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International Journal of Environmental Research and Public Health logoLink to International Journal of Environmental Research and Public Health
. 2020 Sep 21;17(18):6886. doi: 10.3390/ijerph17186886

The Effectiveness of Patient-Centred Medical Home-Based Models of Care versus Standard Primary Care in Chronic Disease Management: A Systematic Review and Meta-Analysis of Randomised and Non-Randomised Controlled Trials

James Rufus John 1,2,*, Hir Jani 1, Kath Peters 3, Kingsley Agho 1,4, W Kathy Tannous 1,5
PMCID: PMC7558011  PMID: 32967161

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.

Keywords: patient-centred medical home, enhanced primary care, chronic disease management, collaborative care, meta-analysis

1. Introduction

Chronic diseases have contributed to increased mortality and morbidity worldwide with the disease burden accelerating across both developed and developing nations [1,2]. The Global Burden of Diseases (GBD) Study in 2017 reported that chronic diseases accounted for 41% of increased disability and 73% of all deaths [1,2]. Moreover, with increasing life expectancy and ageing population, the global prevalence of multiple chronic conditions or multimorbidity is also on the rise, further exacerbating complications in quality and delivery of care [3,4]. As a result, 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 also 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].

The long-term nature of chronic diseases and complexities of care require health care systems, worldwide, to revisit guidelines on effective chronic disease management [7]. The health and economic repercussions of chronic diseases are partly connected to the fragmented design and delivery of health care systems to focus on “single disease framework” as opposed to a “whole-person approach” [9]. However, 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]. In view of this, 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]. There is a large body of evidence suggesting that coordinated team-based approaches in primary care are effective in chronic disease management [13,14].

The patient-centred medical home (PCMH) model is one of the chronic care models (CCM) that has reportedly shown to provide a multidimensional solution to effectively managing chronic illness and multimorbidity in primary care [15]. This enhanced primary care model typically consists of a general practitioner (GP)-led care, as part of a multidisciplinary team (MDT) that aims to provide patient-centred care that is also comprehensive and coordinated, with emphasis on self-management and patient education [12]. There is a growing body of literature, particularly in United States and several parts of United Kingdom and other European countries, reporting the effectiveness of PCMH care models in improving biomedical [16,17], HRQoL [18,19], hospital [20,21], and economic outcomes [22] compared to standard GP care.

A comprehensive systematic review and meta-analysis of PCMH care published in 2013 [23] reported improvements in patient experiences and some reduction in health utilisation among patients with multimorbidity. However, the effect of PCMH models on patients with single-disease care management was not reviewed. Whilst the review focuses on clinical quality and processes of care, there was insufficient evidence to estimate biomedical outcomes and quality of life. In addition, the review also included patients from non-primary care settings such as tertiary care hospitals, thereby limiting understanding of the true effectiveness of PCMH model in primary care settings. The current review was warranted as there has been increased advocacy for PCMH-based care models resulting in a number of new studies evaluating PCMH models being published since 2013 [18,19,20,21].

A systematic review and meta-analysis was conducted to assess the effectiveness of PCMH-based models of care when compared to standard GP care in improving biomedical, hospital, and economic outcomes of primary care patients with one or more chronic diseases. The findings of this review may help inform guidelines and practices.

2. Methods

This review conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [24]. The systematic review protocol (CRD42018085378), registered in the International Prospective Register of Systematic Reviews (PROSPERO) database, has been published elsewhere [25].

2.1. Search Strategy

We conducted literature searches on electronic databases including MEDLINE, CINAHL, Embase, Cochrane library, and Scopus from inception until 31 March 2020. The search strategy and syntaxes were developed in collaboration with an experienced university librarian. The syntax explored a broad range of terms used in definitions of PCMH, collaborative care, chronic care models, RCTs, and Quasi trials (full electronic search strings are listed in Table A1). We supplemented electronic searches by hand-searching bibliographies of several key systematic reviews [23,26,27,28] and retrieved studies to identify any relevant articles missed by the search strategy. Endnote (Version X9, Thompson Reuters, New York, NY, USA) software was used for reference management.

2.2. Eligibility Criteria and Study Selection

A detailed inclusion and exclusion criteria along with explanation of core PCMH principles is reported elsewhere [25]. A summary of Population, Interventions, Comparators, Outcomes, and Study designs (PICOS) framework is presented in Figure 1. Two reviewers (JRJ and KP) independently screened the titles and abstracts of all articles for eligibility. Following the title and abstract screening, a full text screening was conducted on articles which passed the title and abstract screening by two reviewers (JRJ and HJ) independently. Discrepancies were resolved and clarified through discussion.

Figure 1.

Figure 1

Summary of Population, Interventions, Comparators, Outcomes, and Study designs (PICOS) components. Outcomes included but not limited to patient, hospital, and economic outcomes.

2.3. Data Extraction

Data extraction of included articles was carried out independently by two reviewers (JRJ and HJ) using Excel spreadsheet (Microsoft Excel, Microsoft Corporation). Data extracted from included articles included key characteristics: first author and publication year; country of origin; sample size, age, and gender distribution; chronic disease profile; baseline characteristics reported as mean (SD) or proportions; PCMH components implemented; duration of follow-up; and outcomes. Whilst data extraction was performed using a customised spreadsheet, the Centre for Reviews and Dissemination’s (CRD) guidance for undertaking reviews in health care was followed [29]. Authors of studies with missing data were contacted by email up to two times; however, no response was received.

2.4. Quality Assessment and Risk of Bias

Two reviewers (JRJ and HJ) independently evaluated the methodological validity of included articles using relevant Joanna Briggs Institute (JBI) critical appraisal checklists (RCTs, quasi trials, and economic evaluations) [30,31]. Quality of studies were rated as good (≥8), fair (6–7), or poor (≤5) based on the summary scores. We also used risk of bias in non-randomised studies of interventions (ROBINS-I) tool to supplement JBI appraisal for non-randomised trials [32]. Additionally, the quality of evidence across included studies reporting similar outcomes was determined by applying the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria [33]. The overall GRADE quality of evidence from the tables takes into account three factors which include (i) the average quality across the studies for each particular outcome, (ii) the level of heterogeneity between the studies, and (iii) the total number of studies reporting a particular outcome.

2.5. Outcomes

Outcomes identified from the studies include changes in mean differences or proportion of patients achieving recommended levels in

  • (1).

    Biomedical outcomes—blood pressure (BP); glycated haemoglobin (HbA1c); low density lipoprotein cholesterol (LDL-C); high density lipoprotein cholesterol (HDL-C); and serum total cholesterol.

  • (2).

    Self-reported health assessments (using validated questionnaires)—depression; HRQoL (overall, mental and physical functioning components); and self-management.

  • (3).

    Health utilisation outcomes—hospital admissions; emergency department visits; and medications use.

  • (4).

    Economic outcomes—incremental cost-effectiveness ratio (ICER) which is defined as the difference in total cost of an intervention (compared to standard care) divided by the difference in health outcome measure [22].

2.6. Data Analysis

Data of included studies were pooled together using the inverse-variance method of random-effects meta-analysis [34]. Standardised mean differences (SMD) for continuous data and odds ratios (ORs) for dichotomous data, with 95% confidence intervals (CI), were calculated and graphically presented as forest plots. Statistical heterogeneity was calculated using I2 and Cochran’s Q statistics. Subgroup analyses were considered for outcomes with substantial heterogeneity (I2 ≥ 85%). Publication bias for outcomes with at least 6 studies was assessed using funnel plots and Egger’s test of asymmetry [35]. All analyses were conducted using RevMan version 5.3 (The Nordic Cochrane Centre, Copenhagen, Denmark) and R version 4.0 software (R Foundation for Statistical Computing, Vienna, Austria).

3. Results

3.1. Literature Search

The electronic database search resulted in 13,820 citations and an additional 16 citations from hand searching key systematic reviews. After exclusion of duplicate records, 6416 articles were screened by titles and abstracts with 201 articles determined to be eligible for full-text assessment. Of these, 85 studies met the eligibility criteria and were included in our systematic review. Flowchart of the selection process from initial identification to inclusion is shown in Figure 2. Main reasons for exclusion included patients treated in non-primary care settings, not meeting minimum PCMH components or focused on intervention other than PCMH model, lack of control group, and other reasons (list of excluded articles; see Table A2).

Figure 2.

Figure 2

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Flowchart.

3.2. Descriptive Data Synthesis

The characteristics of included studies are presented in the Appendix A Table A3 and Table A4. Of the 85 studies included in the review, 78 studies were RCTs [13,14,16,18,19,20,22,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106] and 7 studies were of non-RCTs, including quasi trials [17,21,107,108] or cohort studies with a control group [109,110,111]. The 85 studies enrolled a total of 60,617 patients with sample sizes ranging from 40 to 8366. Whilst 79 studies had sufficient data for quantitative data synthesis, 6 studies [81,85,95,97,103,107] did not have usable data and therefore, the findings were narratively summarised.

The common inclusion criteria for all 85 studies was primary care patients with diagnosis of one or more chronic conditions, whereas the predominant reason for exclusion was patients with cognitive impairment and terminal illness. In terms of the chronic disease profile of the participants in the included articles, 46% of articles were based on participants with single chronic condition whereas 54% reported on one or more conditions. The most prevalent conditions were mental illness (59%), type 2 diabetes (33%), cardiovascular diseases (CVD) including hypertension (20%), musculoskeletal disorders (6%), and chronic obstructive pulmonary disease (COPD) (6%) (Table A3 and Table A4).

More than half the studies (52%) were conducted in the United States. The mean age of patients ranged between 30 and 83 years. In terms of gender distribution, most of the studies had slightly more women than men, except for studies conducted in Veterans Affairs (VA) primary care settings [16,50,52,53,56]. The duration of follow-up varied from 3 to 48 months. Out of 85 articles included for review, in addition to MDT care, 95% of studies reported coordinated care, patient engagement and education, and self-management; 20% reported continuity of care and long-term patient provider relationship; and only 9% of studies included data driven quality of care (Table A3 and Table A4).

3.3. Quality Assessment and Risk of Bias

Quality assessment and risk of bias for individual studies are reported in the Appendix A Table A5, Table A6, Table A7, Table A8. The overall quality of studies ranged from “fair” to “good” by meeting at least 60% of items on the checklist. Two studies [62,104] were rated as poor due to general lack of information on randomisation, unclear methodology, and clarity of results. Given the nature of PCMH-based intervention, most trials employed a cluster randomisation method where a group of patients were seen by the same GP or same general practice providing PCMH care. Thereby, blinding of patients or GPs was not applicable and, as a result, items related to blinding were not necessarily graded down. However, only 32 studies reported blinding of outcome assessment whilst other studies were graded down in quality. The quality of evidence across included studies assessed using GRADE approach is presented in Table 1.

Table 1.

Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) assessment of randomised controlled trials reporting effectiveness of patient-centred medical home (PCMH) vs. standard general practitioner (GP) care on outcomes of interest.

