a meta-analysis of interventions to improve chronic illness care
DESCRIPTION
A Meta-Analysis of Interventions to Improve Chronic Illness Care. Alexander Tsai 1 ( [email protected] ), S.C. Morton 2 , C.M. Mangione 3 , E.B. Keeler 2. AcademyHealth Annual Research Meeting, June 7, 2004. 1 Case School of Medicine; 2 RAND Health; 3 David Geffen School of Medicine at UCLA. - PowerPoint PPT PresentationTRANSCRIPT
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A Meta-Analysis of Interventions to Improve
Chronic Illness Care
Alexander Tsai1 ([email protected]), S.C. Morton2, C.M. Mangione3,
E.B. Keeler2
1 Case School of Medicine; 2 RAND Health; 3 David Geffen School of Medicine at UCLA
AcademyHealth Annual Research Meeting, June 7, 2004
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The Chronic Care Model
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Objective
• Lack of controlled studies of the CCM– But there have been controlled studies of
interventions that incorporate one or more CCM elements
• Using meta analysis, we sought to:– Determine the extent to which CCM-style
interventions improve chronic illness care– Determine whether any specific CCM
elements were essential to improved outcomes
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Table 1. Outcomes of Interest
Clinical Outcomes Quality of Life Processes
(Continuous) (Dichotomous) (Continuous) (Dichotomous)
Asthma # ED visits % with at least one ED visit
Quality of life % with long-acting meds
CHF # hospital readmissions
% with at least 1 readmission
Quality of life % with ACE inhibitor
Depression Depression Scale
% depressed /symptomatic
Quality of life or SF-36 MCS
% with antidepressant
Diabetes HbA1c % with HbA1c > 7%
Quality of life % tested for HbA1c level
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Data Sources
1. Bibliographies of 23 recently published systematic reviews and meta-analyses: asthma (5), CHF (6), diabetes (7), depression (2), general chronic care (2), information systems (1)
2. MEDLINE 1998-2003
3. Chronic Care Bibliography
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Inclusion/Exclusion Criteria
• Inclusion criteria– 1993-2003– Asthma, CHF, depression, diabetes– Controlled (randomized or non-randomized)– Outcomes of Interest
• Exclusion criteria– Not written in English– Non-adult patient population– Insufficient statistics
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Data Abstraction
• Data obtained from all relevant associated articles and attributed to the primary citation
• Only 12-month follow-up data recorded if multiple follow-up times assessed
• If missing data, SD conservatively assumed to be 1/4 of the theoretical range for that measure
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Statistical Analysis
• Comparisons at follow-up
• Pooled analysis by condition– Hedges’ g (continuous), risk ratio (binary)
• Relative effectiveness of CCM elements– Random-effects meta-regression model
• Funnel plots to detect publication bias
• Cochran’s Q to assess heterogeneity
• Sensitivity analysis for Jadad score ≥3
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Table 2. Summary Statistics (N=112)
Element Type DSD SMS DS CIS CR HCO
N 60 80 38 19 4 6
# Elements One Two Three Four Five Six
N 52 33 19 8 0 0
Jadad score Zero One Two Three Four Five
N 19 23 34 36 0 0
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Table 3. By ConditionClinical Outcomes Quality of life Processes
[continuous] (lower=better)
[dichotomous] (lower=better)
[continuous] (higher=better)
[dichotomous] (higher=better)
Effect Size RR Effect Size RR
OVERALL -0.23 * 0.84 * 0.11 * 1.19 *
Asthma 0.82 * 0.01 1.61
CHF 0.81 * 0.28 * 1.13 *
Depression -0.25 * 0.83 * 0.18 * 1.28 *
Diabetes -0.19 * 0.92 -0.02 1.10 *
* P<0.05
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Table 4. By CCM ElementClinical Outcomes Quality of life Processes
[continuous] (lower=better)
[dichotomous] (lower=better)
[continuous] (higher=better)
