Abstract
BackgroundDespite the development of several models of care delivery for patients with chronic illness, consistent improvements in outcomes have not been achieved. These inconsistent results may be less related to the content of the models themselves, but to their underlying conceptualization of clinical settings as linear, predictable systems. The science of complex adaptive systems (CAS), suggests that clinical settings are non-linear, and increasingly has been used as a framework for describing and understanding clinical systems. The purpose of this study is to broaden the conceptualization by examining the relationship between interventions that leverage CAS characteristics in intervention design and implementation, and effectiveness of reported outcomes for patients with Type II diabetes.MethodsWe conducted a systematic review of the literature on organizational interventions to improve care of Type II diabetes. For each study we recorded measured process and clinical outcomes of diabetic patients. Two independent reviewers gave each study a score that reflected whether organizational interventions reflected one or more characteristics of a complex adaptive system. The effectiveness of the intervention was assessed by standardizing the scoring of the results of each study as 0 (no effect), 0.5 (mixed effect), or 1.0 (effective).ResultsOut of 157 potentially eligible studies, 32 met our eligibility criteria. Most studies were felt to utilize at least one CAS characteristic in their intervention designs, and ninety-one percent were scored as either "mixed effect" or "effective." The number of CAS characteristics present in each intervention was associated with effectiveness (p = 0.002). Two individual CAS characteristics were associated with effectiveness: interconnections between participants and co-evolution.ConclusionThe significant association between CAS characteristics and effectiveness of reported outcomes for patients with Type II diabetes suggests that complexity science may provide an effective framework for designing and implementing interventions that lead to improved patient outcomes.
Highlights
Despite the development of several models of care delivery for patients with chronic illness, consistent improvements in outcomes have not been achieved
We searched Medline from 1989 through 29 December 2005, after developing a search strategy based on four components: 1) the strategy developed by the Effective Practice and Organization of Care (EPOC) Group of the Cochrane Collaboration and updated for a recent systematic review of Medicare-funded preventive services [21,22]; (2) additional search terms for types of organizational interventions not included in the EPOC search strategy, such as total quality improvement, PDSA (PlanDo-Study-Act), and practice redesign; (3) additional search terms used by a recent systematic review of preventive and quality improvement strategies [23]; and (4) bibliographies and Medline indexing terms of relevant
In support of our hypothesis that implementation strategies consistent with complex adaptive systems (CAS) theory will be more likely to be effective, we found a significant relationship between the number of CAS characteristics utilized in an intervention and the intervention's effectiveness in improving process or outcome measures in patients with Type II diabetes
Summary
Despite the development of several models of care delivery for patients with chronic illness, consistent improvements in outcomes have not been achieved. Recent systematic reviews of organizational intervention studies based on the self-management, chronic care, and disease management models reveal small to moderate effects on process or outcome measures [6,10,11,12,13]. These results suggest that it may not be the content of the models, but rather, it may be that the specific way in which they are applied in organizations is critical
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