o Type 2 diabetes has traditionally been managed as a single chronic disease state but it can commonly exist with co-morbidities such as depression.

o Treatment is multifaceted, requiring both primary and secondary care, however, health service delivery is often fragmented.

o Integrated chronic disease management is a growing model of interest underpinned by the Chronic Care Model (CCM) [2].

o The CCM identifies six key elements for effective care, and has shown promise in improving the management of diabetes.

Introduction

Methods

Conclusions

Results

Integrated Chronic Disease Management in Primary/Secondary Care: A Systematic Review

Martin Connor1, David Lim2, Lauren Ward1, Julie Hepworth2

1 Centre for Health Innovation, Griffith University2 School of Public Health and Social Work, Queensland University of Technology

o A systematic review of peer reviewed literature from PubMed, CINAHL, Embase, Cochrane Library and Joanna Briggs was conducted.

o Studies were included that met the following criteria: Published in English, date range between 2004-2014, primary/secondary implementation, and interventions managing chronic disease.

“The current challenge is to be specific about what integrated services look like – what are

the key functions which need to be developed?”[3]

o Fifty-one studies met the inclusion criteria: US (38), Australia (5), UK (2), Canada (2), Netherlands (1), Norway (1), Ireland (1), multi-country (1).

o Interventions adopted at least one (x 4) element of the CCM, with the majority implementing delivery system redesign activities within primary care practice.

o Interventions significantly reduced ED and hospital admissions, improved patient health outcomes such as HbA1c, and reduced costs.

 Outcome MD (SE) Overall effect: d (P)

Heterogeneity: I2, P

Hospital admission

-1 per 1,000 patients (0.001)

-0.59 (<0.001) 4.44, <0.01

ED visit-13 per 1,000 patients (0.002)

-0.77 (<0.001) 2.38, 0.02

Primary health care utilization

-18 per 1,000 patients (0.000)

-0.26 (<0.001) 1.24, 0.385

HbA1c changes (%)-2% over 24 months (0.000)

-0.51 (<0.001) 1.13, 0.420

Direct medical costs (2013, US$)

-US$402.95 per patient (US$48.41)

-0.64 (<0.001) 0.047, <0.01

Chronic disease accounted for 90% of all deaths in 2011 [1]

Aim

o Integrated chronic disease management interventions have numerous definitions and components.

o Integrated care interventions involving elements of the CCM positively impacted service utilisation, patients outcomes and costs.

o Preliminary analysis indicates that the adoption of all CCM elements may not be necessary to improve clinical outcomes and cost effectiveness.

References1 Australian Institute of Health and Welfare. Australia’s health 2014: Australia’s health series no. 14. Canberra: AIHW; 2014 [cited 2014 August 10]. Available from: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=601295477262 Bodenheimer T., Wagner EH., & Grumbach K. Improving Primary Care for Patients with Chronic Illness. JAMA. 2002; 288(14):1775-93 World Health Organisation. Integrated Health Services- What and Why? Making Health Systems Work. Technical Brief No. 1. Geneva: WHO; 2008. [cited 2014 August 10]. Available from : http://www.who.int/healthsystems/service_delivery_techbrief1.pdf

To investigate the effectiveness of integrated chronic disease management interventions across primary/secondary care.

Clinical Information

Systems

CHRONIC CARE MODEL

ELEMENTS

Delivery System Design

Self-management support

Decision Support

Community Linkages

Health Care Organisation

Total citations identified by search:

N= 953

Included Papers:N= 775

Duplicates: N= 175Not English: N= 3

Passed full text screening and included in review:

N= 29

Passed title and abstract screen. Full manuscripts obtained and reviewed

for inclusion:N= 164

Included papers:N= 51

Excluded by abstract and title:

N= 611

Excluded (N= 135)Reasons for exclusion:

1.Emailed author N= 62.Not specifically evaluating integrated care N= 443.Not primary/secondary integrated intervention N= 114.Opinions about integrated care N= 475.Paediatrics N= 126.Not primary study N= 147.Not Chronic Disease N= 1

Snowball papers retrieved N = 30

Excluded N= 8(Subject to exclusion

criteria above)

Figure 1. Stages of the literature search process

Table 1. Mean Differences of Key Outcome Measures