[dichotomous] (higher=better)
Effect Size RR Effect Size RR
DSD -0.21 * 0.77 * 0.33 1.16 *
SMS -0.22 * 0.81 * -0.03 1.31 *
DS -0.14 0.87 0.04 1.29 *
CIS -0.06 0.83 -0.28 1.08
* P<0.05
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Conclusions
1. Interventions that contained one or more CCM elements improved clinical outcomes and processes of care for four chronic illnesses
2. Effect on quality of life was mixed
3. The specific CCM elements most responsible for the beneficial effects could not be determined
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Limitations
• Testing the CCM vs. testing CCM elements– Unable to assess intensity of implementation
• Unexplained heterogeneity in aggregating across conditions and types of interventions
• Conclusions limited to selected outcomes and selected conditions
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Standardized effect size-2 -1 0 1
Combined Whitlock (2000)
Weinberger (1995) Tu (1993)
Thompson (1999) Stroebel (2002)
Ridgeway (1999) Piette (2001) Piette (2000) Pieber (1995)
Olivarius (2001) O'Connor (1996)
Meigs (2003) Laffel (1998)
Kinmonth (1998) Keyserling (2002)
Jaber (1996) Hurwitz (1993)
Hoskins (1993) Hirsch (2002)
Glasgow (2003) Glasgow (2000)
De Sonnaville (199 DICET (1994) Brown (2002)
Benjamin (1999) Worrall (1999)
Whooley (2000) Unutzer (2002)
Tutty (2000) Simon (2000)
Rubenstein (2003) Rost (2001)
Rollman (2002) Rabins (2000)
Mynors-Wallis (200 Miranda (2003)
Mann (1998) Llewellyn-Jones (1
Leveille (1998) Katzelnick (2000)
Katon (1999) Katon (1996) Katon (1995)
Hunkeler (2000) Goldberg (1998)
Datto (2003) Coleman (1999) Callahan (1994)
Brown (2000) Blanchard (1995)
Barrett (2001) Banerjee (1996)
Fig 1. Clinical Outcomes (Continuous)
Pooled Effect Size = -0.23 (-0.31, -0.15) favoring intervention
Q=230, df=51, P<0.001
Depression
Diabetes
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Relative risk.25 .5 1 2 4
Combined Renders (2001)
Piette (2000) Meigs (2003)
De Sonnaville (199 Williams (1999)
Whooley (2000) Wells (2000)
Unutzer (2002) Tutty (2000)
Simon (2000) Rubenstein (2003)
Rollman (2002) Mynors-Wallis (200
Mann (1998) Llewellyn-Jones (1 Katzelnick (2000)
Katon (1999) Banerjee (1996)
Weinberger (1996) Stewart (1999) Stewart (1998) Serxner (1998)
Schneider (1993) Riegel (2002) Riegel (2000)
Rich (1995) Rich (1993)
Philbin (2000) Naylor (1999)
Laramee (2003) Kasper (2002)
Jaarsma (1999) Hughes (2000) Harrison (2002)
Ekman (1998) Cline (1998)
Capomolla (2002) Yoon (1993)
Heard (1999) Harish (2001) Ghosh (1998) Garrett (1994) Cowie (1997) Bailey (1999)
Fig 2. Clinical Outcomes (Binary)
Pooled RR = 0.84 (0.78, 0.90) favoring intervention
Q=135, df=45, P<0.001
Asthma
CHF
Depression
Diabetes
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Standardized effect size-2 -1 0 1
Combined
Piette (2000)
Kinmonth (1998)
Glasgow (2000)
Wells (2000)
Unutzer (2002)
Rubenstein (2003)
Stewart (1999)
Rich (1995)
Philbin (2000)
Kasper (2002)
Jaarsma (1999)
Harrison (2002)
Thoonen (2003)
Premaratne (1999)
Levy (2000)
Lahdensuo (1996)
Kotses (1995)
Knoell (1998)
Kauppinen (1998)
Gallefoss (1999)
De Oliveira (1999)
Cote (1997)
Blixen (2001)
Abdulwadud (1999)
Fig 3. Quality of Life
Pooled Effect Size = 0.11 (0.02, 0.21) favoring intervention
Q=93, df=23, P<0.001
Asthma
CHF
Depression
Diabetes
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Relative risk.25 .5 1 2 4
Combined
Stroebel (2002)
Reed (2001)
O'Connor (1996)
Meigs (2003)
McDermott (2001)
Kiefe (2001)
Davidson (2000)
DICET (1994)
Branger (1999)
Worrall (1999)
Wells (2000)
Weatherall (2000)
Unutzer (2002)
Rubenstein (2003)
Rost (2001)
Rollman (2002)
Mann (1998)
Katon (1999)
Dowrick (1995)
Coleman (1999)
Callahan (1994)
Brown (2000)
Bashir (2000)
Aubert (2003)
Weinberger (1996)
Philbin (2000)
Kasper (2002)
Gattis (1999)
Cline (1998)
Akosah (2002)
Gallefoss (1999)
Eccles (2002)
Fig 4. Processes of Care
Pooled RR = 1.19 (1.10, 1.28) favoring intervention
Q=312, df=31, P<0.001
Asthma
CHF
Depression
Diabetes