrine Disorders removing barriers to care), (2) self-management support Group by adapting and combining published search (ie, facilitating skills-based learning and patient strategies from previous systematic reviews on chronic empowerment), (3) decision support (ie, providing (diabetes) care management.10 12 Given that the CCM— guidance for implementing evidence-based care), (4) and its terminology—had been introduced in the late delivery system design (ie, coordinating care processes), 1990s, we restricted the search to publications from (5) clinical information systems (ie, tracking progress January 2000 onwards. In addition, reference lists of eli- through reporting outcomes to patients and providers gible studies and systematic reviews on multifaceted dia- and (6) community resources and policies (ie, sustaining betes care were searched by hand to identify additional care by using community-based resources and public studies. The full MEDLINE search strategy is available in health policy).7 the online supplementary file S2. The current literature indicates a widespread applica- tion of the CCM to multiple illnesses, and various Study selection studies have provided a rigorous evaluation of its individ- One reviewer (BWCB) identified potentially relevant – ual components.5814 In general, these studies have studies for inclusion by screening title and abstract of all reported positive effects on patient outcomes and pro- citations that resulted from our literature search. Two cesses of care. The reported effect sizes, however, are reviewers (BWCB and WR) then screened the full text relatively small, and many outcomes are flawed by a con- of these articles. Only randomised controlled trials were – siderable level of statistical heterogeneity.10 13 25 considered eligible for inclusion. Non-randomised An aspect that complicates the assessment of effective- studies were excluded, as were studies written in a lan- ness of chronic care programmes is their inherent multi- guage other than English. Since this systematic review component nature.14 20 25 While some authors found was part of a large European project on managed dia- that the total number of CCM elements incorporated in betes care that aimed at developing chronic care man- the interventions did not influence patient outcomes,910 agement standards and guidance for Europe,29 we others concluded that interventions containing more further excluded all non-European CCM trials. Trials eli- than one CCM component were more successful at gible for inclusion had to comply with the following http://bmjopen.bmj.com/ improving the quality of care than single-component inclusion criteria. interventions.11 24 26 27 To date, no summative reviews have evaluated to Type of participants which extent the complete CCM—thus all six compo- Individuals, regardless of gender and ethnicity, diag- nents combined in interventions—improves diabetes nosed with type 2 diabetes and with or without care. comorbidities. As such, the aim of the current review was to systemat- ically identify studies of diabetes care assessing the effect Type of intervention on September 27, 2021 by guest. Protected copyright. of interventions addressing all six components of the Previous systematic reviews on multifaceted chronic care CCM. We subsequently aimed to pool the effect of these have reported that randomised-controlled-trial-interven- models on biochemical outcomes (HbA1c, cholesterol tions are generally described poorly and incomprehen- levels, blood pressure, body mass index (BMI), fasting sively, which complicates mapping the individual glucose, triglyceride and creatinine levels), patient- elements of the intervention to the six CCM compo- reported outcomes (health-related quality of life) and nents. To avoid mapping difficulties, we have reformu- diabetes complications (macrovascular and microvascu- lated the following inclusion criteria for the lar complications,
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