Table 1 Characteristics of included studies in the meta-analysis
Source | Setting | Total No. | Age, years | Duration, months, unless stated | Outcomes measures and Treatment Targets set | Interventions (with CCM elements) | Usual care | No./Type of CCM elements identified |
|---|---|---|---|---|---|---|---|---|
Cleveringa et al, [53] 2008 the Netherlands | Primary care practices | 3391 | I: 65.2 ± 11.3 C: 65.0 ± 11.0 | 12 | HbA1c <7% SBP < 140 mmHg DBP LDL <2.5 mmol/L | Patient diabetes consultation with practice nurse (DSD); Computerized decision support systems (CIS); Diagnostic and treatment algorithm based on national diabetes guidelines (DSD); Patient-specific treatment advice (SMS); Recall system for patients (DSD); Feedback to providers and patients (DS, CIS) | Diabetes care provided by primary care physicians or practice nurse under physician responsibility | 4 SMS DS DSD CIS |
DePue et al, [54] 2013 American Samoa | Community health centre | 268 | I: 56 ± 12.5 C: 54 ± 12.9 | 12 | HbA1c SBP DBP BMI | Nurse care manager teaches patient education self-management support and patient-centred communication skills (SMS, DSD); conducts patient groups sessions for high risk patients (DSD); provides feedback to physicians about patient care needs (CIS) Community health workers: ensure patient’s follow-up (DSD), reinforced adherence to medications, problem-solved barriers to self-care, provide support and mobilize family support for diabetes self-support (SMS) Training of staff on standards of care, diabetes guidelines and CCM (DS) Patient care guided by use of protocol or treatment algorithm (DS) Regular reviews by NCM or CHW based on risk profile and patient’s self-selected goals (SMS) Patients get a copy of National diabetes education programme (DS) | Patients on waitlist to join intervention in one year; Received one phone call at 6 months to update contact information, promote study retention and identify adverse effects that occurred since baseline. Patients get a copy of National diabetes education programme | 4 SMS DS DSD CIS |
Frei et al, [55] 2014 Switzerland | Primary care practices | 326 | I: 65.7 ± 10.4 C: 68.3 ± 10.6 | 12 | HbA1c ≤ 6.5% SBP <130mmHg DBP <80 mmHg LDL <2.6 mmol/L BMI | Training of practice nurses (OHS) on knowledge of treatment of diabetes patients and general communication skills (DS); empowers nurses to provide structured care for chronically ill patients (DS); perform visits and follow-up consultations using a monitoring tool that guides nurses through consultations with patients and ensures treatment recommendations are followed and used as communication tool with PCPs (DSD) Training of primary care physicians and nurses in 2 workshops on implementation of team approach in practice and evidence-based therapy of diabetes (DS); professional exchanges regarding implementation experience and management of cardiovascular risk factors (CIS) Regular patient consultations with nurse to record parameters for self-management support, makes goals and track progress of treatment recommendations (SMS) | Focussed on PCP and PCP-patient relationship, based on good clinical practice | 5 OHS SMS DS DSD CIS |
Hayashino et al [56], 2016 Japan | Primary care practices | 2236 | I: 56.5 ± 5.9 C: 56.5 ± 5.9 | 12 | HbA1c SBP DBP BMI | PCPs: PCPs use a disease management system of monitoring and provided feedback on quality of diabetes care (OHS); PCPs received a monthly report (feedback letter) of their care quality (CIS) Patients: Received reminders for regular visits and lifestyle interventions (DSD); Received patient education (SMS) from diabetes educators, dieticians or nurses on lifestyle changes (information on target body weight, recommended food intake and exercise therapy) by phone or in-person sessions | PCPs provided ordinary medical treatment to their patients | 4 OHS SMS DSD CIS |
Heselmans et al, [57] 2020 Belgium | Primary care practices | 3815 | I: 67.2 ± 13.3 C: 64.6 ± 14.7 | 12 | HbA1c SBP DBP LDL | Use of EBMeDs, a computerized decision support system (CIS) that contains evidence-based guidelines designed to improve clinical decision support (DS); and is integrated into the electronic health records Use of Evidence Linker that provides relevant clinical guidelines on demand | Use of Evidence Linker that provides relevant clinical guidelines on demand | 2 DS CIS |
Hiss et al, [58] 2007 United States | Primary care practices | 197 | I: 55.7 ± 13.1 C: 57.0 ± 11.4 | 6 | HbA1c SBP DBP | NCM provides: Personal report on basic intervention with explanations; Problem identification with problem-specific, short-term goal setting and development off action plan (SMS); communication with PCP (DSD) regarding initial discussions with patient; advice to patient to contact PCP for follow-up on identified problem. | Received basic intervention (comprehensive baseline evaluation of diabetes with results communicated to patient and PCP) | 2 SMS DSD |
Collaborative interaction between nurse, PCP and patient (DSD) leading to short-term goal attainment and experience for patient as active team member (SMS); Proactive and continuous follow-up by NCM | ||||||||
Holbrook et al, [59] 2009 Canada | Primary care practices | 511 | I: 61.0 ±13.1 C: 60.5 ±11.9 | 6 | HbA1c <7% SBP <130 mmHg DBP <80 mmHg LDL <2.6 mmol/L BMI <27 | PCPs: Web-based diabetes tracker (CIS) with 13 variables based on guidelines (DS); Use tracker to set targets for monitoring process and clinical outcomes Patients: Phone reminders for appointments (DSD); Given access to tracker and mailed hard copy tracker to bring to physician’s consultation and most recent lab results (SMS) | Patients in the control group continued receiving usual care from their respective primary care providers. | 4 SMS DS DSD CIS |