Outcomes No of Studies Risk of Bias Inconsistency Indirectness Imprecision Publication Bias GRADE Quality of Evidence þ
Depression 31 Serious Serious Not serious Not serious Undetected Moderate
Quality of Life 21 Serious Not serious Not serious Not serious Undetected Moderate
Blood pressure 13 Serious Not serious Not serious Not serious Undetected Moderate
Glycated Hemoglobin 9 Serious Serious Not serious Not serious Undetected Low ‡¶
LDL Cholesterol 4 Serious Serious Not serious Not serious Undetected Low ‡¶
HDL Cholesterol 1 Serious - Not serious Not serious Undetected Low †‡^
Total Cholesterol 2 Serious - Not serious Not serious Undetected Low ‡^
Hospital admissions 5 Serious Not serious Not serious Not serious Undetected Moderate
Self-management (PACIC scores) 3 Serious Serious Not serious Not serious Undetected Low ‡¶
Cost-effectiveness 19 Serious Serious Not serious Not serious Undetected Low ‡¶

þ High quality: Further research is very unlikely to change our confidence in the estimate of effect; Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate; Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate; Very low quality: We are very uncertain about the estimate; LDL—Low Density Lipoprotein; HDL—High Density Lipoprotein; PACIC—Patient Assessment of Care for Chronic Conditions; Most studies did not blind participants or personnel as it was not practical. Therefore, we did not downgrade for these risks/uncertainties. However, studies not reporting blinding of outcome assessment were downgraded in quality; Significant level of heterogeneity within results (I2 between 80–90%); ^ Single study—Inconsistency not applicable; Because of the nature of the quasi-experimental designs risk of bias is unavoidable.

3.4. Depression Outcomes

Meta-analysis of thirty-one studies [13,14,18,19,36,38,40,42,43,46,50,51,53,55,57,63,67,68,70,76,78,83,84,86,87,88,91,93,100,102,109] of patients with minor or major depression episodes after PCMH-based care reported significant improvement in depression scores compared to patients with standard primary care. With the exceptions of three studies [46,91,102], twenty-two studies reporting changes in mean differences (continuous data) of depression scores showed significant reduction with a pooled SMD of −0.24 (95% CI −0.35, −0.14; p-value < 0.001) (Figure 3).

Figure 3.

Figure 3

Forest plots of depression outcomes between the PCMH care and Standard GP care.

Six studies reported that PCMH care was associated with significantly increased odds of remission of depression with pooled OR 1.79 (95% CI 1.46, 2.21; p-value < 0.001) (Figure 3). Additionally, one other study [85] reported significant improvements among patients with anxiety and mood disorders with an effect size of 0.30 (95% CI 0.05, 0.55; p-value = 0.02) compared to standard care. Given most studies consistently reported improvements, the GRADE of evidence was classified as moderate quality (Table 1).

3.5. Quality of Life Outcomes

Twenty-two studies [18,19,21,22,41,46,49,50,51,53,59,68,72,76,86,89,91,100,102,105,106,108] evaluated the effectiveness of PCMH-based care on HRQoL (overall, physical component and mental component). Patients enrolled in PMCH-based care reported small but significant improvements in HRQoL compared to standard care with a pooled SMD of 0.10 (95% CI 0.04, 0.15; p-value < 0.001) (Figure 4). Additionally, one other study [85] reported significant improvements with an effect size of 0.38 (95 % CI 0.13, 0.63; p-value = 0.003). Moderate heterogeneity was observed among included studies (I2 = 57%), but test for sub-group differences were not significant. The GRADE of evidence was classified as moderate quality (Table 1).

Figure 4.

Figure 4

Forest plots of Quality of life (QoL) outcomes between the PCMH care and Standard GP care.

3.6. Blood Pressure Outcomes

Thirteen studies [16,17,39,42,45,61,64,68,71,82,90,94,96] reported on the effect of PCMH care on blood pressure outcomes. Six studies reported that PCMH care was associated with significantly increased odds of BP control with pooled OR 2.03 (95% CI 1.56, 2.65; p-value < 0.001) (Figure 5). Seven studies reported significant improvements in systolic blood pressure (SBP), in favour of PCMH care, with pooled estimates of SMD −0.15 (95% CI −0.29, −0.01; p-value = 0.03). Similar reduction was observed across five studies reporting on diastolic blood pressure (DBP), but the pooled estimate of SMD −0.12 (95% CI −0.27, 0.02; p-value = 0.09) failed to meet significance (Figure 5). The GRADE of evidence was classified as moderate quality (Table 1).

Figure 5.

Figure 5

Forest plots of blood pressure outcomes between the PCMH care and Standard GP care. BP control refers to blood pressure levels within the guideline’s recommended range.

3.7. Glycated Haemoglobin Outcomes

Ten studies [16,17,39,43,64,68,71,77,82,96] reported on the effect of PCMH care on HbA1c outcomes. HbA1c levels were recorded among patients with a positive diagnosis of Type 2 diabetes. Three studies reported that PCMH care was associated with increased odds of glycaemic control with pooled OR 2.37 (95% CI 0.86, 6.51; p-value = 0.100). However, the pooled estimate was not statistically significant (Figure 6). The substantial heterogeneity of 87% in the three studies reporting ORs was due to a shorter follow-up duration of three months reported by Bogner et al. [43] compared to the other two studies which had follow-up duration of 12 to 13 months. Seven studies reported significant improvements in HbA1c, in favour of PCMH care with pooled estimates of SMD −0.26 (95% CI −0.43, −0.08; p-value = 0.004) (Figure 6). Given the substantial amount of heterogeneity, the GRADE of evidence was classified as low quality (Table 1).

Figure 6.

Figure 6

Forest plots of HbA1c outcomes between the PCMH care and Standard GP care. HbA1c control refers to HbA1c levels within the guideline’s recommended range.

3.8. Cholesterol Outcomes

For LDL-cholesterol outcomes, five studies [17,64,68,71,96] reported significant improvements in favour of PCMH care with pooled SMD of −0.16 (95% CI −0.33, −0.00; p-value = 0.05) compared to standard GP care. Test for subgroup difference between follow-up and change scores showed no statistical significance (I2 = 16.8%, p-value = 0.27) (Figure 7A). For total cholesterol outcomes, two studies [17,82] reported a non-significant increase in total cholesterol with a pooled SMD of 0.07 (95% CI −0.08, 0.23; p-value = 0.34) (Figure 7B). The GRADE of evidence of both LDL and total cholesterol outcomes were classified as low quality given the limited number of studies (Table 1).

Figure 7.

Figure 7

Forest plots of (A) LDLcholesterol and (B) Total cholesterol outcomes between the PCMH care and Standard GP care.

3.9. Hospital Admissions

Five studies [20,21,48,54,111] reported that PCMH care was associated with significant reduction in hospital admissions compared to standard care with pooled OR 0.83 (95% CI 0.70, 0.98; p-value = 0.02) (Figure 8). Additionally, one study [110] reported a reduction in mean hospital admission rates related to diabetic complications 12 months after PCMH based care compared to standard care. Nonetheless, the change in mean difference failed to meet statistical significance. The GRADE of evidence was classified as moderate quality (Table 1).

Figure 8.

Figure 8

Forest plot for hospital admissions between PMCH care and Standard GP care.

3.10. Self-Management Outcomes

Three studies [14,72,89] reported significant improvements in self-management scores in favour of PCMH care compared to standard care with pooled estimates of SMD 0.24 (95% CI 0.03, 0.44; p-value < 0.001) (Figure 9). Given the substantial amount of heterogeneity (I2 = 83%), the GRADE of evidence was classified as low quality (Table 1).

Figure 9.

Figure 9

Forest plots of self-management outcomes (Patient Assessment of Care for Chronic Conditions (PACIC) scores) between the PCMH care and Standard GP care.

3.11. Economic Outcomes

A total of 18 studies [13,22,37,44,46,52,58,59,60,65,66,69,73,79,80,92,98,108] reported cost-effectiveness of PCMH-based models of care compared to standard care. To avoid bias in analysis, all currencies were converted to US Dollars at the time of the respective trials and cost effectiveness was measured in terms of incremental cost of intervention. The incremental cost of PCMH care was small but significantly higher than standard care with a pooled estimate of 0.17 (95% CI 0.08, 0.26; p-value < 0.001) (Figure 10). The substantial heterogeneity of 81% was due to higher costs of intervention reported by Bosanquet et al. [46]. The GRADE of evidence was classified as low quality (Table 1).

Figure 10.

Figure 10

Forest plots of incremental cost of intervention between the PCMH care and Standard GP care.

A summary of results from meta-analyses (where possible) and individual studies from randomised and non-randomised controlled trials are presented in Table 2.

Table 2.

Summary of findings from meta-analyses (where possible) or individual studies from randomised and non-randomised controlled trials.

Outcome No of Studies No of Participants Effect Size (95% CI) p-Value Q Statistic I2 Egger’s Test
p-Value
Citations Figure
Randomised controlled trials
Depression 24
6
7255
1520
SMD −0.24 (−0.35, −0.14)
OR 1.79 (1.46, 2.21)
<0.001
<0.001
78.3
3.58
76%
0%
0.275
0.608
[13,14,18,19,36,38,40,42,43,46,50,51,53,55,57,63,67,68,70,76,78,83,84,86,87,88,91,93,100,102,109] Figure 3
Quality of Life 22 12,370 SMD 0.12 (0.09, 0.15) <0.001 57.38 51% 0.556 [18,19,21,22,41,46,49,50,51,53,59,68,72,76,86,89,91,100,102,105,106,108] Figure 4
Blood pressure
BP control 6 1202 OR 2.03 (1.56, 2.65) <0.001 5.30 6% 0.347 [16,39,42,45,61,64,68,71,82,90,94,96] Figure 5
Systolic BP 6 1947 SMD −0.08 (−0.17, 0.01) 0.09 8.97 44% 0.737
Diastolic BP 5 1836 SMD −0.12 (−0.27, 0.02) 0.10 7.82 49% 0.260
Glycated haemoglobin [16,39,43,64,68,71,77,82,96] Figure 6
Glycaemic control 3 726 OR 2.37 (0.86, 6.51) 0.001 15.00 87% NA
HbA1c 6 2044 SMD −0.21 (−0.30, −0.12) <0.001 27.75 82% 0.405
LDL Cholesterol 4 1086 SMD −0.25 (−0.37, −0.13) <0.001 1.64 0% NA [64,68,71,96] Figure 7A
Total Cholesterol 1 888 SMD 0.00 (−0.13, 0.13) 1.00 NA NA NA [82] Figure 7B
Hospital admissions 3 4770 OR 0.90 (0.80, 1.03) 0.12 0.67 0% NA [20,48,54] Figure 8
Self-management (PACIC scores) 3 2440 SMD 0.24 (0.03, 0.44) 0.02 11.48 83% NA [14,72,89] Figure 9
Cost-effectiveness 17 12,612 SMD 0.17 (0.07, 0.26) 0.001 87.84 82% 0.206 [13,22,37,44,46,52,58,59,60,65,66,69,73,79,80,92,98] Figure 10
Non-randomised trials
Depression 1 314 SMD −0.22 (−0.45, 0.01) 0.06 NA NA NA [109] Figure 3
Quality of Life 2 833 SMD −0.08 (−0.21, 0.06) 0.28 0.94 0% NA [22,108] Figure 4
Blood pressure Figure 5
Systolic BP 1 727 SMD −0.30 (−0.45, −0.16) <0.001 NA NA NA [17]
Glycated haemoglobin 1 727 SMD −0.20 (−0.35, −0.06) 0.006 NA NA NA [17] Figure 6
LDL Cholesterol 1 727 SMD 0.06 (−0.09, 0.20) 0.43 NA NA NA [17] Figure 7
HDL Cholesterol 1 727 SMD 0.15 (0.00, 0.29) 0.05 NA NA NA [17] -
Total Cholesterol 1 727 SMD 0.16 (0.01, 0.30) 0.04 NA NA NA [17] Figure 8
Hospital admissions 2 912 OR 0.63 (0.48, 0.83) 0.001 0.02 0% NA [21,111] Figure 9
Cost-effectiveness 1 358 SMD 0.19 (−0.01, 0.40) 0.07 NA NA NA [108] Figure 10

