Table S1. Search strategy in Ovid Medline.
#
Search Type
Results
1
chronic disease.sh.
204340
2
chronic disease.tw.
15225
3
chronic illness.tw.
6493
4
chronically ill.tw.
3963
5
2 or 3 or 4
24690
6
1 or 5
220082
7
depression.sh.
63781
8
behavior, addictive.sh.
4005
9
substance-related disorders.sh.
71023
10
hiv infections.sh.
123367
11
midwifery.sh.
12983
12
mental disorders.sh.
109922
13
7 or 8 or 9 or 10 or 11 or 12
369396
14
(6 not 13) or (6 and 13)
220082
15
"delivery of health care integrated".sh.
16
delivery of integrated health care.ab,ti,tw.
17
comprehensive health care.ab,ti,tw.
626
18
enhanced communication.ab,ti,tw.
186
19
health planning.ab,ti,tw.
2317
20
care delivery programs.ab,ti,tw.
14
21
patient care team.ab,ti,tw.
155
22
16 or 17 or 18 or 19 or 20 or 21
3295
23
(integrated adj3 (care or treatment)).ab,ti,tw.
4768
24
((shar$ or managed or coordinated or organised or coordination of or integration
of or cooperative) adj3 (care or services) adj2 programs).ab,ti,tw.
370
25
(integrated health adj3 (services or care strategies)).ab,ti,tw.
105
26
23 or 24 or 25
5202
27
((disease or care or case or care transition or patient care) adj3
management).ab,ti,tw
35431
28
(interdisciplinary adj3 (communication or care)).ab,ti,tw
1296
29
(patient adj3 (cent?ed or tailored or integrated) adj3 care).ab,ti,tw.
635
30
28 or 29
1926
6878
2
1
#
Search Type
Results
31
((clinical or collaborative or treatment or team practice or network or linked care
or delivery systems or horizontal or vertical) adj3 integration).ab,ti,tw.
2061
32
27 or 30 or 31
39233
33
Cochrane effective practice and organisation of care group
34
15 or 22 or 26 or 32 or 33
61658
35
(letter or letter$).pt,sh
752323
36
(editorial or historical article or anecdote or commentary or note or case report$
or case study).pt.
2130953
37
35 or 36
2720012
38
(animal studies or animals, laboratory or experimental animal or animal
experiment or animal model or rodentia or rodents or rodent).sh.
39
37 or 38
2739096
*40
((systematic adj3 literature) or systematic review* or meta-analy* or metaanaly*
or metaanaly$ or meta analy$ or "research synthesis" or ((information or data)
adj3 synthesis) or (data adj2 extract*)).ti,ab. or (cinahl or (cochrane adj3 trial*)
or embase or medline or psyclit or (psycinfo not "psycinfo database") or pubmed
or scopus or "sociological abstracts" or "web of science").ab. or "cochrane
database of systematic reviews".jn. or ((((pool$ or combin$) adj3 (studies or
data or trials or results)).mp. or (review adj5 (rationale or evidence)).ti,ab.) and
review.pt.) or meta- analysis as topic/ or meta-analysis.pt. or (systematic$ or
evidence$ or methodol$ or quantitativ$ or analys$ or assessment$).ti,sh,ab.
[mp=title, abstract, original title, name of substance word, subject heading word,
protocol supplementary concept, rare disease supplementary concept, unique
identifier]
4159498
41
40 not 39
3971078
42
14 and 34 and 41
1459
43
limit 42 to human
1361
9995
20184
Similar search strategies were performed and run in EMBASE, The Cochrane Library of Systematic Reviews and CINHAL.
*Search
1.
2.
3.
filters for systematic reviews or meta-analyses:
The University of Texas, School of Public Health: Search filters for systematic reviews and meta-analyses. Accessed 25
Nov 2011. [Ovid, PubMed]. https://sph.uth.tmc.edu/current-students/library/search-filters/
Wilczynski NL, Haynes RB, Hedges Team. EMBASE search strategies achieved high sensitivity and specificity for
retrieving methodologically sound systematic reviews. Journal of Clinical Epidemiology 2007;60(1):29-33. [Ovid]. BMJ
Clinical Evidence strategy [undated] [Ovid]. http://clinicalevidence.bmj.com/x/set/static/ebm/learn/665076.html
Specificity for retrieving methodologically sound systematic reviews. Journal of Clinical Epidemiology 2007;60(1):2933. [Ovid]. BMJ Clinical Evidence strategy [undated] [Ovid].
http://clinicalevidence.bmj.com/x/set/static/ebm/learn/665076.html
2
Table S2. Characteristics of 27 systematic reviews of integrated care interventions.
Review
Population & integrated care
terms used
Adams, 2007 [12]
Chronic Obstructive Pulmonary SR to determine which CCM components have been
Disease
implemented in patients with Chronic Obstructive
Pulmonary Disease; and what combination of CCM
Chronic Care Models
components is associated with improved outcomes
Badamgarav, 2003
[13]
Rheumatoid Arthritis
Disease Management
Boult, 2009 [14]
Chronic Disease Models
Comprehensive Care
Elissen, 2012 [15]
Diabetes Mellitus
Chronic Care Models
Gensichen, 2004 [38] Congestive Heart Failure
Case Management
Göhler, 2006 [16]
Congestive Heart Failure
Disease Management
Gonseth, 2004 [17]
Congestive Heart Failure and
Cerebrovascular Disease
Aim of review
Authors' conclusions
Limited published data exist evaluating the efficacy of program components in
chronic obstructive pulmonary disease management. However, pooled data
demonstrated that patients with chronic obstructive pulmonary disease who
received interventions with two or more program components had lower rates of
hospitalizations and emergency/unscheduled visits and a shorter length of stay
compared with control groups.
Need for well-designed trials in this population.
To evaluate the effectiveness of disease management There were limited data to support or refute the effectiveness of disease
programs in improving functional status and reducing management programs in improving functional status in patients with RA.
disability for patients with RA
Additional studies are needed to confirm if a more intensive intervention may be
of benefit to patients with RA, as suggested by our study.
To identify promising “successful” models of
comprehensive care that high-quality research has
shown to be capable of improving the quality,
outcomes, and efficiency of care for chronically ill
older persons; that should be considered for
replication or further study
Many comprehensive models of chronic care for older adults have been shown to
be capable of improving important outcomes, but the nation's ability to benefit
from these advances will depend on the models' inherent diffusability, on
additional rigorous research, and on public and private insurers' ability and
willingness to reimburse providers adequately for the costs of operating these
models.
MA to support decision making on how best to
redesign diabetes care by investigating three potential
sources of heterogeneity in effectiveness across trials
of diabetes care management
Generally positive outcomes but differ considerably across trials.
The most promising results come from studies with limited follow-up (<1 year)
and by programs including more than two CCM components.
Potential sources of heterogeneity between studies partly influencing the variation
in effectiveness include: follow up times and variety and number of components
addressed.
Other sources of heterogeneity should be investigated to ensure implementation of
evidence-based improvements in diabetes care.
To evaluate the quality and extent of the effects of
Case Management on patients with HF in outpatient
primary care;
Especially "complex" models of CM for patients with Congestive Heart Failure
can be effective in a primary care setting. CM can prevent the fragmentation and
discontinuity of care by strengthening a close contact between patient and health
care provider.
MA to systematically combine the evidence on the
efficacy of disease management programs in the
treatment of Congestive Heart Failure, to identify and
explain heterogeneity in results of prior studies, and
to examine for the potential of publication bias in
prior studies
Programs have the potential to reduce morbidity and mortality for patients with
Congestive Heart Failure. The benefit of the intervention depends on age, severity
of disease, guideline-based treatment at baseline, and DMP modalities. Future
studies should directly compare the effect of different aspects of disease
management programs for different populations.
SR & MA to systematically evaluate the published
evidence regarding the effectiveness of disease
management programs reducing hospital re-
Effectiveness at reducing re-admissions among elderly patients with Congestive
Heart Failure is close to that observed in clinical trials evaluating drugs for HF,
such as angiotensin-converting enzyme inhibitors, beta-blockers or digoxin.
3
Review
Population & integrated care
terms used
Aim of review
Authors' conclusions
Disease Management
admissions among elderly patients with HF
However, studies did not compared different interventions directly, thus the
relative effectiveness of types of healthcare delivery within the program is not
known.
To determine whether hospital-based palliative care
teams improve the process or outcomes of care for
patients and families at the end of life
This review suggests that hospital-based palliative care teams offer some benefits,
although this finding should be interpreted with caution. The study designs need
to be improved and different models of providing support at the end of life in
hospital need comparison. Standardized outcome measures should be used in such
research and in practice.
SR to evaluate the effectiveness of Diabetes Mellitus
disease management programs on glycaemic control
and other relevant outcomes
Diabetes disease management programs can improve glycaemic control to a
modest extent and can increase screening for retinopathy and foot complications.
Further efforts will be required to create more effective disease management
