Effectiveness of comprehensive care programs for patients with multiple chronic conditions or frailty: A systematic literature review

Health Policy

Volumn 120, Issue 7, 2016, Pages 818-832

  Hopman, Petra ^a   de Bruin, Simone R ^b   Forjaz, Maria João ^c   Rodriguez Blazquez, Carmen ^c   Tonnara, Giuseppe ^d   Lemmens, Lidwien C ^b   Onder, Graziano ^d,e   Baan, Caroline A ^b,f   Rijken, Mieke ^a  

^a NETHERLANDS INSTITUTE FOR HEALTH SERVICES RESEARCH   (Netherlands)

^b NATIONAL INSTITUTE FOR PUBLIC HEALTH AND THE ENVIRONMENT   (Netherlands)

^c INSTITUTO DE SALUD CARLOS III   (Spain)

^d CATHOLIC UNIVERSITY   (Italy)

^e ITALIAN MEDICINES AGENCY   (Italy)

^f TILBURG UNIVERSITY   (Netherlands)

Author keywords

Chronic care; Comprehensive care; Effectiveness; Frailty; Integrated care; Multimorbidity

Indexed keywords

CAREGIVER; CHRONIC DISEASE; CHRONIC PATIENT; CLINICAL OUTCOME; COMORBIDITY; COMPREHENSIVE CARE; DEPRESSION; EUROPEAN; FOLLOW UP; FUNCTIONAL STATUS; HEALTH CARE COST; HEALTH CARE UTILIZATION; HOSPITAL CARE; HOSPITAL PATIENT; HUMAN; MEDICAL INFORMATION SYSTEM; MORTALITY; PATIENT CARE; PATIENT SATISFACTION; PRACTICE GUIDELINE; PROGRAM EFFECTIVENESS; QUALITY OF LIFE; RANDOMIZED CONTROLLED TRIAL (TOPIC); REVIEW; SELF CARE; SOCIAL WELFARE; SYSTEMATIC REVIEW; COST BENEFIT ANALYSIS; GLOBAL HEALTH; HEALTH CARE; MULTIPLE CHRONIC CONDITIONS; ORGANIZATION AND MANAGEMENT; TREATMENT OUTCOME;

COMPREHENSIVE HEALTH CARE; COST-BENEFIT ANALYSIS; GLOBAL HEALTH; HEALTH CARE COSTS; HUMANS; MULTIPLE CHRONIC CONDITIONS; OUTCOME AND PROCESS ASSESSMENT (HEALTH CARE);

EID: 84963956001     PISSN: 01688510     EISSN: 18726054     Source Type: Journal    
DOI: 10.1016/j.healthpol.2016.04.002     Document Type: Review

References (80)

