Integrated chronic disease management in primary-secondary care : a systematic literature review of the evidence

O'Connor, Martin, Lim, David, Ward, Lauren, & Hepworth, Julie (2014) Integrated chronic disease management in primary-secondary care : a systematic literature review of the evidence. In Andrikopoulous, Sof, Aylen, Tracey, Gunton, Jenny, & Joannides, Christos (Eds.) Australian Diabetes Society and Australian Diabetes Educators Association Annual Scientific Meeting 2014, 27 - 29 August 2014, Melbourne, Australia. (Unpublished)


Introduction: Diabetes has traditionally been managed as a single chronic disease state, but it exists with co-morbidities such as depression and metabolic syndrome. Treatment is multifaceted, requiring both primary and secondary care, however, the delivery of diabetes care is often fragmented. Integrated chronic disease management is a growing model of interest, and is underpinned by the chronic care model (CCM), devised as a guide for primary care management of patients with chronic conditions. The model identifies six key elements for effective care, and has shown promise in improving the management of diabetes.

Aim: To find empirical evidence of integrated care interventions targeted at co-morbidities including diabetes, across primary/secondary care.

Method: A systematic review of peer reviewed literature from PubMed, CINAHL, Embase, Cochrane Library and Joanna Briggs was performed. Studies were reviewed according to inclusion criteria- studies published in English, between 2004-2014, empirical studies, studies with evidence of primary/secondary implementation, and those dealing with chronic co-morbid disease states.

Results: 51 studies met the inclusion criteria. Included studies were mostly from the US (38), with five from Australia, UK (2), Canada (2), Netherlands (1), Norway (1), Ireland (1), and one multi-country study. It was found that all interventions adopted at least one (average 3-4) of the chronic care model, with the majority implementing delivery system redesign activities within the primary care practice/s. We found evidence of interventions which significantly reduced emergency department and hospital admissions, improved processes of care, patient health outcomes such as HbA1c, improved patient satisfaction, and reduced costs.

Conclusion/Implications for practice: Diabetes exists as a co-morbid disease, requiring both primary and secondary care. We found that integrated care interventions adopting elements of the chronic care model positively impacted on patient outcomes, service utilisation, as well as costs. This review has highlighted that it may not be necessary to adopt all CCM elements to improve clinical outcomes, patient satisfaction and costs.

Impact and interest:

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ID Code: 75961
Item Type: Conference Item (Poster)
Refereed: No
Additional URLs:
Keywords: Chronic Care Model, Chronic disease management, Integrated care, Primary - secondary health care, Delivery of care
Subjects: Australian and New Zealand Standard Research Classification > MEDICAL AND HEALTH SCIENCES (110000)
Australian and New Zealand Standard Research Classification > MEDICAL AND HEALTH SCIENCES (110000) > PUBLIC HEALTH AND HEALTH SERVICES (111700)
Divisions: Current > QUT Faculties and Divisions > Faculty of Health
Current > Institutes > Institute of Health and Biomedical Innovation
Current > Schools > School of Public Health & Social Work
Copyright Owner: Copyright 2014 Please consult the authors
Deposited On: 08 Sep 2014 01:38
Last Modified: 13 Oct 2016 14:28

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