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

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.