programs for patients with diabetes mellitus.
SR to examine the effectiveness of multiple
interventions as compared to single interventions or
usual care on health outcomes and health care
utilisation within the context of integrated disease
management in asthma
In spite of the heterogeneity of disease management studies in asthma and
Chronic Obstructive Pulmonary Disease care, this review showed promising
improvements in quality of life and reductions in hospitalizations, especially for
triple intervention programs.
Higginson, 2002 [18] End of Life Care
Hospital-Based Palliative Care
Knight, 2005 [19]
Diabetes Mellitus
Disease Management
Lemmens, 2009 [20]
Asthma
Disease Management
Lemmens, 2011 [21]
Chronic Obstructive Pulmonary SR & MA to examine the effectiveness of chronic
Disease
care management in Chronic Obstructive Pulmonary
Disease while taking heterogeneity into account,
Chronic Care Management
enabling the understanding of and the decision
making about such programs
McAlister, 2001 [22] Congestive Heart Failure
Disease Management
Mitchell, 2002 [23]
Orthopedic, Asthma,
Hypertension, Diabetes
Mellitus, Frail
Organized and coordinated
cooperation for Managed Care
Chronic Obstructive Pulmonary Disease chronic care management has the
potential to improve outcomes of care.
Generally positive results on QoL and hospitalizations. Inconclusive effects on
ED visits and no effects on mortality.
Not significant improvement on hospitalizations, ED visits and QoL.
No effects on mortality.
Heterogeneity for hospitalization and ED visits partly explained by the number of
components but methodological study quality and length of follow-up did not
significantly explain heterogeneity.
Further research is needed to elucidate the diversity between Chronic Obstructive
Pulmonary Disease chronic care management studies in terms of the effects
measured and strengthen the support for chronic care management.
SR determine whether disease management programs Disease management programs for the care of patients with Congestive Heart
improve outcomes for patients with Congestive Heart Failure that involve specialized follow-up by a multidisciplinary team reduce
Failure
hospitalizations and appear to be cost saving. Data on mortality are inconclusive.
Further studies are needed to establish the incremental benefits of the different
elements of these programs.
SR to determine the impact of involving GPs in
specialist teams on patients’ health outcomes, the
behaviour of medical practitioners, and the costs of
health delivery
Formal liaison between GPs and specialist services leaves most physical health
outcomes unchanged, but improves functional outcomes in chronically mentally
ill patients. It may confer modest long-term health benefits through improvements
in patient concordance with treatment programs and more effective clinical
practice.
4
Review
Population & integrated care
terms used
Mitchell, 2008 [24]
Stroke
Disease Management
(multidisciplinary care
planning)
Aim of review
Authors' conclusions
SR to assess the impact of coordinated
multidisciplinary care planning involving primary
care professionals, either wholly within primary care
or by primary-secondary care teams, on outcomes in
stroke, relative to usual care
While multidisciplinary care planning may not unequivocally improve the care of
patients with completed stroke, there may be process benefits such as improved
task allocation between providers. Further study on the impact of active GP
involvement in multidisciplinary care planning is warranted.
Niesink, 2007 [25]
Chronic Obstructive Pulmonary SR to investigate effectiveness of chronic disease
Disease
management programs on the quality of life of people
with Chronic Obstructive Pulmonary Disease
Disease Management
All chronic disease management projects for people with Chronic Obstructive
Pulmonary Disease involving primary care improved quality of life. In most of the
studies, aspects of chronic disease management were applied to a limited extent.
Quality of randomized-controlled trials was not optimal. More research is needed
on chronic disease management programs in patients with Chronic Obstructive
Pulmonary Disease across primary and secondary care.
Norris, 2002 [26]
Diabetes Mellitus
SR to examine the extent and quality of the evidence
of the effectiveness and economic efficiency of
disease management and case management for
people with diabetes; and to form the basis for
guidance recommendations by the Task Force on
Community Preventive Services
Evidence supports the effectiveness of disease management on glycaemic control;
on screening for diabetic retinopathy, foot lesions and peripheral neuropathy, and
proteinuria; and on the monitoring of lipid concentrations; applicable to adults
with diabetes in managed care organizations and community clinics in the United
States and Europe.
Case management is effective in improving both glycaemic control and provider
monitoring of glycaemic control; applicable primarily in the U.S. managed care
setting for adults with type 2 diabetes.
Case management is effective both when delivered in conjunction with disease
management and when delivered with one or more additional educational,
reminder, or support interventions.
SR to provide additional descriptive information on
disease management programs(in improving care or
reducing costs) related to Cardiovascular Disease
from studies identified and effectiveness reviewed by
Weingarten 2002
Disease management programs were associated with marked improvements in
many different processes and outcomes of care. Only a few studies demonstrated a
notable reduction in costs.
Further research is needed to understand how disease management can most
effectively improve the quality and cost of care for patients with chronic diseases
SR of integrated care interventions and their effects
on the quality of care for patients with cancer
To improve integrated care for patients with cancer, a multicomponent
intervention program is required focusing on patients, professionals and the
organization of care. The promising interventions found in this review should be
part of this program. This program should be evaluated using rigorous methods
and unequivocal outcome measures linked to the intervention.
Disease Management and
Case Management
Ofman, 2004 [27]
Cardiovascular Disease
(Congestive Heart Failure,
Hyperlipidemia, Coronary
Artery Disease, Hypertension)
Disease Management
Ouwens, 2009 [28]
Cancer
Integrated Care
PeytremannBridevaux,
2008 [29]
Chronic Obstructive Pulmonary SR & MA to evaluate the effectiveness of Chronic
Disease
Obstructive Pulmonary Disease disease-management
programs (operational definition elaborated a priori)
Disease Management
which are more comprehensive, and used as long
(Case Management, Selfterm interventions in patients with chronic diseases
management, Home
Rehabilitation, Integrated care,
Pulmonary Rehabilitation,
Chronic Obstructive Pulmonary Disease disease-management programs modestly
improved exercise capacity, health-related quality of life, and hospital admissions,
but not all-cause mortality. Future studies should explore the specific elements or
characteristics of these programs that bring the greatest benefit.
5
Review
Population & integrated care
terms used
Aim of review
Authors' conclusions
MA to determine the efficacy of interventions that
were described as comprehensive discharge planning
plus post-discharge support for older in patients with
Congestive Heart Failure; and to quantify the effect
on readmission rate, all-cause mortality, initial LOS,
QOL, and overall medical costs
Comprehensive discharge planning plus post discharge support for older patients
with Congestive Heart Failure significantly reduced readmission rates and may
improve health outcomes such as survival and QOL without increasing costs.
Specific Program for Chronic
Obstructive Pulmonary
Disease)
Phillips, 2004 [30]
Congestive Heart Failure
Comprehensive Discharge
Planning + Post-Discharge
Support
Rich, 1999 [31]
Congestive Heart Failure
To critically evaluate the current status of Congestive Based on currently available data, Congestive Heart Failure disease management
Heart Failure disease management and to identify
programs appear to be a cost-effective approach to reducing morbidity and
Disease Management
specific areas in which additional research is needed enhancing quality of life in selected patients with Congestive Heart Failure.
(multidisciplinary management)
However, additional study is needed involving larger and more diverse
populations to define the optimal approach to Congestive Heart Failure disease
management.
Smith, 2008 [32,39]
Diabetes Mellitus, Congestive
Heart Failure, Asthma, Patients
on Oral Anticoagulant Therapy,
Cancer, Hypertension, Chronic
Obstructive Pulmonary Disease
SR to determine the effectiveness of shared care
interventions designed to improve the management of
chronic disease across the primary-specialty care
interface
At present, there is insufficient evidence to support the introduction of shared care
services into clinical practice. However, methodological shortcomings,
particularly inadequate length of follow-up, may account for this lack of evidence.
Further research is needed to test models of collaboration across the primaryspecialty care divide both in terms of effectiveness and sustainability over longer
periods of time.
To locate, appraise and evaluate the evidence for the
effectiveness of a case management approach to care