1. [1] Eurostat, Table People having a long-standing illness or health problem, by sex, age and income quintile. 2010 http://epp.eurostat.ec.europa.eu/portal/page/portal/health/public_health/data_public_health/database.
2. [2] Busse, R., Blümel, M., Scheller-Kreinsen, D., Zentner, A., Tackling chronic disease in Europe. Strategies, interventions and challenges. Observatory Studies Series no. 20, 2010, World Health Organization, on behalf of the European Observatory on Health Systems and Policies Series.
3. [3] Boyd, C., Fortin, M., Future of multimorbidity research: how should understanding of multimorbidity inform health system design?. Public Health Reviews 32 (2010), 451–474.
4. [4] Uijen, A.A., van de Lisdonk, E.H., Multimorbidity in primary care: prevalence and trend over the last 20 years. European Journal of General Practice 14:1 (2008), 28–32, 10.1080/13814780802436093.
5. [5] Bower, P., Macdonald, W., Harkness, E., Gask, L., Kendrick, T., Valderas, J.M., et al. Multimorbidity, service organization and clinical decision making in primary care: a qualitative study. Family Practice 28:5 (2011), 579–587, 10.1093/fampra/cmr018.
6. [6] Smith, S.M., Soubhi, H., Fortin, M., Hudon, C., O'Dowd, T., Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. Cochrane Database of Systematic Reviews, 2012, 4, 10.1002/14651858.CD006560.pub2 Art. No.: CD006560.
7. [7] van Oostrom, S.H., Picavet, H.S., van Gelder, B.M., Lemmens, L.C., Hoeymans, N., Verheij, R.A., et al. Multimorbidity and comorbidity in the Dutch population-data from general practices. BMC Public Health, 12, 2012, 715, 10.1186/1471-2458-12-715.
8. [8] Marengoni, A., Angleman, S., Melis, R., Mangialasche, F., Karp, A., Garmen, A., et al. Aging with multi-morbidity: a systematic review of the literature. Aging Research Reviews 10 (2011), 430–439, 10.1016/j.arr2011.03.003.
9. [9] Vogeli, C., Shields, A.E., Lee, T.A., Gibson, T.B., Marder, W.D., Weiss, K.B., et al. Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. Journal of General Internal Medicine 22:3 (2007), 391–395, 10.1007/s11606-007-0322-1.
10. [10] Fried, L.P., Tangen, C.M., Walston, J., Newman, A.B., Hirsch, C., Gottdiener, J., et al. Frailty in older adults: evidence for phenotype. Journal of Gerontology Series A: Biological Sciences and Medical Sciences 56:3 (2001), M146–M157, 10.1093/gerona/56.3.M146.
11. [11] Shamliyan, T., Talley, K.M., Ramakrishnan, R., Kane, R.L., Association of frailty with survival: a systematic literature review. Ageing Research Reviews 12 (2012), 719–736, 10.1016/j.arr.2012.03.001.
12. [12] Fried, L.P., Ferrucci, L., Darer, J., Williamson, J.D., Anderson, G., Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. Journal of Gerontology 59:3 (2004), 255–263, 10.1093/gerona/59.3.M255.
13. [13] Boeckxstaens, P., Vaes, B., Legrand, D., Dalleur, O., De Sutter, A., Degryse, J.M., The relationship of multimorbidity with disability and frailty in the oldest patients: a cross-sectional analysis of three measures of multimorbidity in the BELFRAIL cohort. European Journal of General Practice 21:1 (2015), 39–44, 10.3109/13814788.2014.914167.
14. [14] Sociaal en Cultureel Planbureau, Kwetsbare ouderen [Frail elderly; summary in English included]. 2011, Sociaal en Cultureel Planbureau, Den Haag.
15. [15] Hopman, P., Schellevis, F.G., Rijken, M., Health-related needs of people with multiple chronic diseases: differences and underlying factors. Quality of Life Research, 2015, 10.1007/s11136-015-1102-8 (advance online publication).
16. [16] Fortin, M., Bravo, G., Hudon, C., Lapointe, L., Almirall, J., Dubois, M.F., et al. Relationship between multimorbidity and health-related quality of life of patients in primary care. Quality of Life Research 15 (2006), 83–91, 10.1007/s11136-005-8661-z.