NA—not applicable; SMD—Standard Mean Difference; OR—Odds ratio; Egger’s test was conducted only for outcomes with at least 6 studies. Note: The slight discrepancy in the effect sizes in this table to that reported in the manuscript and figures is because the effects sizes are classified based on their study design. I2 describes the percentage of total variation across studies that is due to heterogeneity rather than chance. A value of 0% indicates no observed heterogeneity, and larger values show increasing heterogeneity.

3.12. Publication Bias

Six or more articles with similar outcomes were inspected for publication bias visually by using funnel plots and statistically by determining the significance from Egger’s test of asymmetry. Visual inspection of included studies reporting similar outcomes did not indicate any obvious sign of asymmetry (Figure 11 and Figure 12). Consistent with visual findings, no evidence of publication bias was detected with Egger’s test, as all outcomes had p > 0.05, showing evidence of funnel plot symmetry (Table 2).

Figure 11.

Figure 11

Funnel plots assessing asymmetry of depression, QoL, hospital admissions, and cost outcomes between the PCMH care and Standard GP care. (A)—Depression (SMD); (B)—Depression (OR); (C)—Quality of Life (SMD); (D)—Hospital admissions (OR); (E)—Direct costs.

Figure 12.

Figure 12

Funnel plots assessing asymmetry of biomedical outcomes between the PCMH care and Standard GP care. (A)—Blood pressure (SMD); (B)—Systolic blood pressure (OR); (C)—Diastolic blood pressure (SMD); (D)—HbA1C (OR); (E)—LDL cholesterol.

4. Discussion

4.1. Summary of Findings

This systematic review comprehensively summarised current evidence on the effectiveness of PCMH-based models on chronic disease management among primary care patients. Compared to standard GP care, PCMH-based care led to significant improvements in depression episodes, quality of life, HbA1c, LDL cholesterol, hospital admissions, and self-management outcomes. Whilst PCMH care was significantly associated with increased odds of blood pressure control, reductions in both pooled estimates of SBP and DBP were not statistically significant. In contrast, the findings suggest that PCMH-based interventions have higher costs and was not cost-effective when compared to standard care. Additionally, the narrative synthesis of studies also corroborated with pooled estimates of the meta-analyses.

4.2. Consistency with Other Systematic Reviews

The most commonly reported PCMH principles in the included studies were patient engagement through education and self-management, and care coordination in addition to team-based care. Findings of this review, underscoring these PMCH elements in primary care, are consistent with previous systematic reviews reporting quality of care and overall patient experiences [26,112]. In terms of study outcomes, depression and HRQoL were frequently reported outcomes in the included studies. Systematic reviews focusing on depression outcomes as a result of collaborative care reported similar improvements, which were consistent with our pooled estimates of SMDs and ORs [113,114]. Similarly, our review showed small but significant improvements in the self-reported HRQoL and self-management scores, which is consistent with previous reviews [115,116]. Variabilities in the duration of intervention and baseline severity of chronic illness may explain smaller pooled estimates of HRQoL outcome.

Changes in biomedical outcomes are common measures employed in evaluating the effectiveness of chronic disease management interventions. With the exception of total cholesterol outcomes, findings of our studies were consistent with previous reviews [117,118], showing improvements in biomedical outcomes in favour of PCMH-based care compared to standard care. In terms of cost-effectiveness of PCMH-based models, some meta-analytic reviews on economic evaluations showed that PCMH care was associated with decreases in total costs compared to standard care [119,120]. However, our review supports evidence from prior reviews [115,121], suggesting that PCMH-based care was not associated with improvement in cost outcomes compared to standard care. This discordance could be due to the variability in the initial and sustained amount of costs incurred as a result of additional staffing and other infrastructure as well as the sample of patients and their comorbidity profile in the included trials [121].

4.3. Strengths and Limitations

Quality assessment for risk of bias was assessed within and across studies of similar outcomes. As aforementioned, blinding of patients and GPs was not possible due to the nature of intervention and design of trials, as reported in other systematic reviews conducted in primary care settings [114,122]. A substantial amount of heterogeneity was observed for measures of depression, HbA1c, and incremental cost of intervention, justifying the choice of random effects model. Higher heterogeneity is expected when pooling results of complex interventions, given the varying levels of intensity of different interventions, follow-up times, chronic disease profile of participants, and country’s primary care setting [115]. Nonetheless, pooled estimates are to be interpreted with caution given unexplained variation observed in outcomes with higher heterogeneity. The review did not consider unpublished data or non-English language studies given the exhaustive number of citations identified. This may have had potential impact on effect size estimates.

Whilst previous reviews and meta-analyses on collaborative care for either single specific disease or multimorbidity have been studied, this review provides a comprehensive current evidence with quantitative synthesis on the effectiveness of PCMH-based care models exclusively on primary care patients with one or more chronic diseases. Other strengths include a registered and published protocol, with a peer-reviewed search strategy, conducted on a wide range of electronic databases.

4.4. Patient, Provider, and Policy-Level Implications and Future Directions

Findings of our systematic review have important implications at patient, practice, and policy-level. The evidence may inform patients on the enhanced biomedical outcomes and quality of life resulting from improved education and self-management support. The transformational changes at practice level may enable GPs to better target and deliver care according to the level and complexity of different patients [123]. Additionally, our study findings may also impact policy and implementation guidelines given the growing advocacy towards patient-centred care. Future research should focus on evaluating sustained benefits of PCMH-based care as well as supporting holistic experiences of patients receiving patient-centred care.

5. Conclusions

Current evidence suggests that PCMH-based care showed significant improvements in depression, HRQoL, self-management, biomedical, and health utilisation outcomes compared to standard GP care. Whilst studies included for pooled estimates showed consistent trend for several outcomes, high heterogeneity in some outcomes resulted in low to moderate grade of evidence, limiting firmer conclusion from the pooled evidence. Further research is needed to evaluate the long-term cost-effectiveness of PCMH-based care after the initial higher costs incurred for intervention, which may prove to be more cost-effective than standard care.

Acknowledgments

The authors would like to express their gratitude to Katrina Chaudhary (Librarian, School of Science and Health, Western Sydney University) and Lily Collison (Librarian, School of Medicine, Western Sydney University) for their help in developing search terms and guidance during the initial search process. We are also particularly grateful to Evan Atlantis for his valuable expertise and feedback provided for this study.

Appendix A

Table A1.

Search strategy.

No Search Terms
1 PCMH.tw.
2 (patient-centred adj medical adj home *).tw.
3 (patient adj centred adj medical adj home *).tw.
4 (patient-centered adj medical adj home *).tw.
5 (patient adj centered adj medical adj home *).tw.
6 (Medical adj home *).tw.
7 (Home adj based adj care).tw.
8 (home adj based adj model).tw.
9 (Health adj home *).tw.
10 (Health adj care adj home *).tw.
11 (Health-care adj home *).tw.
12 (Patient adj centred adj care).tw.
13 (Patient-centred adj care).tw.
14 (Patient adj centered adj care).tw.
15 (Patient-centered adj care).tw.
16 (Patient adj focused adj care).tw.
17 (Patient-focused adj care).tw.
18 (Integrated adj primary adj care).tw.
19 (Integrated adj care).tw.
20 (Integrated adj health adj care).tw.
21 (Integrated adj service *).tw.
22 (Integrated adj delivery).tw.
23 (Team-based adj care).tw.
24 (multidisciplinary adj care *).tw.
25 (care adj team).tw.
26 (care adj coordination).tw.
27 (coordinated adj care).tw.
28 (coordinated adj health adj care).tw.
29 (coordinated adj primary adj care).tw.
30 (collaborative adj practice).tw.
31 (Collaborative adj care).tw.
32 (Advanced adj primary adj care).tw.
33 (enhanced adj primary adj care).tw.
34 (augmented adj care).tw.
35 (augmented adj service *).tw.
36 (guided adj care).tw.
37 (chronic adj care adj model *).tw.
38 (Patient adj aligned adj care adj team).tw.
39 (patient adj care adj team).tw.
40 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39
41 (primary adj health adj care).tw.
42 (family adj practice *).tw.
43 (primary adj care *).tw.
44 (community adj network *).tw.
45 (health adj care adj coalitions).tw.
46 (chronic adj care *).tw.
47 (primary adj physician *).tw.
48 (primary adj care adj physician *).tw.
49 (general adj practice *).tw.
50 (general adj physician *).tw.
51 (general adj practitioner *).tw.
52 (community adj based adj provider *).tw.
53 (community adj practice).tw.
54 (community adj care).tw.
55 (preventive adj service *).tw.
56 (patient adj care).tw.
57 Adult *.tw.
58 (middle adj age *).tw.
59 geriatric.tw.
60 (geriatric adj practice).tw.
61 elder *.tw.
62 exp Chronic Disease/
63 (Chronic adj disease *).tw.
64 (Chronic adj illness *).tw.
65 exp COMORBIDITY/
66 comorbid *.tw.
67 multimorbid *.tw.
68 exp Diabetes Mellitus/
69 ((Diabetes adj mellitus) or Diabet *).tw.
70 exp ASTHMA/
71 Asthma *.tw.
72 exp ARTHRITIS/
73 Arthritis.tw.
74 exp Back Pain/
75 (Back adj pain).tw.
76 exp Cardiovascular Diseases/
77 (cardiovascular adj disease *).tw.
78 (Heart adj disease *).tw.
79 exp Neoplasms/
80 cancer *.tw.
81 (malignant adj neoplasm *).tw.
82 exp Pulmonary Disease, Chronic Obstructive/
83 (chronic adj obstructive adj pulmonary adj disease).tw.
84 (respiratory adj disease *).tw.
85 exp Kidney Diseases/
86 (Kidney adj disease *).tw.
87 41 or 42 or 43 or 44 or 45 or 46 or 47 or 48 or 49 or 50 or 51 or 52 or 53 or 54 or 55 or 56 or 57 or 58 or 59 or 60 or 61 or 62 or 63 or 64 or 65 or 66 or 67 or 68 or 69 or 70 or 71 or 72 or 73 or 74 or 75 or 76 or 77 or 78 or 79 or80 or 81 or 82 or 83 or 84 or 85 or 86
88 40 and 87
89 Randomized Controlled Trials as Topic/
90 (Randomized adj controlled adj trial *).tw.
91 (Randomised adj controlled adj trial *).tw.
92 (Clinical adj Trial *).tw.
93 Random adj allocat *
94 (Clinical adj trial).pt.
95 (Controlled adj trial *).tw.
96 89 or 90 or 91 or 92 or 93 or 94 or 95
97 88 and 96
98 limit 97 to (English language and humans)

* represents wildcard symbol that broadens a search by finding words that start with the same letters.