The evidence generated in this review suggests that nurse case managers have the
potential to achieve improved health outcomes for patients with long term
conditions. Further research is required to support role development and create a
more targeted approach to the intervention.
SR to assess the effects of different clinical service
interventions in preventing death and/or hospital readmissions; and the effects of the different clinical
service interventions in terms of other outcomes that
may have been reported
The data from this review are insufficient for forming recommendations. Further
research should include adequately powered, multicenter studies. Future studies
should also investigate the effect of interventions on patient's and carer's QOL,
their satisfaction with the interventions and cost effectiveness.
MA to classify previously published studies
according to CCM component(s) and to address the
following:
Interventions that contained one or more program elements had beneficial effects
on clinical outcomes and processes of care, and these effects were consistent
across all conditions studied. The effects on quality of life were mixed, with only
Chronic Disease Management
(shared care)
Sutherlands, 2009
[33]
Diabetes Mellitus II, Chronic
Obstructive Pulmonary
Disease, Chronic Respiratory
Disease, Congestive Heart
Failure, Angina
Case Management
Taylor, 2005 [34]
Congestive Heart Disease
Disease Management
(Clinical Service Organization:
Multidisciplinary Care Model,
Case Management, Clinic
Models)
Tsai 2005 [35]
Asthma, Congestive Heart
Failure, Diabetes Mellitus
6
Review
Population & integrated care
terms used
Aim of review
Chronic Care Models
Vlieland, 1997 [36]
Rheumatoid Arthritis
the Congestive Heart Failure and depression studies showing benefit. Publication
bias was noted for the Congestive Heart Failure studies and a subset of the asthma
Studies.
To assess the efficacy of multidisciplinary team care
programs in Rheumatoid Arthritis
Favourable effects on disease activity were seen in most trials comparing short
inpatient team care with regular outpatient care. Proof of efficacy of prolonged
outpatient team care is scanty. Results of trials comparing inpatient with
outpatient team care remain inconclusive.
MA to systematically review and evaluate
quantitatively and qualitatively the published
evidence regarding the characteristics and
effectiveness of disease management programs
All studied interventions were associated with improvements in provider
adherence to practice guidelines and disease control. The type and number of
interventions varied greatly, and future studies should directly compare different
types of intervention to find the most effective.
Multidisciplinary Team Care
Program
Weingarten, 2002
[37]
Asthma, Back pain, Coronary
Artery Disease, Chronic pain,
Congestive Heart Failure,
Chronic Obstructive Pulmonary
Disease
Authors' conclusions
Disease Management
SR: Systematic Review; MA; Meta-Analysis
7
Table S3. Characteristics of integrated care interventions and outcomes evaluated in 27 systematic reviews.
Review
Condition & integrated care Definition of Integrated Care
term used
Focus of integrated care program Comparisons
Overall
Follow-up, m
(months if not
otherwise
specified)
Main outcomes
Adams, 2007 [12]
Chronic Obstructive
Pulmonary Disease
A multidisciplinary and organised
approach proposed as a solution to
improve management, prevention of
complications, and outcomes in patients
with chronic disease
Interventions that allow the
identification of the elements
(community and health system,
self-management support, delivery
system design, decision support,
clinical information system) that
encourage high-quality chronic
disease care
Mean: 10w
median: 12w
Range: 6 w24m
QoL, functional
status, health care
utilisation
A systematic and multidisciplinary
approach to care for chronic conditions
Interventions which allow the
Usual care in all studies
examination of the combined effect
of both a multidisciplinary team
care approach and patient
education on functional status in
patients with rheumatoid arthritis
Range: 11days- Functional status
24m
median: (19
studies on
Ghb): 18
Models on interdisciplinary primary care
or supplemental health-related services
that enhance traditional primary care and
challenges that accompany care
transitions, including facilitates for
transitions from hospital to home;
providing acute care in patients’ homes in
lieu of hospital care; and care after brief
hospital
Interventions addressing several
health-related needs of older
persons, e.g. care for several
chronic conditions, several aspects
of one condition, or for persons
receiving care from several
healthcare providers
NA
NR
QoL, quality of care,
functional autonomy,
survival
Evidence-based guide for improvement in Interventions consisting of at least
the four basic elements necessary for the two components of the Chronic
provision of high- quality chronic care
Care Models
(WHO)
Usual care in all studies
(“some were given access
to educational materials”)
Range: 3-48
Median: 12
HbA1C, blood
pressure, guideline
adherence
continuous support services for patients to Programmes for the improvement
avoid deteriorating of health
of health and cost outcomes
NR
NR
Length of hospital
stay, costs, QoL,
Mortality, functional
status, adherence
Patient or family, Transition Management Disease education for the patient
and Intervention Modes, Additional
and continuing support after
support with scheduled interventions after hospital discharge
discharge
Standard care a per
definition of inclusion
criteria of studies
median: 9
Range: 3-18
Mortality, health care
utilisation
Chronic Care Models
Badamgarav, 2003
[13]
Rheumatoid Arthritis
Disease Management
Boult, 2009 [14]
Chronic Disease Models
Comprehensive Care
Elissen, 2012 [15]
Diabetes Mellitus
Chronic Care Models
Gensichen, 2004 [38] Congestive Heart Failure
NR
Case Management
Göhler, 2006 [16]
Congestive Heart Failure
Disease Management
8
Review
Condition & integrated care Definition of Integrated Care
term used
Focus of integrated care program Comparisons
Overall
Follow-up, m
(months if not
otherwise
specified)
Main outcomes
Gonseth, 2004 [17]
Congestive Heart Failure and
Cerebrovascular Disease
Programmes for hospital readmission for HF or other
Cardiovascular Disease, all-cause
re-admission and re-admission or
death
Usual care in all studies
Range (RCTs):
3-12 (median:
50.4m in
1study)
Health care
utilisation, mortality,
hospital admissions
Palliative care teams working in hospitals: Interventions that included a
two or more health care workers, at least component of hospital support or
one of whom had specialist training or
care
worked principally in palliative care
Usual care in all studies
A few days to
several weeks
Clinical outcomes,
QoL, health care
utilisation
Structured, multifaceted, systematic
approaches to care
Programs with more than one
intervention component
NR
Range: 3-30
Clinical outcomes,
process of care
Concept by which care delivery is better
coordinated through the integration of
several components across the entire
delivery system and the application of
tools specifically designed for the
population in question, e.g. guidelines,
education, information systems
Double interventions (patient
related and organisational
interventions), triple interventions
(patient related, professional
directed and organisational
interventions)
Usual care or single
intervention
Range: 3-36
QoL, health care
utilisation, patient
education, functional
status
No specific definition given
Interventions consisting of 2 or
more components of chronic care
management e.g. self-management
support, delivery system design,
decision support, clinical
information system
Usual care in all studies
Range: 2-24
("poorly described in
primary studies included")
QoL, health care
utilisation, mortality
An intervention designed to manage or
prevent a chronic condition using a
systematic approach to care and
potentially employing multiple treatment
modalities; a guideline or systematic
approach to care is a systematically
developed statements to assist practitioner
and patient decisions about appropriate
health care for a specific clinical
circumstance
Outpatient-based congestive heart
failure management programs on
mortality or hospitalization
rates
NR
Health care
utilisation, mortality
Disease Management
Higginson, 2002 [18]
End of Life Care
Hospital-Based Palliative
Care
Knight, 2005 [19]
Diabetes Mellitus
Interventions designed to manage heart
failure and reduce hospital re-admissions
using a systematic approach to care and
potentially employing multiple treatment
modalities
Disease Management
Lemmens, 2009 [20]
Asthma
Disease Management
Lemmens, 2011 [21]
Chronic Obstructive
Pulmonary Disease
Chronic Care Management
McAlister, 2001 [22]
Congestive Heart Failure
Disease Management
Insufficient
details
9
Review
Condition & integrated care Definition of Integrated Care
term used
Focus of integrated care program Comparisons
Overall
Follow-up, m
(months if not
otherwise
specified)
Main outcomes
Mitchell, 2002 [23]
Orthopedic, Asthma,
Hypertension, Diabetes
Mellitus, Frail
An organised cooperation between
primary medical practitioners and
specialists, as any formal arrangement
that linked the GPs with specialist
practitioners in the care of the patient.
‘Specialist’ included medical and nursing
specialists
Interventions testing organised,
Usual care in 3 studies
close cooperation between GPs and traditional outpatient
an individual specialist or specialist department care in 1 study