17. [17] Alonso-Morán, E., Nuno-Solinis, R., Orueta, J.F., Fernandez-Ruanova, B., Alday-Jurado, A., Gutiérrez-Fraile, E., Health-related quality of life and multimorbidity in community-dwelling telecare-assisted elders in the Basque Country. European Journal of Internal Medicine 26 (2015), 169–175, 10.1016/j.ejim.2015.02.013 (Epub ahead of print).
18. [18] Rochat, S., Cumming, R.G., Blyth, F., Creasey, H., Handelsman, D., Le Couteur, D.G., et al. Frailty and use of health and community services by community-dwelling older men: the Concord Health and Ageing in Men Project. Age and Ageing 39 (2010), 228–233, 10.1093/ageing/afp257.
19. [19] Ilinca, S., Calciolari, S., The patterns of health care utilization by elderly Europeans: frailty and its implications for health systems. Health Services Research 50:1 (2015), 305–320, 10.1111/1475-6773.12211.
20. [20] Boyd, C.M., Darer, J., Boult, C., Fried, L.P., Boult, L., Wu, A.W., Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases. Implications for pay for performance. Journal of the American Medical Association 294 (2005), 716–724, 10.1001/jama.294.6.716.
21. [21] van Weel, C., Schellevis, F.G., Comorbidity and guidelines: conflicting interests (Comment). The Lancet 367 (2006), 550–551, 10.1016/S0140-6736(06)68198-1.
22. [22] Cox, L., Kloseck, M., Crilly, R., McWilliam, C., Diachun, L., Underrepresentation of individuals 80 years of age and older in chronic disease clinical practice guidelines. Canadian Family Physician/Medecin de Famille Canadien 57:7 (2011), e263–e269.
23. [23] Fortin, M., Dionne, J., Pinho, G., Gignac, J., Almirall, J., Lapointe, L., Randomized controlled trials: do they have external validity for patients with multiple comorbidities?. Annals of Family Medicine 4:2 (2006), 104–108, 10.1370/afm.516.
24. [24] Guthrie, B., Payne, K., Alderson, P., McMurdo, M.E., Mercer, S.W., Adapting clinical guidelines to take account of multimorbidity. British Medical Journal, 345, 2012, e6341, 10.1136/bmj.e6341.
25. [25] Hughes, L.D., McMurdo, M.E., Guthrie, B., Guidelines for people not for diseases: the challenges of applying UK clinical guidelines to people with mtulitmorbidity. Age and Ageing 42:1 (2013), 62–69, 10.1093/ageing/afs100.
26. [26] United Nations, Department of Economic and Social Affairs, Population Division. World Population Ageing 1950–2050. 2002, United Nations, New York, NY.
27. [27] Anderson, G., Horvath, J., Chronic conditions: Making the case for ongoing care. Baltimore (MD): Partnership for Solutions. December 2002.
28. [28] Banerjee, S., Multimorbidity – older adults need health care that can count past one. The Lancet 385:9968 (2015), 587–589, 10.1016/S0140-6736(14)61596-8.
29. [29] Onder, G., Palmer, K., Navickas, R., Jurevičienė, E., Mammarella, F., Strandzheva, M., et al. Time to face the challenge of multimorbidity. A European perspective form the joint action on chronic diseases and promoting healthy ageing across the life cycle (JA-CHRODIS). European Journal of Internal Medicine 26 (2015), 157–159, 10.1016/j.ejim.2015.02.020.
30. [30] Greß, S., Baan, C.A., Clanan, M., Dedeu, T., Groenewegen, P., Howson, H., et al. Co-ordination and management of chronic conditions in Europe: the role of primary care – position paper of the European forum for primary care. Quality in Primary Care 17 (2009), 75–86.
31. [31] Mattke, S., Seid, M., Ma, S., Evidence for the effect of disease management: is $1 billion a year a good investment?. American Journal of Managed Care 13 (2007), 670–676.
32. [32] Wagner, E.H., Bennett, S.M., Austin, B.T., Greene, S.M., Schaefer, J.K., Vonkorff, M., Finding common ground: patient-centeredness and evidence based chronic illness care. Journal of Alternative and Complementary Medicine 11:Suppl. 1 (2005), S7–S15, 10.1089/acm.2005.11.s-7.