Table A2.

List of excluded articles from full-text screening stage with an overarching reason.

Articles Number of Articles Overarching Reason for Exclusion
(Aguiar, 2016; Bartels, 2004; Battersby, 2013; Bekelman, 2015; Berry, 2016; Brunisholz, 2017; Casas, 2006; de Stampa, 2014; Druss, 2001; Fors, 2015; Gjerdingen, 2009; Grochtdreis, 2018; Gums, 2016; Gums, 2014; Jakobsen, 2017; Jiao, 2014; Joubert, 2008; Kane, 2016; King, 2019; Ku, 2015; Peikes, 2009; Pourat, 2019; Schillinger, 2009; Siaw, 2018; Speyer, 2016; Walker, 2014; Wolff, 2010; Yoon, 2016; Yuting, 2017; Zatzick, 2015) 30 Participants: Patients less than 18 years; patients recruited and treated in a non-primary care setting; patients diagnosed with a communicable disease.
(Adam, 2010; Anderson, 2009; Borgermans, 2009; Campbell-Sills, 2016; Counsell, 2007; Eggers, 2018; Grunfeld, 2013; Ishani, 2016; Liu, 2003; Oosterbaan, 2013; Raftery, 1996; Rinfret, 2009; Rothman, 2005; Tao, 2015; Uittenbroek, 2017; Vermunt, 2012) 16 Intervention: Does not meet the PCMH definition or not sufficient components of PCMH or more focus on other intervention than PCMH model.
(Anjara, 2019; Bauer, 2019; Callahan, 2006; Ell, 2010; Hedrick, 2003; Jaen, 2010; Kearns, 2017; Kuhmmer, 2016; Meredith, 2016; Meulepas, 2007; Moran, 2011) 11 Comparison: Does not have a comparison group or comparison group received some amount of intervention other than standard care.
(Dwight-Johnson, 2010; Gill, 2017; Griffiths, 2016; Harpole, 2005; Marsteller, 2010; Marsteller, 2013) 6 Irrelevant outcomes
(Areán, 2005; Areán, 2007; Boland, 2015; Boult, 2013; Boyd, 2010; Buist-Bouwman, 2005; Campbell-Scherer, 2018; Chan, 2011; Conn, 2005; Ell, 2012; Ell, 2011; Fann, 2009; Ford, 2019; Fortney, 2014; Gensichen, 2006; Gilbody, 2007; Goering, 2003; Goertz, 2016; Hegel, 2005; Hendricks, 2016; Hirsch, 2014; Houles, 2010; Hunkeler, 2006; Jansen, 2017; Katon, 2006; Katon, 2003; Khambaty, 2015; Kinder, 2006; Kindy, 2003; Kumar, 2005; Lewis, 2017;Lin, 2014; McCusker, 2019; McGregor, 2011; Menchetti, 2013; Mills, 2003; Pieters, 2002; Price, 2004; Romano, 2011; Ruescas-Escolano, 2014; Sepers, 2015; Slimmer, 2003; Spoorenberg, 2016; Stone, 2010; Turner, 2011; Uittenbroek, 2017; Unutzer, 2001; Unutzer, 2006; Upchurch, 2005; Vester, 2019; Wang, 2011; Williams Jr, 2004; Zulman, 2015) 53 Other reasons: Non-English, conference abstracts, secondary data analyses using same sample, duplicate with different title, design and early implementation experiences paper, thesis, commentary, same outcome with same sample but different follow-up times.

Table A3.

Characteristics of randomised controlled trials reviewed.