service
NR in 1 study
NR
Physical and health
outcomes, health care
utilisation, patient
satisfaction
A coordinated care approach that offers
benefits to those with complex needs e.g.
those recovering from Stroke, and which
enables participation by health
professionals from different disciplines,
services or sectors in planning and/or
delivering care
Process related to developing and
evaluating a complex intervention
or theory of change looking at the
function and purpose of the
intervention rather than the
compositional elements alone
NR
Mortality, functional
status, health care
utilisation, QoL
Interventions designed to manage or
prevent a chronic condition using a
systematic approach to care, with the
potential use of multiple treatment
modalities
Comparing quality of life outcomes Usual care in all studies
in outpatient chronic disease
management programmes and
routine care
Range: 2-18
QoL, functional
status
An organised, proactive, multicomponent
approach to healthcare delivery that
involves all members of a population with
a specific disease entity e.g. diabetes
Interventions in the health care
services, communities and those in
which patient populations are
involved
Mean: 16.8
Range: 6-30
(disease
management)
Patient and clinical
outcomes
Organised and coordinated
cooperation for Managed
Care
Mitchell, 2008 [24]
Stroke
Disease Management
(multidisciplinary care
planning)
Niesink, 2007 [25]
Chronic Obstructive
Pulmonary Disease
Disease Management
Norris, 2002 [26]
Diabetes Mellitus
Disease Management and
Case Management
General ward care in 1
study, usual care in 1
study
NR
Range:<1-28
(case
management)
Ofman, 2004 [27]
Cerebrovascular Disease
(Congestive Heart Failure)
Disease Management
Ouwens, 2009 [28]
Cancer
An intervention designed to manage or
prevent a chronic disease using a
systematic approach to care and
potentially employing multiple treatment
modalities; which also incorporates
methodologically developed statements
assisting practitioner and patient decision
making about appropriate health care for
specific clinical circumstances
Interventions focused on disease
control and provider adherence to
guidelines
Usual care 19 studies
NR
Patient satisfaction
and adherence,
clinical outcomes
Organized care around needs and
preferences of patients who are actively
Interventions or programmes that
aim at improving care for adult
Usual care in 24 studies
Range: 1day44m
Patient centeredness
10
Review
PeytremannBridevaux,
2008 [29]
Condition & integrated care Definition of Integrated Care
term used
Focus of integrated care program Comparisons
Integrated Care
involved in decisions about their own
care; care is given in optimal
collaboration of all professionals
involved, seamless and continuously with
optimal coordination and organization of
the total care process; and it should be
based on the general principles of EBM
and continuous quality improvement
patients with cancer in hospital or
in an out-patient; patient
centeredness, multidisciplinary
care or organization of care
Other (e.g. information
support, proactive
listening, usual follow up
care in ambulatory setting)
in 9 studies
Chronic Obstructive
Pulmonary Disease
An operational process with interventions
including two or more different
components (e. g. physical exercise, selfmanagement, structured follow-up), two
or more health care professionals who are
actively involved in patient care, patient
education is considered and at least one
component of the intervention lasting a
minimum of 12 months
Long term interventions of disease
management programs for Chronic
Obstructive Pulmonary Disease
(assumed same as McAlister 2001 since
this Meta-Analysis complements and
extends the findings of McAlister, 2001)
Interventions that were described
as comprehensive discharge
planning plus post-discharge
support for older in patients with
Congestive Heart Failure and
intended to modify hospital
discharge
Disease Management
(Case Management, Selfmanagement, Home
Rehabilitation, Integrated
care, Pulmonary
Rehabilitation, Specific
Program for Chronic
Obstructive Pulmonary
Disease)
Phillips, 2004 [30]
Congestive Heart Failure
Comprehensive Discharge
Planning + Post-Discharge
Support
Rich, 1999 [31]
Congestive Heart Failure
Disease Management
(multidisciplinary
management)
Smith, 2008 [32,39]
Diabetes Mellitus, Congestive
Heart Failure, Asthma,
Patients on Oral
Anticoagulant Therapy,
Cancer, Hypertension,
Chronic Obstructive
Pulmonary Disease
Overall
Follow-up, m
(months if not
otherwise
specified)
Main outcomes
Usual care in 9 RCTs and
in 1 non-RCTs
Range: 18-24
Mortality, functional
status, QoL, health
care utilisation
Usual care
Range: 3-12
Health care
utilisation, mortality,
QoL
Programs that generally involve
Multidisciplinary heart failure
multidisciplinary teams that employ
disease management programmes
system approaches (e.g. guidelines or care
paths) and specialized clinics dedicated to
comprehensive management
Usual care ("poorly
defined in all primary
studies included")
Range: 3-12
QoL, patient
satisfaction,
functional status,
health care utilisation,
patient adherence
Any type of structured system that
involved continuing collaborative clinical
care between primary and specialty care
practitioners in the management of
patients with chronic disease
Usual care in all studies
NR
Physical and clinical
outcomes, patient
satisfaction, health
care utilisation
Interventions for the management
of chronic disease across the
primary-specialty care interface
11
Review
Condition & integrated care Definition of Integrated Care
term used
Focus of integrated care program Comparisons
Overall
Follow-up, m
(months if not
otherwise
specified)
Main outcomes
A highly experienced nurse providing
support to individual patients and
monitoring and organizing care provision
to prevent and/or minimise exacerbations
in the patient’s condition
Chronic Congestive Heart Failure
Usual care for most of the
RCTs, 1 PSBCT, 1 PRCT
Insufficient
details
HbA1C, FEV, lipid
levels, blood
pressure, QoL,
functional status
A holistic approach to the individuals’
medical, psychosocial, behavioural and
financial circumstances which typically
involves several different professions
working in collaboration
Interventions not primarily
educational in focus; and those
directed at preventing death and/or
hospital re-admission in patients
previously admitted to secondary
care
Usual care or routine care
in all but 1 study in which
both groups received a
programme of optimised
medical care during the
index hospitalisation
Range:
12weeks - 12m
Mortality, health care
utilisation
Interventions that foster more
productive interactions between
prepared, pro-active teams and
well-informed, motivated patients
NR
Range: 3-24
(100 studies)
Clinical outcomes,
QoL
Chronic Disease Management
(shared care)
Sutherlands, 2009
[33]
Diabetes Mellitus II, Chronic
Obstructive Pulmonary
Disease, Chronic Respiratory
Disease, Congestive Heart
Failure, Angina
Case Management
Taylor, 2005 [34]
Congestive Heart Disease
Disease Management
(Clinical Service
Organisation:
Multidisciplinary Care
Model, Case Management,
Clinic Models)
Case management models consist of
intense monitoring of the patients
following discharge from hospital usually
done by a nurse and typically involves
home visits and/or telephone calls
Clinic models involve outpatient clinics
for HF, usually run by cardiologists with a
special interest in HF or by specialist
nurses using agreed protocols to manage
medication
Tsai 2005 [35]
Asthma, Congestive Heart
Failure, Diabetes Mellitus
Chronic Care Models
Vlieland, 1997 [36]
Rheumatoid Arthritis
Multidisciplinary Team Care
An approach to identify the essential
elements of a health care system that
encourage high-quality chronic disease
care; evidence-based change concepts
under each element, in combination,
foster productive interactions between
informed patients who take an active part
in their care and providers with resources
and expertise
Optimal treatment which requires a
Multidisciplinary team care for
holistic approach adapted to each patient's patients with rheumatoid arthritis
unique set of medical, psychological,
1m (1 study),
72m (1 study)
Insufficient details
Range: 30days- Functional status,
24m
pain, psychosocial
status
12
Review
Weingarten, 2002
[37]
Condition & integrated care Definition of Integrated Care
term used
Programs
behavioural, and financial circumstances
Asthma, Back pain, Coronary
Artery Disease, Chronic pain,
Congestive Heart Failure,
Chronic Obstructive
Pulmonary Disease
Assignment of authority to a professional
(the case manager) who is not the
provider of direct health care but who
oversees and is responsible for
coordinating and implementing care;
quantitative and qualitative evaluation of
the evidence regarding the effectiveness
of different types of intervention
Disease Management
Focus of integrated care program Comparisons
Interventions in disease
management programmes
Overall
Follow-up, m
(months if not
otherwise
specified)
Usual care in all RCTs and Mean: 13.5
in all but 1 Cohort study
(10 studies)
Range: 6-26
Main outcomes
Patient and provider
education
≤1m (1 study)
9m (2 studies)
12(2 studies)
NR: Not reported; QoL: quality of life
13
Table S4. Principles of integrated care assessed by 27 systematic reviews.
Review
I.
Comprehensive
services across
care continuum
II. Patient
focused
III.
Geographic
coverage and
rostering
IV. Standardized
care delivery
through interprofessional
teams
V. Performance
management
Adams, 2007 [12]



