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A Meta-Analysis of Interventions to Improve Chronic Illness Care
Tsai AC, Morton SC, Mangione CM, Keeler EB. American Journal of Managed Care, 2005 11 478-88.

Context: The Chronic Care Model is a recently developed framework aimed at improving chronic illness care. While the Chronic Care Model in its entirety has not been evaluated in controlled studies, there have been many trials of interventions that have incorporated one or more elements

Objectives: To use empirical data from the literature to address two related research questions: 1) to what extent do interventions that incorporate one or more elements of the chronic care model result in improved outcomes of interest for specific chronic illnesses; and 2) are some elements of the chronic care model more effective than other elements?

Data Sources: Bibliographies of previously published systematic reviews and meta-analyses relevant to this topic, MEDLINE database (1998-2003), and consulting experts.

Article Selection: Articles selected were randomized and non-randomized controlled trials of interventions compared to a control or usual care group for four conditions of interest: asthma, congestive heart failure, depression, and diabetes. Data were extracted on study characteristics and intervention effects on clinical outcomes, quality of life, and processes. Studies were characterized by the elements of the chronic care model in their intervention.

Results: Of 1,345 abstracts screened, 112 studies contributed data to the random-effects meta-analysis: 27 asthma studies, 21 congestive heart failure studies, 33 depression studies, and 31 diabetes studies. Interventions that contained one or more elements of the chronic care model led to a pooled effect size of -0.17 (95% CI, -0.24 to -0.11) on clinical outcomes and 0.11 (95% CI, 0.02-0.21) on quality of life, and a pooled relative risk of 1.19 (95% CI, 1.10-1.28) on key processes. No single element was found to be essential or superfluous for effectiveness. We detected evidence of publication bias for studies of congestive heart failure (all outcome measures) and asthma (clinical outcome measure).

Conclusions: Interventions that contain one or more elements of the Chronic Care Model improve clinical outcomes and processes -- and to a lesser extent, quality of life -- for patients with chronic illnesses. The elements most responsible for these benefits cannot be determined from existing data.

Presented at the AcademyHealth meeting by: Alexander Tsai, Case Western Reserve University, at the panel on Organizational Factors Associated with Successful Chronic Care Delivery, 8:30 — 10:00 a.m., June 7, Chair: Douglas Roblin, Kaiser Permanente Georgia