Janssen et al, [60] 2009 Netherlands | GP practices | 498 | I: 60.1 ±5.4 C: 59.9 ±5.1 | 12 | HbA1c <7% SBP <120 DBP <80 LDL BMI | GPs trained in treatment protocol (DS) regarding intensive multifactorial treatment for cardiovascular risk using intensified treatment consisted of pharmacological treatment to achieve glucose, blood pressure and lipid targets; combined with structured lifestyle education; GPs are reminded once a year to treat patients according to protocol (CIS) Diabetes nurses trained in management of treatment algorithms and in providing lifestyle education (SMS); authorised to prescribe medications supervised by GPs Patients regularly reviewed seen by GPs and nurses (DSD) Patients referred to internist if targets not reached (DS) | Use of local guidelines No detailed instructions on lifestyle education No further training of GPs after initial symposium No nurse involved in care | 4 SMS DS DSD CIS |
Kong et al, [61] 2019 China | Community health centres | 258 | I: 69.1 ±10.5 C: 71.5 ±8.8 | 9 | HbA1c SBP DBP LDL BMI | Health system (OHS): Additional subsidies given to physicians for patient education (enhance patients’ awareness of chronic disease management) and encourage patient initiative through pamphlets and in-person communication) Physicians given appropriate supervision and evaluation procedures Self-management support (SMS): Physicians helped patients in goal-setting, planning, doing, checking and assessing; made self-management plans Decision support (DS): Clinical guidelines implemented by physicians; Physicians received clinical guidelines training and continuing medical education; Physicians received feedback of baseline medical records to better understand care provision Delivery system design (DSD): Each team included a responsible physician, health manager and public health assistant with clear roles and task; Primary role of team is to help patients self-manage their diseases, with monthly follow-up and respond to concerns of patients and other regular tasks | Received conventional follow-up every 3 months by responsible physicians through office visits, home visits and telephone calls Patients examined for lifestyle changes, diabetes control, treatment compliance, drug side effects and target organ damage Patients given general care guidance Physicians received reminders for follow-up every 3 months from tracking system | 5 OHS SMS DS DSD CIS |
Clinical information system (CIS): Provided population-based care for patients including tracking, disease management, and assessment; System could share data between community health centres and other healthcare entities such as tertiary care; Patients’ data regularly collected to facilitate care; Physicians received monthly reminders of follow-ups from tracking system; Physicians required to document timely feedback information | ||||||||
Lee et al, [62] 2011 Hong Kong | General outpatient (primary care) clinics | 157 | Not reported | 28 weeks | HbA1c <6.5% BP BMI | Social worker (DSD) provides self-management programme and assessment (SMS); Programme helps to promote patients’ own problem solving skills; enhanced their self-efficacy on self-management; Used small groups with opportunity for individual advice if needed (DSD) | Attend medical follow-up with general advice on lifestyle and drug compliance. | 2 SMS DSD |
McDermott et al, [63] 2015 Australia | Community health service | 213 | I: 47.9 ±10.7 C: 47.8 ±8.9 | 18 | HbA1c SBP DBP LDL | Indigenous health worker resident (DSD) with case management. Indigenous health worker received training in clinical aspects of diabetes including support patients in self-management skills, advice on clinical care, follow-up appointments. Training included (DS) Rationale for Chronic Care Model and evidence-based management and treatment goals in diabetes Hands-on case management | Wait list group. No other description. | 4 CL SMS DS DSD |
Working in primary care team with clear roles and responsibilities Engage patients and use local resources to support patient self-management (CL) Evidence-based guidelines and reflective practice (DS) Sharing approaches to problem solving with clinical support team and peers (SMS) Tasks included helping patients understand their medications and nutrition and the effects of smoking and work with the family to help support patient in self-management (SMS) | ||||||||
Olivarius et al, [64] 2001 Denmark | GP practices | 1263 | I: 64.9 ±13.9 C: 65.0 ±12.7 | 6 years | HbA1c SBP DBP | Structured personal care: Regular follow-up and individualized goal setting (SMS) supported by prompting of GPs (DSD), clinical guidelines, feedback and continuing medical education; GPs received descriptive feedback reports on patients (CIS) GPs given seminar on clinical treatment guidelines on diet, smoking, persistent hyperglycaemia, hypertension and hyperlipidaemia (DS) GPs handed out patient leaflets to patients on guidelines (DS) | Routine care by GP in ordinary consultations where GPs are free to choose any treatment and change it over time. No disease management sessions run by nurses. | 4 SMS DS DSD CIS |