Badamgarav, 2003 [13]



Boult, 2009 [14]





Elissen, 2012 [15]





Gensichen, 2004 [38]




Göhler, 2006 [16]




Gonseth, 2004 [17]



Higginson, 2002 [18]

Knight, 2005 [19]


Lemmens, 2009 [20]


Lemmens, 2011 [21]


McAlister, 2001 [22]

Mitchell, 2002 [23]

Mitchell, 2008 [24]

Niesink, 2007 [25]

Norris, 2002 [26]
Ofman, 2004 [27]


VI.
Information
systems

VIII. Physician
integration
IX.
Governance
structure
X. Financial
management

















VII. Organizational
culture and
leadership





















Ouwens, 2009 [28]


Peytremann-Bridevaux,
2008 [29]




Phillips, 2004 [30]




Rich, 1999 [31]

Smith, 2008 [32,39]















14
Review
I.
Comprehensive
services across
care continuum
II. Patient
focused
III.
Geographic
coverage and
rostering
IV. Standardized
care delivery
through interprofessional
teams
V. Performance
management
VI.
Information
systems
Sutherlands, 2009 [33]




Taylor, 2005 [34]





Tsai 2005 [35]





Vlieland, 1997 [36]
Weingarten, 2002 [37]





VII. Organizational
culture and
leadership
VIII. Physician
integration
IX.
Governance
structure
X. Financial
management





Principles associated with successful integration according to Suter et al, 2009.
15
Table S5. Characteristics of primary studies included in 27 systematic reviews of integrated care interventions.
Review
Adams, 2007 [12]
Population & integrated care
Country of primary studies (n)
term used
Chronic Obstructive
Pulmonary Disease
Studies, n
design
Patients, N
58% (26) or
100% (1)
n/r
no
USA (5), SWE (3), IRL (1), AUT
(1), NDL (1)
Inpatients &
outpatients
8 RCTs
3 NRS
701
38-73 (1,
with 100%
female)
18-72 (1)
n/r (9)
0% (1) or 100% n/r
(1) or n/r (9)
no
n/r
Hospitals,
nursing homes,
rehabilitation
centers,
homecare
73 RCTs
10 NRS
1 OBS
n/r
≥65
n/r
n/r
no
USA (38), DEU/ITA/SPN (1), AUS Inpatients &
(3), UK (3), NDL (3), SPN (1), ISR outpatients
(2), NOR (1), KOR (2), HKG (1),
CHN (1), CAN (3), JPN (1), IRL (1)
41 RCTs
6 NRS
4 B/A
10 OBS
35,484
47-68
(children
included in
one study)
22-75 (57)
˃90 (4)
n/r
13
n/r
Outpatients
16 RCTs
2 NRS
5 B/A
4,204
(range: 29695)
n/r
n/r
n/r
no
USA (16), SWE (4), UK (4), CAN
(3), AUS (2), NDL (1), NZL (1),
ITA (1), SPN (1), IRL (1), ARG (1),
Europe (1)
Home care,
inpatients,
outpatients)
36 RCTs
8,341
56-79
37-99%
n/r
no
27 RCTs
27 NRS
18,378
72.2
37-71% (25) or
13-100% (24)
or n/r (5)
White: 46-97% (10); n/r
(44)
no
Disease Management
USA (35), ARG (1), SWE (3), NZ
Outpatients
(1), CAN (1), IRL (2), AUS (4), UK
(1), NDL (1), GRC (1), PRT (1),
ITA (1), ISR (1), PRI (1)
End of Life Care
UK (3), ITA (1)
Inpatients
1 RCT
3 OBS
669
n/r
n/r
n/r
no
USA (15), UK (4), ISR (1), ARG
(1), AUT (1), NDL (1), n/r (1 states
5 from ISR, ARG, AUT, UK)
n/r
19 RCTs
5 NRS
6,421
≥55
n/r
n/r
n/r
Rheumatoid Arthritis
Chronic Disease Models
Diabetes Mellitus
Congestive Heart Failure
Case Management
Göhler, 2006 [16]
Congestive Heart Failure
Disease Management
Gonseth, 2004 [17]
Higginson, 2002 [18]
Children, N
42-75.5
Chronic Care Models
Gensichen, 2004 [38]
Ethnicity
(studies, n)
8,686 (30
studies)
Comprehensive Care
Elissen, 2012 [15]
Male, %
(range)
(studies, n)
20 RCTs
5 NRS
7 B/A
Disease Management
Boult, 2009 [14]
Mean age
(range) yrs.,
(studies, n)
USA (13), UK (3), NZ (3), NDL (3), Various
SPN (2), AUS (2), CAN (1), SWE
(1), NOR (1), DNK (1), DEU (1),
n/r (1)
Chronic Care Models
Badamgarav, 2003 [13]
Setting
Congestive Heart Failure and
Cerebrovascular Disease
Hospital-Based Palliative Care
Knight, 2005 [19]
Diabetes Mellitus
Disease Management
16
Review
Population & integrated care
Country of primary studies (n)
term used
Lemmens, 2009 [20]
Asthma*
Disease Management
Lemmens, 2011 [21]
Chronic Obstructive
Pulmonary Disease
Setting
Studies, n
design
Patients, N
Mean age
(range) yrs.,
(studies, n)
Male, %
(range)
(studies, n)
Ethnicity
(studies, n)
Children, N
USA (5), AUS (4), UK (3), MLT
(1), DNK (1), CAN (1), BEL (1),
DEU (1), NDL (1)
Outpatients,
community,
inpatients
13 RCTs
5 B/A
n/r
16-75
n/r
n/r
no
n/r
n/r
20 RCTs
2 NRS
7 B/A
n/r
44.7-79
36-90 (26)
10 (2)
90 (1)
n/r
no
USA (6), SWE (2), AUS (2), NDL
(1)
Inpatients &
discharge
11 RCTs
2,067
70.5 (range:
63-80)
n/r
n/r
no
Outpatients,
4 RCTs
community,
1 NRS
referral, hospital
discharge
1,655
n/r
more women
(1) or n/r (4)
n/r
n/r but
included
material from
undergraduat
e education
n/r
Discharge to
discharge and
homecare
3 RCTs
6 OBS
631 (RCTs)
other, n/r
n/r
n/r
n/r
no
NZL (1), NDL (3), CAN (1), SPN
(1), DNK (2), SWE (1), USA (1)
Outpatients
10 RCTs
868
62-77
42-92% (8) or
1% (1) or 4%
(1)
n/r
no
n/r
mixed gender
(15) or n/r (27)
Minority and racially
mixed populations (7);
White: 40-77% (8);
African American 93%
(1); Hawaiian: 100%
(1); n/r (25)
mean age 9.8
years in 1
study
n/r
n/r
n/r
n/r
Chronic Care Management
McAlister, 2001 [22]
Congestive Heart Failure
Disease Management
Mitchell, 2002 [23]
Asthma, Hypertension,
n/r
Diabetes Mellitus, Orthopedic,
Frail
Organized and coordinated
cooperation for Managed Care
Mitchell, 2008 [24]
Stroke
Disease Management
(multidisciplinary care
planning)
Niesink, 2007 [25]
Chronic Obstructive
Pulmonary Disease
Disease Management
Norris, 2002 [26]
Diabetes Mellitus
Disease management: USA (19),
Urban centers
Europe (8); Case management: USA (predominantly)
(14), UK (1)
& primarily
managed care
organizations
Disease
n/r
management: 27
comparative (n
per type n/r)
Case
management:
6 RCTs
6 B/A
3 NRS
Ofman, 2004 [27]
Congestive Heart Failure
n/r
n/r
8 RCTs
1 NRS
n/r
Disease Management
17
Review
Population & integrated care
Country of primary studies (n)
term used
Ouwens, 2009 [28]
Cancer
Integrated Care
Peytremann-Bridevaux,
2008 [29]
Chronic Obstructive
Pulmonary Disease
Setting
Studies, n
design
Patients, N
Mean age
(range) yrs.,
(studies, n)
Male, %
(range)
(studies, n)
Ethnicity
(studies, n)
Children, N
n/r
n/r
n/r
no
72 (12)
n/r
no
UK (13), USA (6), CAN (5), NDL
(3), AUT (2), DNK (2), SWE (1),
NOR (1)
Inpatients &
outpatients
31 RCTs/NRS
(n per type n/r)
2 B/A
8796
USA (3), NDL (3), SPN (2) NZL
(2), CAN (1), SWE (1), SPN/NDL
(1)
Inpatients &
other
9 RCTs
3 B/A
1 NRS
6428 (range: 61-75
26-6428)
USA (10), AUS (2), CAN (1), UK
Inpatients &
(1), NDL (1), IRL (1), ITA (1), SWE discharged
(1)
patients
18 RCTs
3,304
≥55 (by
inclusion
criteria)
≥70 (16)
≤70 (2)
62%
White: 86%; NonWhite: 14%
no
n/r
Inpatients &
outpatients
6 RCTs
8 B/A
2 OBS
2,192
68.6 (12)
(range in 13
studies: 5279); n/r, 3
n/r
n/r
no
Primary &
specialty
10 RCTs
4,959
20-84 (14)
25-96% (14)
Ethnic minorities 23%
(1); Caucasians 80-85%
(2); English speaking
100% (1); Non-English
speaking 59% (1); NZ
Europeans 78% (1)
no
Outpatients,
community (not
clear in some
studies)
10 RCTs
1 NRS
3 B/A
1 Ecological
3 OBS
n/r
n/r
n/r
n/r
n/r
