Effects of continuity of care on health outcomes among patients with diabetes mellitus and/or hypertension: a systematic review

Abstract

Background: The rising prevalence of non-communicable diseases (NCDs) such as diabetes mellitus (DM) and hypertension (HT) has placed a tremendous burden on healthcare systems around the world, resulting in a call for more effective service delivery models. Better continuity of care (CoC) has been associated with improved health outcomes. This review examines the association between CoC and health outcomes in patients with DM and/or HT.

Methods: This was a systematic review with searches carried out on 13 March 2021 through PubMed, Embase, MEDLINE and CINAHL plus, clinical trials registry and bibliography reviews. Eligibility criteria were: published in English; from 2000 onwards; included adult DM and/or HT patients; examined CoC as their main intervention/exposure; and utilised quantifiable outcome measures (categorised into health indicators and service utilisation). The study quality was evaluated with Critical Appraisal Skills Programme (CASP) appraisal checklists.

Results: Initial searching yielded 21,090 results with 42 studies meeting the inclusion criteria. High CoC was associated with reduced hospitalisation (16 out of 18 studies), emergency room attendances (eight out of eight), mortality rate (six out of seven), disease-related complications (seven out of seven), and healthcare expenses (four out of four) but not with blood pressure (two out of 13), lipid profile (one out of six), body mass index (zero out of three). Six out of 12 studies on diabetic outcomes reported significant improvement in haemoglobin A1c by higher CoC. Variations in the classification of continuity of care and outcome definition were identified, making meta-analyses inappropriate. CASP evaluation rated most studies fair in quality, but found insufficient adjustment on confounders, selection bias and short follow-up period were common limitations of current literatures.

Conclusion: There is evidence of a strong association between higher continuity of care and reduced mortality rate, complication risks and health service utilisation among DM and/or HT patients but little to no improvement in various health indicators. Significant methodological heterogeneity in how CoC and patient outcomes are assessed limits the ability for meta-analysis of findings. Further studies comprising sufficient confounding adjustment and standardised definitions are needed to provide stronger evidence of the benefits of CoC on patients with DM and/or HT.

Keywords: Accident and emergency attendance; Continuity of care; Diabetes mellitus; Hospitalisation; Hypertension; Mortality.

Fig. 1

PRISMA 2020 flow diagram of search strategy

Fig. 2

Summary of reported outcomes with/without significant improvement related to continuity of care. Note: For detailed breakdown of study outcomes, please refer to Additional file 4. “Complications” refers to (but not limited to) onset of cardiovascular disease, end-stage renal disease etc.; “BP” refers to either systolic blood pressure, diastolic blood pressure and a combined target of both; HbA1c = Haemoglobin A1c; “Lipid profile” refers to either levels of low-density lipoprotein, high density lipoprotein, cholesterol or triglyceride; BMI = Body mass index; A&E = Accident and emergency