Chronic Physical Conditions—Baseline Characteristics (Risk Proportion/Mean or Median and SD) Outcomes
Authors and Year of Publication Country of Origin Sample Size (N) Mean Age/Age Groups Gender Distribution
(Female)
Chronic Disease Profile of the Sample Population Treatment Group Control Group PCMH Components Duration of Follow-up Depression Quality of Life/Self-Management Hospital Admission Cost/Health Utility Biomedical Outcomes
Alexopoulos et al., 2009 [36] United States Treatment = 320
Control = 279
Overall ≥ 60 years (mean not reported) Overall = 71.6% Major or minor depression according to DSM-IV criteria HAM-D score = 18.61 (6.12)
Prevalence of suicide ideation = 27.5%
HAM-D score = 17.51 (5.82)
Prevalence of suicide ideation = 18.6%
Team based care;
Co-ordinated care
24 months
Aragonès et al., 2014 [18] Spain Treatment = 189
Control = 149
Overall = 47 years Overall = 80% Moderate or severe major depressive episode or minor depression PHQ-9 score = 18.10 (5.20)
SF12 mental health = 22.26 (9.05)
SF12 physical health = 47.47 (10.98)
PHQ-9 score = 17.66 (4.79)
SF12 mental health = 22.73 (10.44)
SF12 physical health = 48.23 (11.23)
Team based care;
Co-ordinated care;
Patient engagement;
Continuity of care.
36 months
Aragonès et al., 2014
(Cost-effectiveness) [37]
Spain Treatment = 189
Control = 149
Overall = 47 years Overall = 80% Moderate or severe major depressive episode or minor depression Total direct costs—776.30 (664.10)
Total indirect costs—718.30 (1587.70)
Total direct costs—593.80 (603.10)
Total indirect costs—743.40 (1582.10)
Team based care;
Co-ordinated care;
Patient engagement;
Continuity of care.
36 months
Aragonès et al., 2019 [38] Spain Treatment = 167
Control = 161
Treatment = 61.4
years
Control = 59.3 years
Treatment = 82.6%
Control = 83.2%
Major depressive episode and experiencing moderate or severe musculoskeletal pain. HSCL-20 score; mean (SD) = 1.67 (0.80)
BPI score; mean (SD) = 6.45 (1.87)
HSCL-20 score; mean (SD) = 1.69 (0.68)
BPI score; mean (SD) = 6.60 (1.77)
MDT care,
Patient engagement
Coordinated care,
Continuity of care
12 months
Barcelo et al., 2010 [39] Mexico Treatment = 196
Control = 111
6% of <40 years; 54% of 40–59 years; and 42% of ≥60 years NA (baseline stratified by gender) Type 2 Diabetes % with HbA1c (<7%)
Cases: Baseline—27.6%
% with HbA1c (<7%)
Control: Baseline—20.7%
MDT care,
All other components of CCM
13 months
Bjorkelund et al., 2018 [40] Sweden Treatment = 192
Control = 184
Treatment = 40.8 years
Control = 41.6 years
Treatment = 68.2%
Control = 74.5%
Mild or moderate Depression MADRS-S Mean (SD) = 20.8 (7.2)
BDI-II Mean (SD) = 23.9 (8.7)
EQ5D Mean (SD) = 0.58 (0.24)
MADRS-S Mean (SD) = 21.9 (7.1)
BDI-II Mean (SD) = 25.1 (8.5)
EQ5D Mean (SD) = 0.56 (0.25)
MDT care,
Patient engagement
Coordinated care
6 months
Blom et al., 2016 [41] Netherlands Treatment = 3145
Control = 4133
Treatment = 80.5 years
Control = 81.3 years
Treatment = 60.9%
Control = 61.7%
Depression with complex daily functioning problems Cantri’s ladder median (range) = 7 (6–8)
GARS total score median (range) = 36 (27,45)
BADL subscale score median (range) = 11 (9,15)
IADL subscale score median (range) = 18 (25,30)
Cantri’s ladder median (range) = 7 (6–8)
GARS total score median (range) = 37 (29,46)
BADL subscale score median (range) = 11 (9,15)
IADL subscale score median (range) = 20 (26,32)
MDT care,
Self-management plans,
Coordinated care
12 months
Bogner et al., 2008 [42] United States Treatment = 32
Control = 32
Treatment = 59.7 years
Control = 57.5 years
Treatment = 75%
Control = 78.1%
Depression and hypertension CES-D mean score (SD) = 17.5 (13.2)
SBP, mean (SD) = 146.7 (20.9)
DBP, mean (SD) = 83.0 (10.7)
CES-D mean score (SD) = 19.6 (14.2)
SBP, mean (SD) = 143.1 (22.5)
DBP, mean (SD) = 81.4 (11.1)
MDT care,
Patient engagement
6 weeks
Bogner et al., 2012 [43] United States Treatment = 92
Control = 88
Treatment = 57.8 years
Control = 57.1 years
Treatment = 70%
Control = 66%
Type 2 Diabetes, current prescription for antidepressant. HbA1c, mean (SD) = 7.2 (1.8)
PHQ-9 score, mean (SD) = 10.6 (7.9)
HbA1c, mean (SD) = 7.0 (1.9)
PHQ-9 score, mean (SD) = 9.9 (7.2)
MDT care,
Patient engagement
12 weeks
Boland et al., 2015 [44] Netherlands Treatment = 554
Control = 532
Treatment = 68.2 years
Control = 68.4 years
Treatment = 49.5%
Control = 42.7%
Chronic obstructive pulmonary disease according to GOLD (Global Initiative for COPD) guidelines. CCQ score, mean (SD) = 1.54 (0.98) CCQ score, mean (SD) = 1.46 (0.96) MDT care,
Self-management plans,
Coordinated care
24 months
Borenstein et al., 2003 [45] United States Treatment =98
Control = 99
Treatment = 62.5 years
Control = 61.5 years
Treatment = 63.2%
Control = 58.5%
Hypertension Mean SBP = 162
Mean DBP = 92
(no SD or 95% CI reported)
Mean SBP = 156
Mean DBP = 90
(no SD or 95% CI reported)
MDT care
Patient education
12 months
Bosanquet et al. 2017 [46] United Kingdom Treatment = 198
Control = 217
Treatment = 72 years
Control = 72 years
Treatment = 59%
Control = 63%
Depression PHQ-9 score Mean (SD) = 12.3 (5.43) PHQ-9 score Mean (SD) = 12.0 (5.32) MDT care,
Self-management plans,
Coordinated care
18 months
Boult et al., 2008 [47] United States Treatment = 485
Control = 419
Treatment = 77.2 years
Control = 78.1 years
Treatment = 54.2%
Control = 55.4%
Multimorbidity (specific conditions not reported) PACIC aggregate score = 5.9 PACIC aggregate score = 2.9 MDT care,
Self-management plans,
Coordinated care
6 months
Boult et al., 2011 [48] United States Treatment = 446
Control = 404
Treatment = 77.1 years
Control = 77.8 years
Treatment = 54.3%
Control = 55.7%
Circulatory system disorders, musculoskeletal disorders, Type 2 Diabetes, and cancers No. of chronic diseases, mean (range) = 4.3 (1–11) No. of chronic diseases, mean (range) = 4.3 (0–12) MDT care,
Self-management plans,
Coordinated care
6 months
Callahan et al., 2005 [49] United States Treatment = 906
Control = 895
Treatment = 71 years
Control = 71.4 years
Treatment = 64.1%
Control = 65.6%
Major depression and/or dysthymia SF-12 Mean (SD) = 40.43 (7.44)
IADL Mean (SD) = 0.68 (1.37)
SF-12 Mean (SD) = 40.11 (7.40)
IADL Mean (SD) = 0.61 (1.31)
MDT care,
Patient engagement
Coordinated care
12 months
Camacho et al., 2018 [13] United Kingdom Treatment = 191
Control = 196
Treatment = 57.9 years
Control = 59.2 years
Treatment = 41%
Control = 35%
Diabetes and/or coronary heart disease SCL-D13 Mean (SD) = 2.364 (0.696) SCL-D13 Mean (SD) = 2.330 (0.822) MDT care,
Patient engagement
Coordinated care
24 months
Campins et al., 2017 [20] Spain Treatment = 252
Control = 251
Treatment = 79.2 years
Control = 78.8 years
Treatment = 60.3%
Control = 57.4%
Patients with multimorbidity and polymedicated Medications Mean (SD) = 10.79 (2.52) Medications Mean (SD) = 10.91 (2.65) MDT care,
Patient engagement
Coordinated care
12 months
Chaney et al., 2011 [50] United States Treatment = 288
Control = 258
Treatment = 64 years
Control = 64.4 years
Treatment = 4.2%
Control = 3.5%
Subthreshold depression or dysthmia PHQ-9 score Mean (SD) = 15.5 (4.4)
SF-12 role physical score Mean (SD) = 29.2 (36.2)
SF-12 role emotional score Mean (SD) = 47.1 (41.4)
PHQ-9 score Mean (SD) = 15.7 (4.7)
SF-12 role physical score Mean (SD) = 34.8 (40.7)
SF-12 role emotional score Mean (SD) = 50.0 (41.8)
MDT care,
Patient engagement
Coordinated care
7 months
Cooper et al., 2013 [51] United States Treatment = 67
Control = 65
Treatment = 45.9 years
Control = 47 years
Treatment = 55%
Control = 50%
Major depressive disorder CESD score, mean (SD) = 29.52 (14.48)
MCS-12 score, mean (SD) = 35.97 (13.10)
CESD score, mean (SD) = 30.17 (13.78)
MCS-12 score, mean (SD) = 36.41 (12.19)
MDT care,
Patient engagement
Coordinated care
12 months
Coventry et al., 2015 [14] United Kingdom Treatment = 191
Control = 196
Treatment = 57.9 years
Control = 59.2 years
Treatment = 41%
Control = 35%
Diabetes and/or coronary heart disease SCL-D-13 Mean (SD) = 2.36 (0.70)
PHQ-9 Mean (SD) = 16.4 (4.2)
GAD-7 Mean (SD) = 12.3 (5.1)
SCL-D-13 Mean (SD) = 2.33 (0.82)
PHQ-9 Mean (SD) = 16.5 (4.1)
GAD-7 Mean (SD) = 11.9 (5.3)
MDT care,
Patient engagement
Coordinated care
4 months
Dickinson et al., 2010 [52] United States Treatment = 187
Control = 214
Treatment = 62.1 years
Control = 61.3 years
Treatment = 8%
Control = 8%
Musculoskeletal disorders with chronic pain RMDQ Mean (SD) = 14.9 (4.4)
Pain disability-free days 0–3 months = 31.3 (25.3)
RMDQ Mean (SD) = 14.5 (4.4)
Pain disability-free days 0–3 months = 30.0 (26.6)
MDT care,
Patient engagement
Coordinated care
12 months
Dobscha et al., 2009 [53] United States Treatment = 187Control = 214 Treatment = 62.1 years
Control = 61.3 years
Treatment = 8%
Control = 8%
Musculoskeletal disorders with chronic pain RMDQ Mean (SD) = 14.9 (4.4)
Current pain intensity, mean (SD) = 5.3 (2.2)
PHQ-9 score Mean (SD) = 8.1 (5.7)
RMDQ Mean (SD) = 14.5 (4.4)
Current pain intensity, mean (SD) = 5.1 (2.1)
PHQ-9 score Mean (SD) = 8.4 (6.0)
MDT care,
Patient engagement
Coordinated care
12 months
Dorr et al., 2008 [54] United States Treatment = 1144
Control = 2288
Treatment = 76.2 years
Control = 76.2 years
Treatment = 64.6%
Control = 64.6%
Circulatory system disorders, depression, and Type 2 Diabetes Hospitalizations Mean (SD) = 257 (22.5)
ED visits in previous year Mean (SD) = 407 (35.5)
Hospitalizations Mean (SD) = 514 (22.5)
ED visits in previous year = 807 (35.3)
MDT care,
Patient engagement
Coordinated care,
Data driven quality of care
24 months
Edelman et al., 2010 [16] United States Treatment = 133
Control = 106
Treatment = 63 years
Control = 60.8 years
Treatment = 4.5%
Control = 3.8%
Diabetes and hypertension HbA1c % Mean (SD) = 9.2 (1.3)
Mean SBP (SD) mmHg = 153.7 (14.8)
Mean DBP (SD) mmHg = 84.7 (12.1)
HbA1c % Mean (SD) = 9.2 (1.5)
Mean SBP (SD) mmHg = 153.7 (14.8)
Mean DBP (SD) mmHg = 84.7 (12.1)
MDT care,
Patient engagement
Coordinated care
12 months
Engel et al., 2016 [55] United States Treatment = 332
Control = 334
Treatment = 30.9 years
Control = 31.4 years
Treatment = 80%
Control = 82%
Posttraumatic Stress Disorder and Depression PTSD severity, mean (SD) = 29.4 (9.4)
SCL-20, mean (SD) = 2.1 (0.6)
PTSD severity, mean (SD) = 28.9 (8.9)
SCL-20, mean (SD) = 2.0 (0.7)
MDT care,
Patient engagement
Coordinated care,
Data driven quality of care
12 months
Fihn et al., 2011 [56] United States Treatment = 344
Control = 359
Treatment = 68.3 years
Control = 67.2 years
Treatment = 1.2%
Control = 3.6%
Circulatory system disorders—Angina SAQ anginal frequency score, mean (SD) = 52.8 (17.3) SAQ anginal frequency score, mean (SD) = 53.8 (16.5) MDT care,
Patient engagement
Coordinated care
12 months
Gilbody et al., 2017 [57] United Kingdom Treatment = 274
Control = 327
Treatment = 76.6 years
Control = 77.4 years
Treatment = 55.5%
Control = 62.4%
Subthreshold depression or dysthmia PHQ-9 score, mean (SD) = 7.6 (4.32)
Mean (SD) SF-12 score (physical component) = 38.5 (13.15)
PHQ-9 score, mean (SD) = 7.6 (4.55)
Mean (SD) SF-12 score (physical component) = 36.6 (13.11)
MDT care,
Self-management plans,
Coordinated care
12 months
Goorden et al., 2015 [58] Netherlands Treatment = 45
Control = 48
Treatment = 52 years
Control = 53 years
Treatment = 66.7%
Control = 72.9%
Major depressive disorder Mean (SD) utility score EQ5D = 0.54 (0.25) Mean (SD) utility score EQ5D = 0.56 (0.25) MDT care,
Patient engagement
Coordinated care,
Data driven quality of care
12 months
Green et al., 2014 [59] United Kingdom Treatment = 276
Control = 305
Overall = 44.8 years Overall = 71.9% Depressive episode according to ICD-10 Mean (SD) utility score EQ5D = 0.504 (0.288) Mean (SD) utility score EQ5D = 0.464 (0.313) MDT care,
Self-management plans,
Coordinated care
12 months
Grochtdreis et al., 2019 [60] Germany Treatment = 139
Control = 107
Treatment = 71.1 years
Control = 71.6 years
Treatment = 77%
Control = 79.4%
Depressive episode, recurring depressive disorder, or dysthmia according to ICD-10 EQ-5D-Index: mean (SD) = 0.55 (0.31)
PHQ-9-Index: mean (SD) = 10.67 (4.02)
Total costs: Mean (SD) = €2920 (€4425)
EQ-5D-Index: mean (SD) = 0.55 (0.31)
PHQ-9-Index: mean (SD) = 9.64 (3.62)
Total costs: Mean (SD) = €4222 (€7729)
MDT care,
Patient engagement
Coordinated care,
Continuity of care
12 months
Hirsch et al., 2014 [61] United States Treatment = 75
Control = 91
Treatment = 65.4 years
Control = 69.6 years
Treatment = 60%
Control =71 %
Diabetes and hypertension Systolic BP (mmHg)—mean (SD) = 134.8 (17.4)
Diastolic BP (mmHg)—mean (SD) = 75.1 (12.5)
Systolic BP (mmHg)—mean (SD) = 134.4 (16.5)
Diastolic BP (mmHg)—mean (SD) = 75.7 (13.4)
MDT care,
Patient engagement
Coordinated care
9 months
Hsu et al., 2014 [62] Taiwan Treatment = 789
Control = 271
NA NA Type 2 Diabetes Mean (SD) HbA1c % = 8.4 Mean (SD) HbA1c % = 8.6 MDT care,
Patient engagement
Coordinated care
42 months
Huijbregts et al., 2013 [63] Netherlands Treatment = 101
Control = 49
Treatment = 47 years
Control = 52.1 years
Treatment = 72.3%
Control = 73.5%
Major depressive disorder Mean (SD) PHQ-9 = 15.5 (4.8) Mean (SD) PHQ-9 = 14.8 (4.8) MDT care,
Patient engagement
Coordinated care,
Data driven quality of care
12 months
Ip et al., 2013 [64] United States Treatment = 147
Control = 147
Treatment = 55.5years
Control = 57.2 years
Treatment = 12%
Control = 12%
Type 2 Diabetes Mean (SD) HbA1c % = 9.5 (1.4)
Mean SBP (SD) mmHg = 128.9 (16.2)
Mean DBP (SD) mmHg = 73.9 (9.8)
Mean (SD) HbA1c % = 9.3 (1.5)
Mean SBP (SD) mmHg = 131 (14.8)
Mean DBP (SD) mmHg = 76.6 (11.6)
MDT care,
Patient engagement
Coordinated care
12 months
Johnson et al., 2016 [65] United States Treatment = 95
Control = 71
Treatment = 57 years
Control = 63.4 years
Treatment = 58%
Control = 40%
Type 2 Diabetes with depressive symptoms PHQ, mean (SD) = 14.5 (3.8) PHQ, mean (SD) = 14.2 (3.4) MDT care,
Patient engagement
Coordinated care
12 months
Katon et al., 1999 [67] United States Treatment = 114
Control = 114
Treatment = 47.2 years
Control = 46.7 years
Treatment = 67.5%
Control = 81.6%
Depression or anxiety SCL-depression mean (SD) = 1.9 (0.5) SCL-depression mean (SD) = 1.9 (0.5) MDT care,
Patient engagement
Coordinated care
6 months
Katon et al., 2004 [70] United States Treatment = 164
Control = 165
Treatment = 58.6 years
Control = 58.1 years
Treatment = 65.2%
Control = 64.8%
Diabetes and depression SCL-20 score, mean (SD) = 1.7 (0.51) SCL-20 score, mean (SD) = 1.6 (0.45) MDT care,
Patient engagement
Coordinated care
12 months
Katon et al., 2005 [69] United States Treatment = 906
Control = 895
Treatment = 71 years
Control = 71.4 years
Treatment = 64%
Control = 66%
Major depression and/or dysthymia Mean (SE) SCL-20 Depression Scores = 1.7 (0.6) Mean (SE) SCL-20 Depression Scores = 1.7 (0.6) MDT care,
Patient engagement
Coordinated care
24 months
Katon et al., 2010 [68] United States Treatment = 106
Control = 108
Treatment = 57.4 years
Control = 56.3 years
Treatment = 48%
Control = 56%
Diabetes, coronary heart disease, depression, and hypertension SCL-20 mean (SD) = 1.7 (0.6)
Glycated haemoglobin % mean (SD)= 8.1 (2.0)
LDL cholesterol mg/dl mean (SD)= 106.5 (35.3)
Systolic blood pressure mm Hg mean (SD)= 136 (18.4)
SCL-20 mean (SD) = 1.7 (0.6)
Glycated haemoglobin % mean (SD)= 8.0 (1.9)
LDL cholesterol mg/dl mean (SD)= 109.0 (36.5)
Systolic blood pressure mmHg mean (SD)= 132 (17.2)
MDT care,
Patient engagement
Coordinated care
12 months
Katon et al., 2012 [66] United States Treatment = 106
Control = 108
Treatment = 57.4 years
Control = 56.3 years
Treatment = 48%
Control = 56%
Diabetes and/or coronary heart disease SCL-20 mean (SD) = 1.7 (0.6)
PHQ-9 mean (SD) = 14.7 (3.8)
SBP mean (SD) = 136 (18.4)
HbA1c mean (SD) = 8.1 (2.0)
Outpatient costs in the previous 12 months, mean (95% CI), $ = 10,026 (8312–11,741)
Inpatient costs in the previous 12 months, mean (95% CI), $ = 3210 (1553–4868)
SCL-20 mean (SD) = 1.7 (0.6)
PHQ-9 mean (SD) = 13.9 (3.1)
SBP mean (SD) = 132 (17.2)
HbA1c mean (SD) = 8.0 (1.9)
Outpatient costs in the previous 12 months, mean (95% CI), $ = 9663 (8070–11,254)
Inpatient costs in the previous 12 months, mean (95% CI), $ = 2748 (1453–4043)