Disease Management
(Case Management, Selfmanagement, Home
Rehabilitation, Integrated care,
Pulmonary Rehabilitation,
Specific Program for Chronic
Obstructive Pulmonary
Disease)
Phillips, 2004 [30]
Congestive Heart Failure
Comprehensive Discharge
Planning plus Post-Discharge
Support
Rich, 1999 [31]
Congestive Heart Failure
Disease Management
(multidisciplinary
management)
Smith, 2008 [32,39]
Diabetes Mellitus, Congestive UK (4), NZL (1), DNK (1), AUS
Heart Failure, Asthma,
(1), SWE (1), IRL (1), n/r (1)
Patients on Oral Anticoagulant
Therapy, Cancer,
Hypertension, Chronic
Obstructive Pulmonary
Disease
Chronic Disease Management
(shared care)
Sutherlands, 2009 [33]
Diabetes Mellitus II, Chronic
Obstructive Pulmonary
Disease, Chronic Respiratory
Disease, Congestive Heart
Failure, Angina
n/r
18
Review
Population & integrated care
Country of primary studies (n)
term used
Setting
Studies, n
design
Patients, N
Mean age
(range) yrs.,
(studies, n)
Male, %
(range)
(studies, n)
Ethnicity
(studies, n)
Children, N
Case Management
Taylor, 2005 [34]
Congestive Heart Disease
Disease Management
(Clinical Service Organization:
Multidisciplinary Care Model,
Case Management, Clinic
Models)
Tsai 2005 [35]
Asthma, Congestive Heart
Failure, Diabetes Mellitus
USA (7), UK (2), SWE (2), NZL
(1), CAN (1), NDL (1), ITA (1),
AUS (1)
Inpatient,
outpatient or
community
16 RCTs
2,960
70-80 (14)
23-86
median: 63.5
(range 25-88)
(2)
White 45-74% (4)
NZL European 79% (1)
no
n/r
Outpatients &
inpatients
93 RCTs
19 NRS
n/r
n/r
n/r
n/r
n/r
USA (7), UK (2), CAN (2), NDL
(1), FIN (1), SWE (1), DEU (1)
Inpatients &
outpatients
8 RCTs
7 NRS
1,044
50-65 (6)
15-35% (3); or
0%, (4) or n/r
(1)
n/r
no
n/r
Various
including
primary &
ambulatory care
102 by EPOC
n/r
definition
included RCTs,
quasi-RCT, B/A,
ITS (n per type
n/r)
n/r
n/r
n/r
n/r
Chronic Care Models
Vlieland, 1997 [36]
Rheumatoid Arthritis
Multidisciplinary Team Care
Programs
Weingarten, 2002 [37]
Asthma, Back pain, Coronary
Artery Disease, Chronic pain,
Congestive Heart Failure,
Chronic Obstructive
Pulmonary Disease
Disease Management
n/r: not reported; RCTs: Randomized Controlled Trials; NRS: Non-Randomised Study; B/A: Before/After; OBS: Observational; Australia: AUS; The Netherlands: NLD; United States of America: USA; Germany: DEU;
Switzerland: CHE; Austria: AUT; Canada: CAN; Spain: ESP; United Kingdom: UK; Denmark; DNK; Norway: NOR; Finland: FIN; Italy: ITA; Greece: GRC; Israel: ISR; Ireland: IRL; Puerto Rico: PTR; Argentina: ARG;
Malta: MLT; Belgium: BEL; Korea: KOR; Hong Kong: HKG; China: CHN; Japan: JPN.
* Lemmens et al. (2009) examined Chronic Obstructive Pulmonary Disease and Asthma. Only the Asthma studies are presented here. The Chronic Obstructive Pulmonary Disease primary studies are shown in Lemmens et
al. (2011).
19
Appendix 1. Studies excluded from review based on appraisal of full-text articles.
[1]
Agencia de Evaluacion de Tecnologias S. Utilization of information and communication technology in managing chronic diseases:
a systematic review (IPE-05/45). Madrid: Agencia de Evaluacion de Tecnologias Sanitarias (AETS). 2005.
[2]
Alberts MJ, Hademenos G, Latchaw RE, Jagoda A, Marler JR, Mayberg MR, et al. Recommendations for the establishment of
primary stroke centers. Journal of the American Medical Association. 2000; 283:3102-9.
[3]
Ann McKibbon K, Lokker C, Handler SM, Dolovich LR, Holbrook AM, O'Reilly D, et al. The effectiveness of integrated health
information technologies across the phases of medication management: a systematic review of randomized controlled trials.
Journal of the American Medical Informatics Association. 2012; 19:22-30.
[4]
Atun R, de Jongh TE, Secci FV, Ohiri K, Adeyi O, Car J. Integration of priority population, health and nutrition interventions into
health systems: systematic review. BMC public health 2011; 11:780.
[5]
Belanger E, Rodriguez C. More than the sum of its parts? A qualitative research synthesis on multi-disciplinary primary care
teams. Journal of Interprofessional Care. 2008; 22:587-97.
[6]
Blaiss MS. Asthma disease management: A critical analysis. Annals of Allergy, Asthma and Immunology. 2005; 95:S10-S6.
[7]
Bodenheimer T. Interventions to improve chronic illness care: Evaluating their effectiveness. Dis Manage. 2003; 6:63-71.
[8]
Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. Jama. 2002;
288:2469-75.
[9]
Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. Journal of the American
Medical Association. 2002; 288:1775-9.
[10]
Bott DM, Kapp MC, Johnson LB, Magno LM. Disease management for chronically ill beneficiaries in traditional Medicare.
Health Aff (Millwood). 2009; 28:86-98.
[11]
Boulet LP. Improving knowledge transfer on chronic respiratory diseases: a Canadian perspective. How to translate recent
advances in respiratory diseases into day-to-day care. J Nutr Health Aging. 2008; 12:758S-63S.
[12]
Bourbeau J. Disease-specific self-management programs in patients with advanced chronic obstructive pulmonary disease: a
comprehensive and critical evaluation (Structured abstract). Disease Management and Health Outcomes. 2003:311-9.
[13]
Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with
multiple comorbid diseases: implications for pay for performance. Jama. 2005; 294:716-24.
[14]
Bravata DM, Gienger AL, Holty JEC, Sundaram V, Khazeni N, Wise PH, et al. Quality improvement strategies for children with
asthma: a systematic review. Archives of Pediatrics and Adolescent Medicine. 2009; 163:572-81.
[15]
Brouwers M, Oliver TK, Crawford J, Ellison P, Evans WK, Gagliardi A, et al. Cancer diagnostic assessment programs: Standards
for the organization of care in Ontario. Current Oncology. 2009; 16:29-41.
[16]
Cerimele JM, Strain JJ. Integrating primary care services into psychiatric care settings: A review of the literature. Primary Care
Companion to the Journal of Clinical Psychiatry. 2010; 12.
[17]
Chaudhry SI, Phillips CO, Stewart SS, Riegel B, Mattera JA, Jerant AF, et al. Telemonitoring for patients with chronic heart
failure: a systematic review. Journal of Cardiac Failure. 2007; 13:56-62.
[18]
Chin MH. Quality improvement implementation and disparities: the case of the health disparities collaboratives. Medical Care.
2010; 48:668-75.
[19]
Chiu WK, Newcomer R. A systematic review of nurse-assisted case management to improve hospital discharge transition
outcomes for the elderly. Prof Case Manag. 2007; 12:330-6; quiz 7-8.
[20]
Chodosh J, Morton SC, Mojica W, Maglione M, Suttorp MJ, Hilton L, et al. Improving patient care. Meta-analysis: chronic
disease self-management programs for older adults. Ann Intern Med. 2005; 143:427.
[21]
Cochran J. Meta-analysis of quality of life outcomes following diabetes self-management training: University of Missouri Columbia; 2007.