Prezio et al, [65] 2013 United States | Community health services clinic | 180 | I: 47.9 ±11.0 C: 45.7 ±10.7 | 12 | HbA1c <7% SBP DBP LDL BMI | A culturally tailored diabetes education and case management programme by bilingual community health worker (DSD) along with usual medical care CHW received training in role of diabetes educator and manager Scheduled appointments with patients (DS) Use of printed educational materials targeted for low literacy levels Taught patient education (SMS) including self-monitoring of glucose, meal planning, medication use, sick day rules, smoking cessation, exercise recommendations and information about diabetes complications including recommendations of community resources for exercise (CL) Facilitated physician contact to address acute problems, assisted with pharmacy refills and arranged specialty visits (DS) Physicians follow-up with patients for usual medical care (DSD) | Waitlist group that received usual medical care by physicians Patients provided with glucose monitor and test strips and instructed by medical assistants to use. Patients provided with culturally tailored printed diabetes education materials | 4 CL SMS DS DSD |
Ramli et al, [66] 2016 Malaysia | Public primary care clinics | 888 | I: 58 ±0.5 C: 57 ±0.5 | 12 | HbA1c <6.5% SBP <130 mmHg DBP <80 mmHg LDL ≤2.6 mmol/L BMI <23 kg/m2 | Organisation of Health Care (OHS) and Delivery system design (DSD): Create or strengthened a chronic disease management team (multidisciplinary team led by Family Medicine Specialist to improve coordination of care for type 2 diabetes and co-existing cardiovascular risk factors) Decision support (DS): Use the national Clinical Practice Guidelines for type 2 diabetes to aid management and prescribing; Training provided to intervention team to facilitate and support intervention Self-management support (SMS): Used the Global Cardiovascular Risks Self-Management Booklet to support patients’ self-management | Allied health available but may not be functioning as a team in managing type 2 diabetes. Control clinics have access to Clinical Practice Guidelines but did not receive training and Clinical Practice Guidelines utilisation not emphasized or monitored. | 4 OHS SMS DS DSD |
Schillinger et al, [67] 2009 United States | Community health network clinics | 226 I: 112 C: 114a | I: 55.9 ±12.7 C: 55.8 ±11.8 | 12 | HbA1c SBP DBP BMI | ATSM, automated telephone self-management support Patients received automated telephone calls Nurse case management (DSD): Patient responses triggered either immediate, automated health education messages and/or subsequent nurse phone follow-up. Meant to promote self-efficacy, goal-setting and action plans (SMS) All patient interactions and action plans recorded on standardized self-management support records to communicate with patient’s physician | Not described | 2 SMS DSD |
Schillinger et al, [67] 2009 United States | Community health network clinics | 227 I: 113 C: 114 | I: 56.5 ±11.4 C: 55.8 ±11.8 | 12 | HbA1c SBP DBP BMI | GMV, group medical visits Uses a group process (DSD) to provide support, education and patient activation (SMS): GMV involved monthly sessions, co-facilitated by a primary care physician and health educator (DSD) Meant to promote self-efficacy, goal-setting and action plans (SMS) All patient interactions and action plans recorded on standardized self-management support records to communicate with patient’s physician (SMS) | Not described | 2 SMS DSD |
Sonnichsen et al, [68] 2010 Austria | GP practices | 1,489 | I: 65.4 ±10.4 C: 65.5 ±10.4 | 12 | HbA1c SBP DBP LDL BMI | DMP that consist of: Physician training on diabetes care, current guidelines and practice management training (DS) Patient education in groups (SMS) Standardised documentation of clinical information (physical examination, laboratory findings and diabetes complications) in a DMP form once a year (CIS) Structured interdisciplinary care according to national diabetes guidelines (DS) Agreement on therapeutic goals in a shared patient-physician decision-making process at 3-monthly intervals (SMS) | Physicians performed usual care; Physicians not permitted to participate in DMP training course; Patient education for diabetes publicly available but not explicitly invited to participate Patients put on waitlist | 4 SMS DS DSD CIS |
Talavera et al, [69] 2021 United States | Community health centre | 456 | I: 55.4 ±9.8 C: 56.0 ±9.9 | 6 | HbA1c SBP DBP LDL | Co-location of clinical team (physician/mid-level medical provider and specialty behavioural health provider) (DS) Warm hand-off from medical provider to behavioural health provider (DSD) Shared treatment plan (CIS) Up to 4 integrated medical visits with medical provider for medical management of diabetes and other chronic medical conditions and with specialty behavioural health provider for management of psychosocial and behavioural factors (DSD) Care coordination to facilitate shared treatment plan (DSD) Six culturally appropriate, group-health education classes led by community health worker (SMS) All intervention providers are Spanish-English bilingual and Latino/a. | Care follows national consensus guidelines Practitioners stay current through peer review and access to “UpToDate” a point of care clinical support resource; Quarterly primary care visits for patients not on insulin and not meeting treatment goals; Patients are referred to health educator and/or to behavioural health at physician’s discretion; 60% of primary care providers in clinical setting and most of ancillary staff are Spanish-English bilingual and Latino/a. | 4 SMS DS DSD CIS |