33. [33] de Bruin, S.R., Versnel, N., Lemmens, L.C., Molema, C.C.M., Schellevis, F.G., Nijpels, G., et al. Comprehensive care programs for patients with multiple chronic conditions: a systematic literature review. Health Policy 107 (2012), 108–145, 10.1016/j.healthpol.2012.06.006.
34. [34] van der Heide, I., Snoeijs, S., Boerma, W., Schellevis, F., Rijken, M., et al. Innovating care for people with multiple chronic conditions in Europe: an overview. 2015, NIVEL, Utrecht, The Netherlands.
35. [35] Noordman, J., van der Heide, I., Hopman, P., Schellevis, F., Rijken, M., Innovative health care approaches for people with multi-morbidity in Europe. The availability of integrated care programmes including care pathways and/or addressing poly-pharmacy and patient adherence, for patients with multiple chronic conditions in 31 European countries. 2015, NIVEL, Utrecht, The Netherlands.
36. [36] Tsai, A.C., Morton, S.C., Mangione, C.M., Keeler, E.B., A meta-analysis of interventions to improve care for chronic illnesses. American Journal of Managed Care 11 (2005), 478–488.
37. [37] Zwar, N., Harris, M., Griffiths, R., Roland, M., Dennis, S., Powell Davis, G., et al. APHCRI stream four: a systematic review of chronic disease management. 2006, Australian Primary Health Care Research Institute (APHCRI), Canberra.
38. [38] Adams, S.G., Smith, P.K., Allan, P.F., Anzueto, A., Pugh, J.A., Cornell, J.E., Systematic review of the chronic care model in chronic obstructive pulmonary disease prevention and management. Archives of Internal Medicine 167 (2007), 551–561, 10.1001/archinte.167.6.551.
39. [39] de Bruin, S.R., Heijink, R., Lemmens, L., Struijs, J.N., Baan, C.A., 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 101 (2011), 105–121, 10.1016/j.healthpol.2011.03.006.
40. [40] Lemmens, K., Lemmens, L., Boom, J., Drewes, H., Meeuwissen, J., Steuten, L., et al. Chronic care management for patients with COPD: a critical review of available evidence. Journal of Evaluation in Clinical Practice 19:5 (2013), 734–752, 10.1111/j. 1365-2753.2011.01805.x.
41. [41] Wagner, E.H., Austin, B.T., Davis, C., Hindmarsh, M., Schaefer, J., Bonomi, A., Improving chronic illness care: translating evidence into action. Health Affairs (Millwood) 20 (2001), 64–78, 10.1377/hlthaff.20.6.64.
42. [42] Wagner, E.H., Austin, B.T., Davis, C., Hindmarsh, M., Schaefer, J., Bonomi, A., Improving chronic illness care: translating evidence into action. Health Affairs (Millwood) 20 (2001), 64–78.
43. [43] Wagner, E.H., The role of patient care teams in chronic disease management. British Medical Journal 320 (2000), 569–572.
44. [44] Data on cross-country purchasing power differences (PPP) and Gross Domestic Product prices (inflation), http://stats.oecd.org/ (retrieved 15.6.15).
45. [45] Verhagen, A.P., de Vet, H.C., de Bie, R.A., Kessels, A.G., Boers, M., Bouter, L.M., et al. The Delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi consensus. Journal of Clinical Epidemiology 51 (1998), 1235–1241, 10.1016/S0895-4356(98)00131-0.
46. [46] Van Tulder, M., Furlan, A., Bombardier, C., Bouter, L., Updated method guidelines for systematic reviews in the Cochrane collaboration back review group. Spine (Phila Pa 1976) 28 (2003), 1290–1299, 10.1097/01.BRS.0000065484.95996.AF.
47. [47] Peikes, D., Chen, A., Schore, J., Brown, R., Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA 301 (2009), 603–618, 10.1001/jama.2009.126.
48. [48] Proper, K.I., Singh, A.S., van Mechelen, W., Chinapaw, M.J., Sedentary behaviors and health outcomes among adults: a systematic review of prospective studies. American Journal of Preventive Medicine 40 (2011), 174–182, 10.1016/j.amepre.2010.10.015.
49. [49] Singh, A.S., Mulder, C., Twisk, J., Van Mechelen, W., Chinapaw, M.J., Tracking of childhood overweight into adulthood: a systematic review of the literature. Obesity reviews 9 (2008), 474–488, 10.1111/j.1467-789X.2008.00475.x.