[22]
Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic Care Model in the new millennium. Health Aff
(Millwood). 2009; 28:75-85.
[23]
Conklin AaN, E. Disease Management Evaluation. A Comprehensive Review of Current State of the Art. Cambridge: The RAND
Corporation.; 2011.
[24]
Courtenay M, Carey N. The impact and effectiveness of nurse-led care in the management of acute and chronic pain: A review of
the literature. Journal of Clinical Nursing. 2008; 17:2001-13.
[25]
Cunningham FC, Ranmuthugala G, Plumb J, Georgiou A, Westbrook JI, Braithwaite J. Health professional networks as a vector
for improving healthcare quality and safety: a systematic review. BMJ Quality and Safety. 2012; 21:239-49.
[26]
Currell R, Urquhart C, Wainwright P, Lewis R. Telemedicine versus face to face patient care: effects on professional practice and
health care outcomes. Cochrane Database Syst Rev. 2000:CD002098.
[27]
Dancer S, Courtney M. Improving diabetes patient outcomes: framing research into the chronic care model. J Am Acad Nurse
Pract. 2010; 22:580-5.
[28]
de Bruin SR, Baan CA, Struijs JN. Pay-for-performance in disease management: a systematic review of the literature. BMC Health
Serv Res. 2011; 11:272.
[29]
De Bruin SR, Heijink R, Lemmens LC, Struijs JN, Baan CA. Impact of disease management programs on healthcare expenditures
for patients with diabetes, depression, heart failure or chronic obstructive pulmonary disease: a systematic review of the literature.
Health Policy. 2011; 101:105-21.
[30]
Effing T, Monninkhof, Evelyn EM, van der Valk Paul PDLPM, Zielhuis Gerhard GA, Walters EH, van der Palen Job J, et al. Selfmanagement education for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2007.
[31]
Ehrlich C, Kendall E, Muenchberger H, Armstrong K. Coordinated care: what does that really mean? Health Soc Care
Community. 2009; 17:619-27.
20
[32]
Eklund K, Wilhelmson K. Outcomes of coordinated and integrated interventions targeting frail elderly people: a systematic review
of randomised controlled trials. Health Soc Care Community. 2009; 17:447-58.
[33]
Freund T, Kayling F, Miksch A, Szecsenyi J, Wensing M. Effectiveness and efficiency of primary care based case management
for chronic diseases: systematic review and meta-analysis of randomized and non-randomized trials. Protocol for a systematic
review. HTA Database. 2009:Crd32009100316.
[34]
Frich LMH. Nursing interventions for patients with chronic conditions. Journal of Advanced Nursing. 2003; 44:137-53.
[35]
Gohler A OZ, Siebert V. Long-term effectiveness and cost-effectiveness of disease management programs in congestive heart
failure a decision-analytic view. Circulation. 2004; 110:639.
[36]
Greenhalgh PM. Shared care for diabetes: a systematic review. Royal College of General Practitioners. 1994:35.
[37]
Greenhalgh PM. Shared care for diabetes. a systematic review. Occasional paper (Royal College of General Practitioners). 1994:iviii, 1-35.
[38]
Griffiths Peter D, Edwards Margaret E, Forbes A, Harris Ruth G, Ritchie G. Effectiveness of intermediate care in nursing-led inpatient units. Cochrane Database Syst Rev. 2007.
[39]
Gruen R, Weeramanthri T, Knight S, Bailie R. Specialist outreach clinics in primary care and rural hospital settings. Community
eye health / International Centre for Eye Health. 2006; 19:31.
[40]
Grundel BL, White GL, Jr., Eichold BH, 2nd. Diabetes in the managed care setting: a prospective plan. South Med J. 1999;
92:459-64.
[41]
Guzman J, Esmail R, Karjalainen K, Malmivaara A, Irvin E, Bombardier C. Multidisciplinary bio-psycho-social rehabilitation for
chronic low back pain. Cochrane Database Syst Rev. 2002:CD000963.
[42]
Guzman J, Esmail R, Karjalainen K, Malmivaara A, Irvin E, Bombardier C. WITHDRAWN: Multidisciplinary bio-psycho-social
rehabilitation for chronic low-back pain. Cochrane database of systematic reviews (Online). 2007:CD000963.
[43]
Hansen LJ, Drivsholm TB. Interventions to improve the management of diabetes mellitus in primary health care and outpatient
community settings. Ugeskr Laeger. 2002; 164:607-9.
[44]
Hayes Sara L, Mann Mala K, Morgan Fiona M, Kitcher H, Kelly Mark J, Weightman Alison L. Collaboration between local health
and local government agencies for health improvement. Cochrane Database Syst Rev. 2011.
[45]
Hearn J, Higginson IJ. Do specialist palliative care teams improve outcomes for cancer patients? A systematic literature review.
Palliative medicine. 1998; 12:317-32.
[46]
Hickman L, Newton P, Halcomb EJ, Chang E, Davidson P. Best practice interventions to improve the management of older people
in acute care settings: a literature review. Journal of Advanced Nursing. 2007; 60:113-26.
[47]
Higginson IJ, Finlay IG, Goodwin DM, Hood K, Edwards AGK, Cook A, et al. Is there evidence that palliative care teams alter
end-of-life experiences of patients and their caregivers? Journal of Pain and Symptom Management. 2003; 25:150-68.
[48]
Inglis Sally C, Clark Robyn A, McAlister Finlay A, Ball J, Lewinter C, Cullington D, et al. Structured telephone support or
telemonitoring programmes for patients with chronic heart failure. Cochrane Database Syst Rev. 2010.
[49]
Inglis SC, Clark RA, McAlister FA, Stewart S, Cleland JGF. Which components of heart failure programmes are effective? a
systematic review and meta-analysis of the outcomes of structured telephone support or telemonitoring as the primary component
of chronic heart failure management in 8323 patients: Abridged Cochrane Review. European Journal of Heart Failure. 2011;
13:1028-40.
[50]
Inglis SC, Pearson S, Treen S, Gallasch T, Horowitz JD, Stewart S. Extending the horizon in chronic heart failure: effects of
multidisciplinary, home-based intervention relative to usual care. Circulation. 2006:2466-73.
[51]
Jerant AF, Nesbitt TS. Heart failure disease management incorporating telemedicine: a critical review. Journal of Clinical
Outcomes Management. 2005; 12:207-17.
[52]
Kastner M, Straus SE. Clinical decision support tools for osteoporosis disease management: a systematic review of randomized
controlled trials. J Gen Intern Med. 2008; 23:2095-105.
[53]
Kesteloot K. Disease management. A new technology in need of critical assessment. Int J Technol Assess Health Care. 1999;
15:506-19.
[54]
Kim YJ, Soeken KL. A meta-analysis of the effect of hospital-based case management on hospital length-of-stay and readmission.
Nursing Research. 2005:255-64.
[55]
Klaic M, Lunt A. Interdisciplinary care in stroke rehabilitation. International Journal of Stroke. 2011; 6:49-50.
[56]
Koff PB, Jones RH, Cashman JM, Voelkel NF, Vandivier RW. Proactive integrated care improves quality of life in patients with
COPD. European Respiratory Journal. 2009:1031-8.
