Original Article
Meta-analysis of the effectiveness of chronic care management for diabetes: investigating heterogeneity in outcomes
Arianne M. J. Elissen MSc,
Lotte M. G. Steuten PhD,
Lidwien C. Lemmens PhD, Hanneke W. Drewes MSc,
Karin M. M. Lemmens PhD,
Jolanda A. C. Meeuwissen MSc,
Caroline A. Baan PhD,
Hubertus J. M. Vrijhoef PhD,
Corresponding Author
Arianne M. J. Elissen MSc
PhD Student/Researcher, Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
Ms Arianne M.J. Elissen, Department of Health Services Research, Maastricht University, Duboisdomein 30, 6229 GT Maastricht, The Netherlands, E-mail: [email protected]Search for more papers by this authorLotte M. G. Steuten PhD
Senior Researcher, Health Technology and Services Research, University of Twente, Enschede, The Netherlands
Search for more papers by this authorHanneke W. Drewes MSc
PhD Student/Researcher
PhD Student/Researcher
Search for more papers by this authorKarin M. M. Lemmens PhD
Senior Researcher, Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
Search for more papers by this authorJolanda A. C. Meeuwissen MSc
Senior Researcher, Netherlands Institute for Mental Health and Addiction (Trimbos Institute), Utrecht, The Netherlands
Search for more papers by this authorCaroline A. Baan PhD
Senior Researcher, Centre for Prevention and Health Services Research, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
Search for more papers by this authorHubertus J. M. Vrijhoef PhD
Professor, Department of Integrated Care, TRANZO, Tilburg University, Tilburg, The Netherlands
Search for more papers by this authorArianne M. J. Elissen MSc,
Lotte M. G. Steuten PhD,
Lidwien C. Lemmens PhD, Hanneke W. Drewes MSc,
Karin M. M. Lemmens PhD,
Jolanda A. C. Meeuwissen MSc,
Caroline A. Baan PhD,
Hubertus J. M. Vrijhoef PhD,
Corresponding Author
Arianne M. J. Elissen MSc
PhD Student/Researcher, Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
Ms Arianne M.J. Elissen, Department of Health Services Research, Maastricht University, Duboisdomein 30, 6229 GT Maastricht, The Netherlands, E-mail: [email protected]Search for more papers by this authorLotte M. G. Steuten PhD
Senior Researcher, Health Technology and Services Research, University of Twente, Enschede, The Netherlands
Search for more papers by this authorHanneke W. Drewes MSc
PhD Student/Researcher
PhD Student/Researcher
Search for more papers by this authorKarin M. M. Lemmens PhD
Senior Researcher, Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
Search for more papers by this authorJolanda A. C. Meeuwissen MSc
Senior Researcher, Netherlands Institute for Mental Health and Addiction (Trimbos Institute), Utrecht, The Netherlands
Search for more papers by this authorCaroline A. Baan PhD
Senior Researcher, Centre for Prevention and Health Services Research, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
Search for more papers by this authorHubertus J. M. Vrijhoef PhD
Professor, Department of Integrated Care, TRANZO, Tilburg University, Tilburg, The Netherlands
Search for more papers by this authorAbstract
Purpose The study aims to support decision making on how best to redesign diabetes care by investigating three potential sources of heterogeneity in effectiveness across trials of diabetes care management.
Methods Medline, CINAHL and PsycInfo were searched for systematic reviews and empirical studies focusing on: (1) diabetes mellitus; (2) adult patients; and (3) interventions consisting of at least two components of the chronic care model (CCM). Systematic reviews were analysed descriptively; empirical studies were meta-analysed. Pooled effect measures were estimated using a meta-regression model that incorporated study quality, length of follow-up and number of intervention components as potential predictors of heterogeneity in effects.
Results Overall, reviews (n = 15) of diabetes care programmes report modest improvements in glycaemic control. Empirical studies (n = 61) show wide-ranging results on HbA1c, systolic blood pressure and guideline adherence. Differences between studies in methodological quality cannot explain this heterogeneity in effects. Variety in length of follow-up can explain (part of) the variability, yet not across all outcomes. Diversity in the number of included intervention components can explain 8–12% of the heterogeneity in effects on HbA1c and systolic blood pressure.
Conclusions The outcomes of chronic care management for diabetes are generally positive, yet differ considerably across trials. The most promising results are attained in studies with limited follow-up (<1 year) and by programmes including more than two CCM components. These factors can, however, explain only part of the heterogeneity in effectiveness between studies. Other potential sources of heterogeneity should be investigated to ensure implementation of evidence-based improvements in diabetes care.
Supporting Information
Table S1 Overview of systematic reviews.
Table S2 Overview of empirical studies.
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Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
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