MDT care,
Patient engagement
Coordinated care,
Continuity of care
24 months
Konnopka et al., 2016 [22] Germany Treatment = 170
Control = 130
Treatment = 50.8 years
Control = 46.1 years
Treatment = 75%
Control = 75%
Depression and mild somatic symptom severity PHQ-15 score, mean (SD) = 12.6 (4.73)
SF-36 PCS, mean (SD) = 43.2 (9.1)
SF-36 MCS, Mean (SD) = 41.5 (10.2)
PHQ-15 score, mean (SD) = 12.7 (4.86)
SF-36 PCS, mean (SD) = 42.0 (8.9)
SF-36 MCS, Mean (SD) = 40.7 (11.4)
MDT care,
Patient engagement
Coordinated care
12 months
Krein et al., 2004 [71] United States Treatment = 123
Control = 123
Treatment = 61 years
Control = 61 years
Treatment = 2%
Control = 5 %
Type 2 Diabetes Haemoglobin A1C (%) = 9.3 (1.5)
LDL cholesterol (mg/dL) = 123 (37)
Systolic blood pressure (mm Hg) = 145 (21)
Diastolic blood pressure (mm Hg) = 86 (12)
Haemoglobin A1C (%) = 11 (9)
LDL cholesterol (mg/dL) = 9.2 (1.4)
Systolic blood pressure (mm Hg) = 123 (38)
Diastolic blood pressure (mm Hg) = 145 (20)
MDT care,
Patient engagement
Coordinated care
18 months
Kruis et al., 2014 [72] Netherlands Treatment = 554
Control = 532
Treatment = 68.2 years
Control = 68.4 years
Treatment = 50.5 %
Control = 57.3%
COPD according to GOLD (Global Initiative for COPD) guidelines. Mean (SD) CCQ score Total = 1.5 (1.0)
Mean (SD) SF-36 PCS = 38 (10.9)
Mean (SD) SF-36 MCS = 48.3 (10.5)
Mean (SD) PACIC score Total = 2.3 (0.9)
Mean (SD) CCQ score Total = 1.5 (1.0)
Mean (SD) SF-36 PCS = 38.6 (10.7)
Mean (SD) SF-36 MCS = 48.9 (10.3)
Mean (SD) PACIC score Total = 2.3 (0.9)
MDT care,
Patient engagement
Coordinated care
24 months
Leeuwen et al., 2015 [73] Netherlands Treatment = 3017
Control = 1354
Overall = 80.5 years Overall = 66.5% Multimorbidity (specific conditions not reported) with high frailty index EQ5D, mean (SD) = 0.60 (0.28) EQ5D, mean (SD) = 0.59 (0.29) MDT care,
Patient engagement
Coordinated care
24 months
Lin et al., 2000 [76] United States Treatment = 114
Control = 114
Treatment = 47.2 years
Control = 46.7 years
Treatment = 67.5 %
Control = 81.6%
Depression Sheehan Disability Scale = 5.4 (5.0–5.8)
SF-36 social functioning = 49.4 (44.6–54.2)
SF-36 Role limitation
due to emotional problems = 26.4 (21.1–31.7)
Sheehan Disability Scale = 5.3 (4.9–5.7)
SF-36 social functioning = 49.4 (44.6–54.2)
SF-36 Role limitation
due to emotional problems = 26.4 (21.1–31.7)
MDT care,
Patient engagement
Coordinated care,
Continuity of care
6 months
Lin et al., 2006 [74] United States Treatment = 506
Control = 495
Overall = 72 years Overall = 68.3% Major depression and/or dysthymia Mean (SD) arthritis pain severity = 6.1 (2.7)
Mean (SD) activity interference = 5.0 (3.2)
Mean (SD) HSCL score = 1.7 (0.6)
Mean (SD) arthritis pain severity = 6.1 (2.7)
Mean (SD) activity interference = 5.0 (3.2)
Mean (SD) HSCL score = 1.7 (0.6)
MDT care,
Patient engagement
Coordinated care
12 months
Lin et al., 2012 [75] United States Treatment = 90
Control = 91
Overall = 56.8 years Overall = 52.4% Diabetes and/or coronary heart disease Mean medication adherence
Oral hypoglycaemic drugs = 0.83 (0.19)
Antihypertensive = 0.85 (0.18)
Lipid lowering = 0.82 (0.21)
Antidepressant = 0.79 (0.23)
Mean medication adherence
Oral hypoglycaemic drugs = 0.83 (0.20)
Antihypertensive = 0.86 (0.18)
Lipid lowering = 0.85 (0.18)
Antidepressant = 0.80 (0.19)
MDT care,
Patient engagement
Coordinated care,
Continuity of care
12 months
Maislos et al., 2004 [77] Israel Treatment = 48
Control = 34
Treatment = 58 years
Control = 63 years
Treatment = 50 %
Control = 65%
Type 2 Diabetes Mean (SD) HbA1C, % = 11.6 (1.3) Mean (SD) HbA1C, % = 11.1 (1.1) MDT care,
Patient engagement
Coordinated care
6 months
Menchetti et al., 2013 [78] Italy Treatment = 128
Control = 99
Treatment = 50.1 years
Control = 53.9 years
Treatment = 78.9%
Control = 72.7%
Depression PHQ-9, Mean (SD) = 13.7 (4.7) PHQ-9, Mean (SD) = 12.8 (4.6) MDT care,
Patient engagement
Coordinated care
3 months
Metzelthin et al., 2015 [79] Netherlands Treatment = 103
Control = 91
Treatment = 77.5 years
Control = 76.8 years
Treatment = 55%
Control = 60%
Multimorbidity (specific conditions not reported) with high frailty index GARS 18–72 = 33.1 (11.5)
Mean EQ5D (SD) = 0.6 (0.2)
GARS 18–72 = 30.6 (10.6)
Mean EQ5D (SD) = 0.7 (0.2)
MDT care,
Patient engagement
Coordinated care
24 months
Morgan et al., 2015 [80] United States Treatment = 269
Control = 165
Treatment = 79.1 years
Control = 80.3 years
NA Dementia Charlson-Deyo index score Mean (SD) = 2.6 (2.4) Charlson-Deyo index score Mean (SD) = 1.8 (1.7) MDT care,
Patient engagement
Coordinated care
30 months
Muntingh et al., 2013 [19] Netherlands Treatment = 114
Control = 66
Treatment = 45 years
Control = 49 years
Treatment = 73%
Control = 61%
Panic and/or general anxiety disorders Anxiety score (BAI) mean (SD) = 24.59 (11.52)
Depression score (PHQ-9) mean (SD) = 9.40 (5.62)
MCS (SF-36) mean (SD) = 32.56 (11.26)
PCS (SF-36) mean (SD) = 48.43 (8.73)
EQ-5D score mean (SD) = 0.67 (0.17)
Anxiety score (BAI) mean (SD) = 20.04 (11.28)
Depression score (PHQ-9) mean (SD) = 8.98 (5.77)
MCS (SF-36) mean (SD) = 35.74 (13.00)
PCS (SF-36) mean (SD) = 47.75 (10.38)
EQ-5D score mean (SD) = 0.70 (0.14)
MDT care,
Patient engagement
Coordinated care
12 months
Pyne et al., 2003 [81] United States Treatment = 115
Control = 96
Treatment = 40 years
Control = 47 years
Treatment = 83.5%
Control = 85.4%
Major depressive disorder Mean mCES-D (SD) = 57.6 (18.5)
Mean VAS SF-36 (SD) = 0.453 (0.127)
Mean mCES-D (SD) = 50.8* (19.2)
Mean VAS SF-36 (SD) = 0.446 (0.160)
MDT care,
Patient engagement
Coordinated care
12 months
Ramli et al., 2016 [82] Malaysia Treatment = 471
Control = 417
Treatment = 58 years
Control = 57 years
Treatment = 62%
Control = 64%
Type 2 Diabetes HbA1c (%) = 8.4 (0.09)
% HbA1c (≤7%) = 15.3
HbA1c (%) = 8.4 (0.09)
% HbA1c (≤7%) = 17.0
MDT care,
Patient engagement
Coordinated care,
Data driven quality of care
12 months
Richards et al., 2008 [84] United Kingdom Treatment = 41
Control = 38
Treatment = 43 years
Control = 43 years
Treatment = 78%
Control = 76%
Depression Mean (SD) PHQ-9 = 17.5 (4.9) Mean (SD) PHQ-9 = 16.3 (4.5) MDT care,
Self-management plans,
Coordinated care;
Continuity of care
3 months
Richards et al., 2013 [83] United Kingdom Treatment = 276
Control = 305
Treatment = 45 years
Control = 44.5 years
Treatment = 73.2%
Control = 70.8%
Depression according to ICD-10 Mean (SD) PHQ-9 = 17.4 (5.2)
Mean (SD) GAD- 7 = 12.9 (5.3)
Mean (SD) SF-36 MCS = 23.2 (10.4)
Mean (SD) SF-36 PCS = 44.8 (12.4)
Mean (SD) PHQ-9 = 18.1 (5.0)
Mean (SD) GAD- 7 = 13.6 (4.7)
Mean (SD) SF-36 MCS = 22.3 (10.3)
Mean (SD) SF-36 PCS = 44.5 (12.3)
MDT care,
Self-management plans,
Coordinated care
12 months
Rollman et al., 2005 [86] United States Treatment = 116
Control = 75
Treatment = 44 years
Control = 45 years
Treatment = 84%
Control = 77%
Panic and/or general anxiety disorders Mean SIGH-A (SD) = 20.1 (6.4)
Mean PDSS (SD) = 8.4 (6.0)
Mean SF-12 MCS (SD) = 30.6 (8.8)
Mean SF-12 PCS (SD) = 43.8 (11.8)
Mean SIGH-A (SD) = 20.6 (6.4)
Mean PDSS (SD) = 8.5 (6.1)
Mean SF-12 MCS (SD) = 29.9 (10.5)
Mean SF-12 PCS (SD) = 45.1 (12.1)
MDT care,
Self-management plans,
Coordinated care
12 months
Rollman et al., 2017 [85] United States Treatment = 124
Control = 126
Treatment = 45 years
Control = 44.2 years
Treatment = 67%
Control = 68%
Panic and/or general anxiety disorders SF-36 MCS, mean (SD) = 27.4 (10.5)
SF-36 PCS, mean (SD) = 45.6 (12.1)
SIGH-A, mean (SD) = 28.4 (7.3)
PDSS, mean (SD) = 12.8 (6.8)
GADSS, mean (SD) = 15.9 (3.1)
PHQ-9, mean (SD) = 15.2 (5.1)
SF-36 MCS, mean (SD) = 28.7 (9.9)
SF-36 PCS, mean (SD) = 45.3 (11.7)
SIGH-A, mean (SD) = 28.1 (6.5)
PDSS, mean (SD) = 12.4 (6.4)
GADSS, mean (SD) = 15.7 (3.2)
PHQ-9, mean (SD) = 15.0 (5.1)
MDT care,
Self-management plans,
Coordinated care
24 months
Rollman et al., 2018 [87] United States Treatment = 302
Control = 101
Treatment = 43 years
Control = 42 years
Treatment = 81%
Control = 81%
Panic and/or general anxiety disorders SF-12 MCS, mean (SD) = 31.7 (9.4)
PROMIS Depression T-score, mean (SD) = 62.0 (6.3)
PHQ-9 score, mean (SD) = 13.4 (4.7)
SF-12 MCS, mean (SD) = 31.1 (9.3)
PROMIS Depression T-score, mean (SD) = 61.4 (6.4)
PHQ-9 score, mean (SD) = 13.1 (4.9)
MDT care,
Self-management plans,
Coordinated care
6 months
Rost et al., 2001 [88] United States Treatment = 209
Control = 223
Overall = 43 years Overall = 83.9% Major depressive disorder Mean mCESD = 56.9 Mean mCESD = 57.4 MDT care,
Coordinated care
6 months
Salisbury et al., 2018 [89] United Kingdom Treatment = 797
Control = 749
Treatment = 71 years
Control = 70.7 years
Treatment = 51%
Control = 50%
At least three types of chronic condition—Circulatory system disorders, musculoskeletal disorders, Type 2 Diabetes, cancers, and mental illnesses Mean (SD) EQ-5D-5L score = 0.574 (0.282)
Mean (SD) PACIC score =
Mean (SD) EQ-5D-5L score = 0.542 (0.292)
Mean (SD) PACIC score =
MDT care,
Self-management plans,
Coordinated care;
Continuity of care
15 months
Scherpbier-de Haan et al., 2013 [90] Netherlands Treatment = 99
Control = 75
Treatment = 73.9 years
Control = 72.4 years
Treatment = 62.2%
Control = 47.3%
Depression and/or hypertension Mean (SD) SBP = 142.7 (17.6)
Mean (SD) DBP = 74.9 (9.2)
Mean (SD) SBP = 142.5(15.1
)Mean (SD) DBP = 80.4 (8.2)
MDT care,
Self-management plans,
Coordinated care
12 months
Schnurr et al., 2013 [91] United States Treatment = 96
Control = 99
Treatment = 46.1 years
Control = 44.4 years
Treatment = 7%
Control = 10%
Posttraumatic Stress Disorder and Depression PTSD Diagnostic Scale mean (SD)= 33.2 (8.3)
Hopkins SCD mean (SD) = 1.98 (0.69)
SF-36 Mental Component mean (SD) = 33.8 (8.8)
SF-36 Physical Component mean (SD) = 42.2 (13.0)
PTSD Diagnostic Scale mean (SD)= 34.0 (9.7)
Hopkins SCD mean (SD) = 2.06 (0.78)
SF-36 Mental Component mean (SD) = 32.7 (8.1)
SF-36 Physical Component mean (SD) = 43.4 (12.6)
MDT care,
Self-management plans,
Coordinated care
6 months
Simon et al., 2001 [92] United States Treatment = 110
Control = 109
Overall = 47 years Treatment = 67%
Control = 82%
Depression Mean number of depression-free days was 87.7 (95%
CI = 76.6–96.7) for the collaborative care group
Mean number of depression-free days was 70.9 (95%
CI = 60.8–81.3) for the usual care group
MDT care,
Self-management plans,
Coordinated care
6 months
Simon et al., 2004 [93] United States Treatment = 198
Control = 195
Treatment = 44.7 years
Control = 44 years
Treatment = 74%
Control = 78%
Depression Mean (SD) SCL = 1.52 (0.58)
Mean PHQ (SD) = 14.6 (5.1)
Mean (SD) SCL = 1.55 (0.62)
Mean PHQ (SD) = 15.0 (5.5)
MDT care,
Self-management plans,
Coordinated care;
Continuity of care
6 months
Simpson et al., 2011 [94] Canada Treatment = 131
Control = 129
Treatment = 58.8 years
Control = 59.4 years
Treatment = 74%
Control = 75%
Type 2 Diabetes Mean (SD)SBP = 130.4 (14.9)
Mean (SD) DBP = 74.4 (10.0)
Mean (SD) SBP = 128.3 (15.7)
Mean (SD) DBP = 73.9 (10.8)
MDT care,
Coordinated care
12 months
Smith et al., 2004 [95] Ireland Treatment = 96
Control = 87
Treatment = 64.7 years
Control = 65.6 years
Treatment = 54%
Control = 57%
Type 2 Diabetes Mean (SD) HbA1c (%) = 6.85% (1.6) Mean (SD) HbA1c (%) = 6.6% (1.9) MDT care,
Coordinated care
12 months
Tang et al., 2013 [96] United States Treatment = 202
Control = 213
Treatment = 54 years
Control = 53.5 years
Treatment = 83%
Control = 83%
Type 2 Diabetes Mean (SD) HbA1c (%) = 9.28 (1.74) Mean (SD) HbA1c (%) = 9.24 (1.59) MDT care,
Self-management plans,
Coordinated care;
Continuity of care;
Data driven quality of care
12 months
Taylor et al., 2005 [97] Canada Treatment = 20
Control = 19
Treatment = 58 years
Control = 67 years
Treatment = 35%
Control = 32%
Type 2 Diabetes HbA1c (%) = 7.69
Systolic blood pressure (mm Hg) = 134
Diastolic blood pressure (mm Hg) = 79
Cholesterol (mg/dL) = 194.1
HDL cholesterol (mg/dL) = 44.9
LDL cholesterol (mg/dL) = 116
Triglycerides (mg/dL) = 205.5
(SD or 95% CI not reported)
HbA1c (%) = 7.69
Systolic blood pressure (mm Hg) = 129
Diastolic blood pressure (mm Hg) = 70
Cholesterol (mg/dL) = 201.01
HDL cholesterol (mg/dL) = 50.3
LDL cholesterol (mg/dL) = 119.1
Triglycerides (mg/dL) = 156.8
(SD or 95% CI not reported)
MDT care,
Self-management plans,
Coordinated care
4 months
Thorn et al., 2020 [98] United Kingdom Treatment = 797
Control = 749
Treatment = 71 years
Control = 70.7 years
Treatment = 51%
Control = 50%
Three or more chronic conditions from those
included in the National Health Service (NHS) Quality
and Outcomes Framework—Circulatory system disorders, musculoskeletal disorders, Type 2 Diabetes, cancers, and mental illnesses
No. of long-term conditions from QOF: median (IQR) = 3.0 (3.0 to 3.0) No. of long-term conditions from QOF: median (IQR) = 3.0 (3.0 to 3.0) MDT care,
Patient engagement
Coordinated care,
Continuity of care
6 months
Uijen et al., 2012 [99] Netherlands Treatment = 64
Control = 49
Treatment = 64 years
Control = 63 years
Treatment = 58% Control = 75% Chronic obstructive pulmonary disease according to ICD-10 Self-management group GOLD stage, n (%)
GOLD 1 = 13 (20.3)
GOLD 2 = 42 (65.6)
GOLD 3/4 = 9 (14.1)
GOLD stage, n (%)
GOLD 1 = 11 (22.4)
GOLD 2 = 29 (59.2)
GOLD 3/4 = 9 (18.4)
MDT care,
Self-management plans,
Coordinated care;
Continuity of care;
24 months
Unutzer et al., 2002 [100] United States Treatment = 906
Control = 895
Treatment = 71.2 years
Control = 71.4 years
Treatment = 64%
Control = 66%
Major depression and/or dysthymia Mean (SD) SCL-20 = 1.7 (0.6) Mean (SD) SCL-20 = 1.7 (0.6) MDT care,
Patient engagement
Coordinated care
12 months
Unutzer et al., 2008 [101] United States Treatment = 279
Control = 272
Treatment = 72.6 years
Control = 72.7 years
Treatment = 70%
Control = 75%
Major depression and/or dysthymia Depression severity score, mean (SD) = 1.7 (0.5) Depression severity score, mean (SD) = 1.7 (0.6) MDT care,
Patient engagement
Coordinated care
48 months
van Orden et al., 2009 [102] Netherlands Treatment = 102
Control = 63
Treatment = 40.2 years
Control = 40.4 years
Treatment = 72%
Control = 62%
Mental disorder SCL-90 Mean (SD) = 181.2 (58.6)
WHOQOL-BREF Mean (SD) = 3.0 (0.8)
SCL-90 Mean (SD) = 188.4 (64.2)
WHOQOL-BREF Mean (SD) = 3.0 (1.0)
MDT care,
Patient engagement
Coordinated care
12 months
Vera et al., 2010 [103] Puerto Rico Treatment = 89
Control = 90
Treatment = 57 years
Control = 53 years
Treatment = 74%
Control = 78%
Major depression and had any of the following health conditions: diabetes, hypothyroidism, asthma, hypertension, chronic bronchitis, arthritis, heart disease, high cholesterol, or stroke. HSCL depression Mean (SD) = 2.22 (0.54) HSCL depression Mean (SD) = 2.34 (0.58) MDT care,
Self-management plans,
Coordinated care;
Continuity of care;
6 months
Von Korff et al., 1998 [104] United States 1st trial Treatment = 41
Control = 33
2nd trialTreatment = 26
Control = 31
NA NA Depression and on anti-depressant medications Major depression
Total depression treatment costs = $1337
Minor depression
Total depression treatment costs = $1298
Major depression
Total depression treatment costs = $850
Minor depression
Total depression treatment costs = $656
MDT care,
Patient engagement
Coordinated care
12 months
Von Korff et al., 2011 [105] United States Treatment = 106
Control = 107
Treatment = 57.4 years
Control = 56.3 years
Treatment = 48%
Control = 56%
Diabetes, coronary heart disease, and depression Sheehan social role disability scale = 5.6 (2.4)
Global quality of life rating = 4.2 (1.9)
WHODAS-2 activities of daily living = 15.8 (9.6)
Sheehan social role disability scale = 5.1 (2.6)
Global quality of life rating = 4.7 (1.8)
WHODAS-2 activities of daily living = 13.8 (9.6)
MDT care,
Patient engagement
Coordinated care,
Continuity of care
12 months
Zwar et al., 2016 [106] Australia Treatment = 144
Control = 110
Treatment = 66.5 years
Control = 65.4 years
Treatment = 61.1%
Control = 58.2%
Chronic obstructive pulmonary disease Mean total SGRQ score (SD) = 20.0 (17.2) Mean total SGRQ score (SD) = 18.9 (16.8) MDT care,
Patient engagement
Coordinated care
12 months