50. [50] Hoogendoorn, W.E., van Poppel, M.N., Bongers, P.M., Koes, B.W., Bouter, L.M., Systematic review of psychosocial factors at work and private life as risk factors for back pain. Spine (Phila Pa 1976) 25 (2000), 2114–2125, 10.1097/00007632-200008150-00017.
51. [51] Berry, L.L., Rock, B.L., Smith Houskamp, B., Brueggeman, J., Tucker, L., Care coordination for patients with complex health profiles in inpatient and outpatient settings. Mayo Clinic Proceedings 88:2 (2013), 184–194, 10.1016/j.mayocp.2012.10.016.
52. [52] Boult, C., Reider, L., Leff, B., Frick, K.D., Boyd, C.M., Wolff, J.L., et al. The effect of guided care teams on the use of health services: results from a cluster-randomized controlled trial. Archives of internal medicine 171:5 (2011), 460–466, 10.1001/archinternmed.2010.540.
53. [53] Cameron, I.D., Fairhall, N., Langron, C., Lockwood, K., Monaghan, N., Aggar, C., et al. A multifactorial interdisciplinary intervention reduces frailty in older people: randomized trial. BMC Medicine 11 (2013), 65–70, 10.1186/1741-7015-11-65.
54. [54] Davis, E., Janssen, J., Johnson, A., Fontil, V., Aronson, L., Handley, M.A., et al. Primary care-based complex care management: using an interdisciplinary geriatric approach to improve care for frequently admitted patients in a safety net primary care clinic. Journal of General Internal Medicine, 28(3), 2013, 445.
55. [55] Fleming, M.O., Haney, T.T., Improving patient outcomes with better care transitions: the role for home health. Cleveland Clinic Journal of Medicine 80:Electronic Suppl 1 (2013), eS2–eS6, 10.3949/ccjm.80.e-s1.02.
56. [56] Gharacholou, S.M., Sloane, R., Cohen, H.J., Schmader, K.E., Geriatric inpatient units in the care of hospitalized frail adults with a history of heart failure. International Journal of Gerontology 6:2 (2012), 112–116, 10.1016/j.ijge.2012.01.012.
57. [57] Hébert, R., Raîche, M., Dubois, M.F., Gueye, N.R., Dubuc, N., Tousignant, M., et al. Impact of PRISMA, a coordination-type integrated service delivery system for frail older people in Quebec (Canada): a quasi-experimental study. Journals of Gerontology Series B: Psychological Sciences and Social Sciences 65B:1 (2010), 107–118, 10.1093/geronb/gbp027.
58. [58] Kono, A., Kanaya, Y., Fujita, T., Tsumura, C., Kondo, T., Kushiyama, K., et al. Effects of a preventive home visit program in ambulatory frail older people: a randomized control trial. Journals of Gerontology Series A: Biological Sciences and Medical Sciences 67:3 (2012), 302–309, 10.1093/gerona/glr176.
59. [59] Levine, S., Steinman, B.A., Attaway, K., Jung, T., Enguidanos, S., Home care program for patients at high risk of hospitalization. American Journal of Managed Care 18:8 (2012), 269–276.
60. [60] Marek, K.D., Stetzer, F., Ryan, P.A., Bud, L.D., Adams, S.J., Schlidt, A., et al. Nurse care coordination and technology effects on health status of frail older adults via enhanced self-management of medication. Nursing Research 62:4 (2013), 269–278, 10.1097/NNR.0b013e318298aa55.
61. [61] Metzelthin, S.F., van Rossum, E., de Witte, L.P., Ambergen, A.W., Hobma, S.O., Sipers, W., et al. Effectiveness of interdisciplinary primary care approach to reduce disability in community dwelling frail older people: cluster randomised controlled trial. British Medical Journal, 347, 2013, f5264, 10.1136/bmj.f5264.
62. [62] Rosenberg, T., Acute hospital use, nursing home placement, and mortality in a frail community-dwelling cohort managed with primary integrated interdisciplinary elder care at home. Journal of the American Geriatric Society 60:7 (2012), 1340–1346, 10.1111/j.1532-5415.2012.03965.x.
63. [63] Schulz, R.M., Porter, C., Lane, M., Cornman, C., Branham, L., Impact of a medication management system on nursing home admission rate in a community-dwelling nursing home-eligible Medicaid population. American Journal of Geriatric Pharmacotherapy 9:1 (2011), 69–79, 10.1016/j.amjopharm.2011.02.008.
