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J Eval Clin Pract. 2013 Oct;19(5):753-62. doi: 10.1111/j.1365-2753.2012.01817.x. Epub 2012 Feb 29.

Meta-analysis of the effectiveness of chronic care management for diabetes: investigating heterogeneity in outcomes.

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1
PhD Student/Researcher, Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands Senior Researcher, Health Technology and Services Research, University of Twente, Enschede, The Netherlands Senior Researcher PhD Student/Researcher Senior Researcher, Centre for Prevention and Health Services Research, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands PhD Student/Researcher Professor, Department of Integrated Care, TRANZO, Tilburg University, Tilburg, The Netherlands Senior Researcher, Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands Senior Researcher, Netherlands Institute for Mental Health and Addiction (Trimbos Institute), Utrecht, The Netherlands.

Abstract

PURPOSE:

The study aims 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.

METHODS:

Medline, CINAHL and PsycInfo were searched for systematic reviews and empirical studies focusing on: (1) diabetes mellitus; (2) adult patients; and (3) interventions consisting of at least two components of the chronic care model (CCM). Systematic reviews were analysed descriptively; empirical studies were meta-analysed. Pooled effect measures were estimated using a meta-regression model that incorporated study quality, length of follow-up and number of intervention components as potential predictors of heterogeneity in effects.

RESULTS:

Overall, reviews (n = 15) of diabetes care programmes report modest improvements in glycaemic control. Empirical studies (n = 61) show wide-ranging results on HbA1c, systolic blood pressure and guideline adherence. Differences between studies in methodological quality cannot explain this heterogeneity in effects. Variety in length of follow-up can explain (part of) the variability, yet not across all outcomes. Diversity in the number of included intervention components can explain 8-12% of the heterogeneity in effects on HbA1c and systolic blood pressure.

CONCLUSIONS:

The outcomes of chronic care management for diabetes are generally positive, yet differ considerably across trials. The most promising results are attained in studies with limited follow-up (<1 year) and by programmes including more than two CCM components. These factors can, however, explain only part of the heterogeneity in effectiveness between studies. Other potential sources of heterogeneity should be investigated to ensure implementation of evidence-based improvements in diabetes care.

KEYWORDS:

chronic disease management; diabetes mellitus; health services research; quality improvement

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