BADL—Basic Activities of Daily Living; BAI—Beck Anxiety Inventory; BP—blood pressure; CCM—chronic care model; CCQ—Clinical COPD questionnaire; CES-D—Center for Epidemiologic Studies Depression Scale; CI—confidence interval; DBP—diastolic blood pressure; DSM-IV—Diagnostic and Statistical Manual of Mental Disorders 4th edition; EQ3D—EuroQol 3 dimensions; EQ5D—EuroQol 5 dimensions; GAD—Generalized Anxiety Disorder; GADSS—Generalized Anxiety Disorder Severity Scale; GARS—Gilliam Autism Rating Scale; GOLD—Global initiative for Chronic Obstructive Lung Disease; HAM-D—Hamilton Depression Rating Scale; HbA1c—glycated haemoglobin; HDL—high density lipoprotein; HSCL—Hopkins Symptom Checklist; IADL—Instrumental Activities of Daily Living; ICD-10—10th revision of the International Statistical Classification of Diseases and Related Health Problems; IQR—interquartile range; LDL—low density lipoprotein; MADRS-S—Montgomery and Asberg Depression Rating Scale; MCS—mental component scores; MDT—multidisciplinary team; NA—not available; PACIC- Patient Assessment of Care for Chronic Conditions; PCS—physical component scores; PDSS—Panic Disorder Severity Scale; PHQ—Patient Health Questionnaire; PROMIS—Patient-Reported Outcomes Measurement Information System; PTSD—Post-traumatic stress disorder; QOF—Quality and Outcomes Framework; RMDQ—Roland-Morris Questionnaire; SAQ—Seattle Angina Questionnaire; SBP—systolic blood pressure; SD—standard deviation; SF 12 and SF 36—short and long format of a single measures of HRQoL.