64. [64] Wade, M.J., Desai, A.S., Spettell, C.M., Snyder, A.D., McGowan-Stackewicz, V., Kummer, P.J., et al. Telemonitoring with case management for seniors with heart failure. American Journal of Managed Care 17:3 (2011), 71–79.
65. [65] Wakefield, B.J., Holman, J.E., Ray, A., Scherubel, M., Adams, M.R., Hillis, S.L., et al. Effectiveness of home telehealth in comorbid diabetes and hypertension: a randomized, controlled trial. Telemedicine and e-Health 17:4 (2011), 254–261, 10.1089/tmj.2010.0176.
66. [66] Wald, H.L., Glasheen, J.J., Guerrasio, J., Youngwerth, J.M., Cumbler, E.U., Evaluation of a hospitalist-run acute care for the elderly service. Journal of Hospital Medicine 6:6 (2011), 313–321, 10.1002/jhm.906.
67. [67] Watkins, L., Hall, C., Kring, D., Hospital to home: a transition program for frail older adults. Professional Case Management 17:3 (2012), 117–123, 10.1097/NCM.0b013e318243d6a7.
68. [68] Weber, C., Beaulieu, M., Djurdjev, O., Er, L., Taylor, P., Ignaszewski, A., et al. Towards rational approaches of health care utilization in complex patients: an exploratory randomized trial comparing a novel combined clinic to multiple specialty clinics in patients with renal disease-cardiovascular disease-diabetes. Nephrology Dialysis Transplantation 27:3 (2012), iii104–iii110, 10.1093/ndt/gfr292.
69. [69] Metzelthin, S.F., van Rossum, E., Hendriks, M.R.C., De Witte, L.P., Hobma, S.O., Sipers, W., et al. Reducing disability in community-dwelling frail older people: cost-effectiveness study alongside a cluster randomised controlled trial. Age Ageing 0 (2015), 1–7, 10.1093/ageing/afu200.
70. [70] Hoogendijk, E.O., van der Horst, H.E., van de Ven, P.M., Twisk, J.R., Deeg, D.J.H., Frijters, D.H.M., et al. Effectiveness of a Geriatric Care Model for frail older adults in primary care: results from a stepped wedge cluster randomized trial. European Journal of Internal Medicine 28 (2016), 43–51, 10.1016/j.ejim.2015.10.023.
71. [71] Muntinga, M.E., Together toward transition, implementing a comprehensive care program for frail, older people in primary care. (unpublished doctoral dissertation), 2015, VU University Amsterdam, Amsterdam, the Netherlands.
72. [72] Lemmens, L.C., Molema, C.C.M., Versnel, N., Baan, C.A., de Bruin, S.R., Integrated care programs for patients with psychological comorbidity: a systematic review and meta-analysis. Journal of Psychosomatic Research 79 (2015), 580–594, 10.1016/j.jpsychores.2015.07.013.
73. [73] Leichsenring, K., Billings, J., Nies, H., Long Term Care in Europe – Improving Policy and Practice. 2013, Palgrave Macmillan, Basingstoke.
74. [74] Rijken, M., Struckmann, V., Dyakova, M., Melchiorre, M.G., Rissanen, S., van Ginneken, E., ICARE4EU: improving care for people with multiple chronic conditions in Europe. Eurohealth 19:3 (2013), 29–31.
75. [75] http://www.sustain-eu.org.
76. [76] Toto, P.E., Skidmore, E.R., Terhorst, L., Rosen, J., Weiner, D.K., Goal Attainment Scaling (GAS) in geriatric primary care: a feasibility study. Archives of Gerontology and Geriatrics 60 (2015), 16–21, 10.1016/j.archger.2014.10.022.
77. [77] Rockwood, K., Howlett, S., Stadnyk, K., Carver, D., Powell, C., Stolee, P., Responsiveness of goal attainment scaling in a randomized controlled trial of comprehensive geriatric assessment. Journal of Clinical Epidemiology 56 (2003), 736–743, 10.1016/S0895-4356(03)00132-X.
78. [78] www.chrodis.eu.
79. [79] http://ec.europa.eu/research/innovation-union/index_en.cfm?section=active-healthy-ageing.
80. [80] Nolte, E., Hinrich, S., on behalf of the DISMEVAL Consortium, (eds.) DISMEVAL – Developing and validating disease management evaluation methods for European healthcare systems. Final report, 2012, RAND Europe.