Elsevier

Health Policy

Volume 107, Issues 2–3, October 2012, Pages 108-145
Health Policy

Review
Comprehensive care programs for patients with multiple chronic conditions: A systematic literature review

https://doi.org/10.1016/j.healthpol.2012.06.006Get rights and content

Abstract

Objective

To provide insight into the characteristics of comprehensive care programs for patients with multiple chronic conditions and their impact on patients, informal caregivers, and professional caregivers.

Methods

Systematic literature search in multiple electronic databases for English language papers published between January 1995 and January 2011, supplemented by reference tracking and a manual search on the internet. Wagner's chronic care model (CCM) was used to define comprehensive care. After inclusion, the methodological quality of each study was assessed. A best-evidence synthesis was applied to draw conclusions.

Results

Forty-two publications were selected describing thirty-three studies evaluating twenty-eight comprehensive care programs for multimorbid patients. Programs varied in the target patient groups, implementation settings, number of included interventions, and number of CCM components to which these interventions related. Moderate evidence was found for a beneficial effect of comprehensive care on inpatient healthcare utilization and healthcare costs, health behavior of patients, perceived quality of care, and satisfaction of patients and caregivers. Insufficient evidence was found for a beneficial effect of comprehensive care on health-related quality of life in terms of mental functioning, medication use, and outpatient healthcare utilization and healthcare costs. No evidence was found for a beneficial effect of comprehensive care on cognitive functioning, depressive symptoms, functional status, mortality, quality of life in terms of physical functioning, and caregiver burden.

Conclusion

Because of the heterogeneity of comprehensive care programs, it is as yet too early to draw firm conclusions regarding their effectiveness. More rigorous evaluation studies are necessary to determine what constitutes best care for the increasing number of people with multiple chronic conditions.

Introduction

Chronic diseases are the leading cause of disability and death in the western part of the world [1]. Over the coming years, the prevalence of chronic diseases is predicted to increase because of the rapid ageing of the world population and the greater longevity of people with chronic conditions [2], [3], [4]. An increasing proportion of the chronically ill is multimorbid [5], [6]. The term “multimorbidity” refers to any co-occurrence of multiple chronic conditions within one person, and is to be distinguished from the term “co-morbidity” which refers to the combination of additional diseases beyond an index disorder [6], [7], [8]. The prevalence of multiple chronic conditions among individuals increases with age and is substantial among older adults [5]. In people over age 65 about 65% is multimorbid; in people over age 85 this proportion is about 85% [6], [8], [9].

Having multiple chronic conditions is associated with poor quality of life, disability, psychological distress, and an increased mortality risk [6], [10]. The complex healthcare needs of most patients with multiple chronic conditions usually require the involvement of a large number of healthcare providers in the care process. Coordination of care is therefore difficult and healthcare providers often fail to address the integral healthcare demand, including psychosocial issues, of patients with multiple chronic conditions [8], [11], [12], [13]. As a result, multimorbid patients are prone to receive fragmented, incomplete, inefficient, and ineffective care, which in turn may lead to unnecessary hospitalizations, increased use of emergency facilities, polypharmacy, adverse drug events, duplicative tests, and conflicting medical advices [5], [8], [14], [15].

Increasingly, comprehensive care programs are implemented in healthcare systems worldwide to address the integral healthcare demand of multimorbid patients [5], [16], [17]. Models are considered to be comprehensive if they address several healthcare needs of people with multiple chronic conditions, functional disabilities, and/or high healthcare utilization and if healthcare services are provided by multiple healthcare providers [17]. Comprehensive care programs are patient-centered and aim to structure and coordinate delivery of healthcare services [5], [16], [17]. Such programs are referred to as e.g. integrated care programs, disease management programs, guided care, transitional care or shared care [13], [17]. By improving quality and continuity of care, these programs aim to improve patient health outcomes, whilst making efficient use of healthcare resources [13], [18], [19].

Reviews that provide an overview of implemented comprehensive care programs for patients with multiple chronic conditions indicate that evidence for their impact on patients and caregivers is inconsistent [17], [20], [21], [22], [23], [24], [25]. In most of these reviews criteria for the inclusion of studies were rather narrow. Some reviews predominantly included randomized controlled trials [17], [21], [23], whereas others just evaluated the impact of programs on patient outcomes [17], [23], [24], [25] or included studies suggesting positive effects of comprehensive care programs [17]. Furthermore, most reviews provide limited information about the contents of the comprehensive care programs included. As a result, relevant information from non-randomized trials and information about the impact of programs on caregiver outcomes have hardly been summarized yet. Moreover, little is known about the program characteristics that may be related to positive outcomes of care and about the patient groups that may benefit most from comprehensive care. This information is, however, of importance since interest in what constitutes best care for patients with multimorbidity is growing. We therefore performed a thorough review of the literature using less narrow inclusion criteria than earlier review studies. We aimed to provide more insight into the characteristics of comprehensive care programs for patients with multiple chronic conditions and their impact on patients, informal caregivers, and professional caregivers.

Section snippets

Study design and search strategy

We conducted a systematic literature search in the electronic databases Cinahl, Cochrane, Embase, Medline, PsycInfo, and SciSearch. The databases were searched for English language papers focusing on comprehensive care programs for people aged 18 years and older and published between January 1995 and January 2011. January 1995 was used as a starting point since from that year on comprehensive care has become an increasingly important focus of attention in the medical literature [26].

A

Study retrieval

Our literature search yielded 3544 potentially relevant publications. On the basis of their title and abstract, 184 papers were selected by the reviewers to be retrieved full-text for in-depth screening. This screening process resulted in 32 publications for inclusion in our study. The addition of 10 papers from our manual search resulted in a total of 42 publications that were classified as eligible for our review. Reasons for exclusion are shown in Fig. 1.

Study designs and length of follow-up

The 42 included publications

Discussion

This systematic literature review summarizes available information about the characteristics of comprehensive care programs for people with multiple chronic conditions and about their impact on patients and caregivers. There is a vast amount of literature on comprehensive care. However, most literature focuses on comprehensive care programs for people with a single disease [19], [29], [30], [31], [82], [83], [84], [85]. Our work focuses on comprehensive care programs for people with multiple

Conclusion

There is a broad array of comprehensive care programs available to patients with multiple chronic conditions that often integrate both medical and social services. Despite indications that comprehensive care programs for multimorbid patients decrease inpatient healthcare utilization and healthcare costs, improve health behavior of patients and perceived quality of care, and realize satisfaction of patients and caregivers because of the heterogeneity of the programs it is as yet too early to

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