[57]
Lamb BW, Brown KF, Nagpal K, Vincent C, Green JSA, Sevdalis N. Quality of care management decisions by multidisciplinary
cancer teams: a systematic review. Annals of Surgical Oncology. 2011; 18:2116-25.
[58]
Legare F, Ratte S, Stacey D, Kryworuchko J, Gravel K, Graham ID, et al. Interventions for improving the adoption of shared
decision making by healthcare professionals. Cochrane database of systematic reviews (Online). 2010; 5:CD006732.
[59]
Linden A, Adams, J. and Roberts, N. Evaluation methods in disease management: determining programme effectiveness. Position
Paper for the Disease Management Association of America (DMAA). Washington DC: Disease Management Association of
America. 2003.
[60]
Lupari M, Coates V, Adamson G, Crealey GE. 'We're just not getting it right'- how should we provide care to the older person
with multi-morbid chronic conditions? Journal of Clinical Nursing. 2011; 20:1225-35.
[61]
Mattke S, Seid M, Ma S. Evidence for the effect of disease management: is $1 billion a year a good investment? Am J Manag
Care. 2007; 13:670-6.
[62]
McLean S, Nurmatov U, Liu Joseph LY, Pagliari C, Car J, Sheikh A. Telehealthcare for chronic obstructive pulmonary disease.
Cochrane Database Syst Rev. 2011.
[63]
Mitchell GK, Tieman JJ, Shelby-James TM. Multidisciplinary care planning and teamwork in primary care. Med J Aust. 2008;
188:S61-4.
21
[64]
Niesink A, Trappenburg JC, de Weert-van Oene GH, Lammers JW, Verheij TJ, Schrijvers AJ. Systematic review of the effects of
chronic disease management on quality-of-life in people with chronic obstructive pulmonary disease. Respiratory Medicine.
2007:2233-9.
[65]
Nuno R, Coleman K, Bengoa R, Sauto R. Integrated care for chronic conditions: the contribution of the ICCC Framework. Health
Policy. 2012; 105:55-64.
[66]
Oeseburg B, Wynia K, Middel B, Reijneveld SA. Effects of case management for frail older people or those with chronic illness: a
systematic review. Nursing Research. 2009:201-10.
[67]
Office CCB. An Analysis of the Literature on Disease Management Programmes. Washington DC: United States Congress2004.
[68]
Offredy M, Bunn F, Morgan J. Case management in long term conditions: an inconsistent journey? Br J Community Nurs. 2009;
14:252-7.
[69]
Ouwens M, Wollersheim H, Hermens R, et al. Integrated care programmes for chronically ill patients: a review of systematic
reviews. International Journal for Quality in Health Care. 2005;17(2):141-6.
[70]
Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to improve
professional practice. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 1995;
153:1423-31.
[71]
Paré G, Jaana M, Sicotte C. Systematic review of home telemonitoring for chronic diseases: the evidence base. Journal of the
American Medical Informatics Association. 2007; 14:269-77.
[72]
Peytremann-Bridevaux I, Gex G, Bridevaux P-O, Burnand B. Chronic disease management programs for adults with asthma.
Cochrane Database Syst Rev. 2009.
[73]
Ravenek MJ, Hughes ID, Ivanovich N, Tyrer K, Desrochers C, Klinger L, et al. A systematic review of multidisciplinary outcomes
in the management of chronic low back pain. Work. 2010:349-67.
[74]
Renders CM, Valk GD, Griffin S, Wagner EH, Eijk JT, Assendelft WJ. Interventions to improve the management of diabetes
mellitus in primary care, outpatient and community settings. Cochrane Database Syst Rev. 2001:CD001481.
[75]
Savard LA, Thompson DR, Clark AM. A meta-review of evidence on heart failure disease management programs: The challenges
of describing and synthesizing evidence on complex interventions. Trials. 2011; 12.
[76]
Scott I. What are the most effective strategies for improving quality and safety of health care? Intern Med J. 2009; 39:389-400.
[77]
Sin DD, McAlister FA, Man SFP, Anthonisen NR. Contemporary Management of Chronic Obstructive Pulmonary Disease:
Scientific Review. Journal of the American Medical Association. 2003; 290:2301-12.
[78]
Sinha SK, Bessman ES, Flomenbaum N, Leff B. A systematic review and qualitative analysis to inform the development of a new
emergency department-based geriatric case management model. Annals of Emergency Medicine. 2011; 57:672-82.
[79]
Sochalski J, Jaarsma T, Krumholz HM, Laramee A, McMurray JJV, Naylor MD, et al. What works in chronic care management:
the case of heart failure. Health Aff (Millwood). 2009; 28:179-89.
[80]
Taylor SJ, Candy B, Bryar RM, Ramsay J, Vrijhoef HJ, Esmond G, et al. Effectiveness of innovations in nurse led chronic disease
management for patients with chronic obstructive pulmonary disease: systematic review of evidence. Bmj. 2005:485.
[81]
The Netherlands Organisation for Health R, Development. Costs and effects of two modes for disease managementof chronic
obstructive pulmonary disease (COPD) in general practice. A randomized controlled trial comparing regular nurse practitioner
review and self-management education. The Netherlands Organisation for Health Research and Development (ZonMw). 2005.
[82]
Tieman J, Mitchell G, Shelby-James T, Currow D, Fazekas B, O'Doherty L, et al. Integration, coordination and multidisciplinary
care: What can these approaches offer to Australian primary health care? Australian Journal of Primary Health. 2007; 13:56-65.
[83]
Tran K, Polisena J, Coyle D, Coyle K, Kluge EH, Cimon K, et al. Home telehealth for chronic disease management. Canadian
Agency for Drugs and Technologies in Health. 2008:1.
[84]
van Bruggen JAR, Gorter KJ, Stolk RP, Rutten GEHM. Shared and delegated systems are not quick remedies for improving
diabetes care: a systematic review. Prim Care Diabetes. 2007; 1:59-68.
[85]
Wise PH, Huffman LC, Brat G. A critical analysis of care coordination strategies for children with special health care needs.
Agency for Healthcare Research and Quality. 2007:36.
[86]
Wong Christopher X, Carson Kristin V, Smith Brian J. Home care by outreach nursing for chronic obstructive pulmonary disease.
Cochrane Database Syst Rev. 2011.
[87]
Wulff CN, Thygesen M, Sondergaard J, Vedsted P. Case management used to optimize cancer care pathways: a systematic review.
BMC Health Serv Res. 2008; 8.
[88]
Yu DS, Thompson DR, Lee DT. Disease management programmes for older people with heart failure: crucial characteristics
which improve post-discharge outcomes. Eur Heart J. 2006; 27:596-612.
[89]
Zwar N, Harris, M., Griffiths, R., Roland, M., Dennis, S., Powell Davis, G. and Hasan, I., editor. APHCRI stream four: a
systematic review of chronic disease management.: Canberra, Australian Primary Health Care Research Institute (APHCRI). 2006.
[90]
Zwarenstein M, Bryant W. Interventions to promote collaboration between nurses and doctors. Cochrane database of systematic
reviews (Online). 2000:CD000072.
22