Abstract
Patient-centred care by a coordinated primary care team may be more effective than standard care in chronic disease management. We synthesised evidence to determine whether patient-centred medical home (PCMH)-based care models are more effective than standard general practitioner (GP) care in improving biomedical, hospital, and economic outcomes. MEDLINE, CINAHL, Embase, Cochrane Library, and Scopus were searched to identify randomised (RCTs) and non-randomised controlled trials that evaluated two or more principles of PCMH among primary care patients with chronic diseases. Study selection, data extraction, quality assessment using Joanna Briggs Institute (JBI) appraisal tools, and grading of evidence using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach were conducted independently. A quantitative synthesis, where possible, was pooled using random effects models and the effect size estimates of standardised mean differences (SMDs) and odds ratios (ORs) with 95% confidence intervals were reported. Of the 13,820 citations, we identified 78 eligible RCTs and 7 quasi trials which included 60,617 patients. The findings suggested that PCMH-based care was associated with significant improvements in depression episodes (SMD −0.24; 95% CI −0.35, −0.14; I2 = 76%) and increased odds of remission (OR 1.79; 95% CI 1.46, 2.21; I2 = 0%). There were significant improvements in the health-related quality of life (SMD 0.10; 95% CI 0.04, 0.15; I2 = 51%), self-management outcomes (SMD 0.24; 95% CI 0.03, 0.44; I2 = 83%), and hospital admissions (OR 0.83; 95% CI 0.70, 0.98; I2 = 0%). In terms of biomedical outcomes, with exception to total cholesterol, PCMH-based care led to significant improvements in blood pressure, glycated haemoglobin, and low-density lipoprotein cholesterol outcomes. The incremental cost of PCMH care was identified to be small and significantly higher than standard care (SMD 0.17; 95% CI 0.08, 0.26; I2 = 82%). The quality of individual studies ranged from “fair” to “good” by meeting at least 60% of items on the quality appraisal checklist. Additionally, moderate to high heterogeneity across studies in outcomes resulted in downgrading the included studies as moderate or low grade of evidence. PCMH-based care has been found to be superior to standard GP care in chronic disease management. Results of the review have important implications that may inform patient, practice, and policy-level changes.
Highlights
Chronic diseases have contributed to increased mortality and morbidity worldwide with the disease burden accelerating across both developed and developing nations [1,2]
The World Health Organisation (WHO) and other leading organisations have acknowledged the importance of primary care as an ideal setting to facilitate patient-centred care, which could result in better patient outcomes [11,12]
Main reasons for exclusion included patients treated in non-primary care settings, not meeting minimum patient-centred medical home (PCMH) components or focused on intervention other than PCMH model, lack of control group, and other reasons
Summary
Chronic diseases have contributed to increased mortality and morbidity worldwide with the disease burden accelerating across both developed and developing nations [1,2]. Patients with one or more chronic diseases often experience poor mental and physical functioning with increased psychological distress affecting their overall health-related quality of life (HRQoL) [5,6]. In addition to negative health outcomes, chronic diseases contribute to significant economic ramifications to both patients and health care system in the form of increased health care utilisation and costs of care [7,8]. There has been an increasing advocacy towards shift from a reactive health care system to one that is proactive, enabling an integrated systems approach towards chronic disease management [10]. There is a large body of evidence suggesting that coordinated team-based approaches in primary care are effective in chronic disease management [13,14]
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