Table A4.

Characteristics of non-randomised controlled trials reviewed.

Chronic Physical Conditions—Baseline Characteristics (Risk Proportion/Mean or Median and SD) Outcomes
Authors and Year of Publication Country of origin Sample Size (N) Mean Age/Age Groups Gender Distribution
(Female)
Chronic Disease Profile of the Sample Population Treatment Group Control GROUP PCMH Components Duration of Follow-up Depression Quality of Life/Self-Management Hospital Admission Cost/Health Utility Biomedical Outcomes
Bray et al., 2013 [17] United States Treatment = 368
Control = 359
Treatment = 59.5 years
Control = 60.6 years
Treatment = 66%
Control = 63%
Type 2 diabetes mellitus HbA1c, mean (SD), % = 7.9 (2.2)
SBP/DBP, mean (SD), mm Hg = 138 (18)/81 (10)
HDL cholesterol, mean (SD), mg/dL= 50 (13.3)
Total cholesterol, mean (SD), mg/dL = 176 (39.7)
HbA1c, mean (SD), % = 7.9 (2.2)
SBP/DBP, mean (SD), mm Hg = 138 (18)/81 (10)
HDL cholesterol, mean (SD), mg/dL= 50 (13.3)
Total cholesterol, mean (SD), mg/dL = 176 (39.7)
6 key elements to the intervention design: education with behavioural coaching, treatment intensification, point-of-care management, expanded roles of clinic staff to facilitate management, a team care approach, and physician leadership 36 months
Kravertz et al., 2016 [107] United States Treatment = 350
Control = 315
Treatment = 72.7 years
Control = 72.2 years
NA Hypertension SBP = 167.7
DBP = 84
(SD or 95% CI not reported)
NA MDT care,
Patient education
Coordinated care
4 months
Petersen et al., 2019 [109] South Africa Treatment = 137
Control = 236
Treatment = 42.6 years
Control = 44 years
Treatment = 83.2%
Control = 80.5%
Mental and other comorbid conditions PHQ-9 mean (SD) = 14.5 (3.47)
WHODAS mean (SD) = 37.6 (17.19)
PHQ-9 mean (SD) = 12.8 (3.01)
WHODAS mean (SD) = 40.0 (19.48)
MDT care,
Patient engagement
Coordinated care
12 months
Ruikes et al., 2016 [21] Netherlands Treatment = 287
Control = 249
Treatment = 83.1 years
Control = 80.5 years
Treatment = 66.9%
Control = 64.3%
Frail elderly people with multimorbidity Katz-15 index, mean (SD) = 5.4 (2.9) Katz-15 index, mean (SD) = 4.6 (2.7) MDT care,
Self-management plans,
Coordinated care
12 months
Seidu et al., 2017 [110] United Kingdom Treatment = 6054
Control = 2312
% above 65 years
Treatment = 14.20
Control = 11.31
Treatment = 50.6%
Control = 47.4%
Type 2 diabetes mellitus Non-elective bed days, mean (SD) = 5.62 (2.11) Non-elective bed days, mean (SD) = 3.82 (1.62) MDT care,
Self-management plans,
Coordinated care
12 months
Sommers et al., 2000 [111] United States Treatment = 280
Control = 263
Treatment = 78 years
Control = 77 years
1 Frail elderly people with multimorbidity Hospital admissions per patient per year, mean (SD) = 0.34 (0.68)
≥1 hospital admission within 60 days % = 4.5
≥1 ED visit % = 9.0
Hospital admissions per patient per year, mean (SD) = 0.39 (0.81)
≥1 hospital admission within 60 days % = 5.9
≥1 ED visit % = 5.9
MDT care,
Self-management plans,
Coordinated care
24 months
Vestjens et al., 2019 [108] Netherlands Treatment = 232
Control = 232
Treatment = 82.4 years
Control = 82.4 years
Treatment = 72.4%
Control = 72.4%
Frail elderly people with multimorbidity EQ5D3L = 0.63 (0.26) EQ5D3L = 0.66 (0.24) MDT care,
Patient engagement
Coordinated care
12 months

BP—blood pressure; CI—confidence interval; DBP—diastolic blood pressure; ED—emergency department; EQ3D—EuroQol 3 dimensions; HbA1c—glycated haemoglobin; HDL—high density lipoprotein; LDL—low density lipoprotein; MDT—multidisciplinary team; NA—not available; PHQ—Patient Health Questionnaire; SBP—systolic blood pressure; SD—standard deviation; WHODAS—World Health Organization Disability Assessment Schedule.

Table A5.

Quality assessment of randomised controlled studies using Joanna Briggs Institute (JBI) critical appraisal checklist.

Author and Year Q 1 Q 2 Q 3 Q 4 Q 5 Q 6 Q 7 Q 8 Q 9 Q 10 Q 11 Q 12 Q 13 Quality
Alexopoulos et al., 2009 [36] U U N NA NA U Y N Y Y Y Y Y Fair
Aragonès et al., 2014 [18] U U Y NA NA Y Y Y Y Y Y Y Y Good
Aragonès et al., 2019 [38] Y Y Y NA NA Y Y N Y Y Y Y Y Good
Barcelo et al., 2010 [39] U U Y NA NA U Y N Y Y Y U Y Fair
Bjorkelund et al., 2018 [40] U U Y NA NA U Y Y Y Y Y Y Y Good
Blom et al., 2016 [41] U U Y NA NA Y Y N Y Y Y Y Y Good
Bogner et al., 2008 [42] U U Y NA NA U Y N Y Y Y Y Y Fair
Bogner et al., 2012 [43] