Figure 1
Rainbow model for integrated care [22].
Figure 2
Flowchart of search strategy and study selection process.
Table 1
Clusters of integrated care interventions [9].
| RAINBOW MODEL INTERVENTIONS CHARACTERISATION | TOTAL STUDIES | CLUSTER 1: PATIENT EMPOWERMENT | CLUSTER 2: NETWORK CARE COORDINATION | CLUSTER DIFFERENCES |
|---|---|---|---|---|
| N (%) | 54 (100%) | 22 (41%) | 32 (59%) | |
| Organizational level | ||||
| 34 (63%) | 6 (27%) | 28 (88%) | 0.000*** |
| 10 (19%) | 4 (18%) | 6 (19%) | 1.000 |
| 15 (28%) | 1 (5%) | 14 (44%) | 0.002** |
| 7 (13%) | 3 (14%) | 4 (13%) | 1.000 |
| Professional domain | ||||
| 41 (76%) | 11 (50%) | 30 (94%) | 0.001*** |
| 28 (52%) | 6 (27%) | 22 (69%) | 0.005** |
| 27 (50%) | 13 (59%) | 14 (44%) | 0.41 |
| 9 (17%) | 2 (9%) | 7 (22%) | 0.28 |
| 9 (17%) | 2 (9%) | 6 (19%) | 0.45 |
| Patient domain | ||||
| 33 (61%) | 1 (5%) | 31 (97%) | 0.000*** |
| 24 (44%) | 4 (18%) | 20 (63%) | 0.002*** |
| 15 (28%) | 4 (18%) | 11 (34%) | 0.23 |
| 26 (48%) | 14 (64%) | 12 (38%) | 0.09 |
| 25 (46%) | 13 (59%) | 12 (38%) | 0.17 |
| 3 (6%) | 2 (9%) | 1 (3%) | 0.56 |
[i] **Significant level < 0.01.
***Significant level < 0.001.
Figure 3
Summary risks of bias in included studies.
Figure 4
Effect of integrated care on all-cause mortality.
Table 2
Summary of findings and assessment of quality of evidence for outcomes.
| CERTAINTY ASSESSMENT | N OF PATIENTS | EFFECT | CERTAINTY | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| N OF STUDIES | STUDY DESIGN | RISK OF BIAS | INCONSISTENCY | INDIRECTNESS | IMPRECISION | OTHER CONSIDERATIONS | [INTERVENTION] | [COMPARISON] | RELATIVE (95% CI) | ABSOLUTE (95% CI) | |
| PRIMARY OUTCOMES | |||||||||||
| All-cause mortality (follow-up: mean 39 weeks) | |||||||||||
| 6 | randomised trials | seriousa | not serious | not serious | not serious | none | 56/1334 (4.2%) | 97/1347 (7.2%) | RR 0.60 (0.44 to 0.81) | 29 fewer per 1.000(from 14 fewer to 44 fewer) | ⨁⨁⨁◯ Moderate |
| All-cause hospital admissions (follow-up: mean 39 weeks) | |||||||||||
| 6 | randomised trials | seriousa | seriousb | not serious | not serious | none | 429/1334 (32.2%) | 659/1347 (48.9%) | RR 0.63(0.56 to 0.71) | 181 fewer per 1,000 (from 142 fewer to 215 fewer) | ⨁⨁◯◯ Low |
| Adverse events (follow-up: mean 45.5 weeks) | |||||||||||
| 4 | randomised trials | not serious | seriousb | not serious | not serious | none | 143/1251 (11.4%) | 177/1108 (16.0%) | RR 0.53(0.27 to 1.05) | 75 fewer per 1.000(from 8 fewer to 117 fewer) | ⨁⨁⨁◯ Moderate |
| Healthcare use (follow-up: mean 52 weeks) | |||||||||||
| 3 | randomised trials | not serious | seriousb | not serious | seriousc | none | 135 | 132 | - | SMD 0.3 SD higher (0.05 lower to 1.10 higher) | ⨁⨁◯◯ Low |
| SECONDARY OUTCOMES | |||||||||||
| Quality of life (follow-up: mean 35 weeks) | |||||||||||
| 15 | randomised trials | not serious | seriousb | not serious | not serious | none | 2278 | 2180 | - | SMD 0.38 SD higher (0.03 higher to 0.73 higher) | ⨁⨁⨁◯ Moderate |
| Physical functioning (follow-up: mean 34 weeks) | |||||||||||
| 19 | randomised trials | not serious | seriousb | not serious | not serious | none | 2062 | 1843 | - | SMD 0.17 SD higher (0.03 higher to 0.30 higher) | ⨁⨁⨁◯ Moderate |
| Weight management (follow-up: median 45 weeks) | |||||||||||
| 10 | randomised trials | seriousa | seriousb | not serious | seriousc | none | 902 | 693 | - | SMD 0.08 SD higher (0.07 lower to 0.24 higher) | ⨁◯◯◯ Very low |
| Mental health (follow-up: mean 35 weeks) | |||||||||||
| 20 | randomised trials | not serious | seriousb | not serious | not serious | none | 2319 | 2083 | - | SMD 0.29 SD higher (0.12 higher to 0.46 higher) | ⨁⨁⨁◯ Moderate |
| Self-management (follow-up: mean 30 weeks) | |||||||||||
| 13 | randomised trials | not serious | seriousb | not serious | not serious | none | 1487 | 1304 | - | SMD 0.3 SD higher (0.10 higher to 0.50 higher) | ⨁⨁⨁◯ Moderate |
| TERTIARY OUTCOMES | |||||||||||
| HbA1c (follow-up: mean 40 weeks) | |||||||||||
| 15 | randomised trials | seriousa | seriousb | not serious | not serious | none | 947 | 865 | - | SMD 0.45 SD higher (0.15 higher to 0.75 higher) | ⨁⨁◯◯ Low |
| Cholesterol (follow-up: mean 52 weeks) | |||||||||||
| 6 | randomised trials | seriousa | not serious | not serious | seriousc | none | 590 | 376 | - | SMD 0.02 SD lower (0.12 lower to 0.07 higher) | ⨁⨁◯◯ Low |
| Pulmonary measures (follow-up: mean 264 weeks) | |||||||||||
| 4 | randomised trials | seriousa | not serious | not serious | seriousc | none | 713 | 785 | - | SMD 0.17 SD higher (0.16 lower to 0.49 higher) | ⨁⨁◯◯ Low |
| Blood pressure control (follow-up: mean 50 weeks) | |||||||||||
| 11 | randomised trials | seriousa | not serious | not serious | not serious | none | 1601 | 1395 | - | SMD 0.11 SD higher (0.00 to 0.21 higher) | ⨁⨁⨁◯ Moderate |
[i] CI: confidence interval; RR: risk ratio; SMD: standardised mean difference.
Explanations
Most of the studies have high frequency of other bias.
Large heterogeneity between studies (I2>50%).
95% CI includes possible benefits from both control and health interventions.
Figure 5
Effect of integrated care on all-cause hospitalization.
Figure 6
Effect of integrated care on adverse events.
Figure 7
Effect of integrated care on healthcare use.
Figure 8
Effect of integrated care on quality of life.
Figure 9
Effect of integrated care on physical functioning.
Figure 10
Effect of integrated care on weight management.
Figure 11
Effect of integrated care on mental health.
Figure 12
Effect of integrated care on self-management.