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Meta-Analysis
. 2018 Aug 27;190(34):E1004-E1012.
doi: 10.1503/cmaj.171391.

Effectiveness of interventions for managing multiple high-burden chronic diseases in older adults: a systematic review and meta-analysis

Monika Kastner  1 , Roberta Cardoso  2 , Yonda Lai  2 , Victoria Treister  2 , Jemila S Hamid  2 , Leigh Hayden  2 , Geoff Wong  2 , Noah M Ivers  2 , Barbara Liu  2 , Sharon Marr  2 , Jayna Holroyd-Leduc  2 , Sharon E Straus  2
Affiliations
Meta-Analysis

Effectiveness of interventions for managing multiple high-burden chronic diseases in older adults: a systematic review and meta-analysis

Monika Kastner et al. CMAJ. .

Abstract

Introduction: More than half of older adults (age ≥ 65 yr) have 2 or more high-burden multimorbidity conditions (i.e., highly prevalent chronic diseases, which are associated with increased health care utilization; these include diabetes [DM], dementia, depression, chronic obstructive pulmonary disease [COPD], cardiovascular disease [CVD], arthritis, and heart failure [HF]), yet most existing interventions for managing chronic disease focus on a single disease or do not respond to the specialized needs of older adults. We conducted a systematic review and meta-analysis to identify effective multimorbidity interventions compared with a control or usual care strategy for older adults.

Methods: We searched bibliometric databases for randomized controlled trials (RCTs) evaluating interventions for managing multiple chronic diseases in any language from 1990 to December 2017. The primary outcome was any outcome specific to managing multiple chronic diseases as reported by studies. Reviewer pairs independently screened citations and full-text articles, extracted data and assessed risk of bias. We assessed statistical and methodological heterogeneity and performed a meta-analysis of RCTs with similar interventions and components.

Results: We included 25 studies (including 15 RCTs and 6 cluster RCTs) (12 579 older adults; mean age 67.3 yr). In patients with [depression + COPD] or [CVD + DM], care-coordination strategies significantly improved depressive symptoms (standardized mean difference -0.41; 95% confidence interval [CI] -0.59 to -0.22; I2 = 0%) and reduced glycosylated hemoglobin (HbA1c) levels (mean difference -0.51; 95% CI -0.90 to -0.11; I2 = 0%), but not mortality (relative risk [RR] 0.79; 95% CI 0.53 to 1.17; I2 = 0%). Among secondary outcomes, care-coordination strategies reduced functional impairment in patients with [arthritis + depression] (between-group difference -0.82; 95% CI -1.17 to -0.47) or [DM + depression] (between-group difference 3.21; 95% CI 1.78 to 4.63); improved cognitive functioning in patients with [DM + depression] (between-group difference 2.44; 95% CI 0.79 to 4.09) or [HF + COPD] (p = 0.006); and increased use of mental health services in those with [DM + (CVD or depression)] (RR 2.57; 95% CI 1.90 to 3.49; I2 = 0%).

Interpretation: Subgroup analyses showed that older adults with diabetes and either depression or cardiovascular disease, or with coexistence of chronic obstructive pulmonary disease and heart failure, can benefit from care-coordination strategies with or without education to lower HbA1c, reduce depressive symptoms, improve health-related functional status, and increase the use of mental health services.

Protocol registration: PROSPERO-CRD42014014489.

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Conflict of interest statement

Competing interests: Noah Ivers reports receiving personal fees and grants from the Canadian Institutes of Health Research and the Government of Ontario during the conduct of the study; he also reports receiving personal fees from Diabetes Canada, outside the submitted work. Noah Ivers held a volunteer position as Chair of the Ontario Vascular Coalition, which envisioned a multicondition approach to management of chronic diseases and risk factors in primary care. Sharon Marr reports a patent issued for the trademark for the Geriatric Certificate program (February 2013). Geoff Wong reports that his salary is partly supported by The Evidence Synthesis Working Group of the National Institute for Health Research School for Primary Care Research (Project Number 390). He is Deputy Chair of the UK National Institute of Health Research Health Technology Assessment Out-of-Hospital Panel. No other competing interests were declared.

Figures

Figure 1:
Figure 1:
Flow of article selection for the systematic review.
Figure 2:
Figure 2:
Meta-analysis of primary outcomes. (A) Depression: Care-coordination interventions with the exact intervention components of education (ED) + case management (CM) + self-management (SM) in patients with diabetes (DM) + depression (DEP), cardiovascular disease (CVD) or heart failure (HF) or chronic obstructive pulmonary disease (COPD) + DEP. (B) Glycosylated hemoglobin (HbA1c): Care-coordination interventions with ED + CM as shared components in patients with DM + (CVD, COPD or DEP). (C) Systolic blood pressure: interventions with ED + SM as shared components in patients with DM + (chronic kidney disease or CVD). (D) Mortality: Care-coordination interventions with at least ED as the shared component in patients with COPD + (DEP or HF) or DEP + HF. Note: CI = confidence interval, DMC = difference in mean change, MC = mean change, MD = mean difference, RR = relative risk, SD = standard deviation, SE = standard error, SMD = standardized mean difference.
Figure 3:
Figure 3:
Meta-analysis of secondary outcomes. Use of mental health services: Interventions with education plus care pathways as shared components in patients with diabetes + (cardiovascular disease or depression). Note: CI = confidence interval, RR = relative risk.
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