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 HbA_1c 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; P_difference = 0.013), studies from Asia (HbA_1c -0.51% vs. -0.23% for North America [-5.5 vs. -2.5 mmol/mol]; P_difference = 0.046), and studies lasting >12 months (SBP -3.4 vs. -1.4 mmHg, P_difference = 0.034; DBP -1.7 vs. -0.7 mmHg, P_difference = 0.047; LDL-C -0.21 vs. -0.07 mmol/L for 12-month studies, P_difference = 0.049). Patients with median age <60 years had greater HbA_1c reduction (-0.35% vs. -0.18% for ≥60 years [-3.8 vs. -2.0 mmol/mol]; P_difference = 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.

Figure 1

Meta-analyses results of the effects of multicomponent integrated care on HbA_1c (%) (A), HbA_1c (mmol/mol) (B), SBP (mmHg) (C), DBP (mmHg) (D), and LDL-C (mmol/L) (E), stratified by different levels of baseline cardiometabolic control and geographic regions. To convert LDL-C to mg/dL, multiply by 38.67. MD, mean difference; N, number of trials with analyzable data.

Figure 2

Meta-analyses results of the effects of individual QI strategies on HbA_1c (%) (A), HbA_1c (mmol/mol) (B), SBP (mmHg) (C), DBP (mmHg) (D), and LDL-C (mmol/L) (E). To convert LDL-C to mg/dL, multiply by 38.67. MD, mean difference; N, number of trials with analyzable data.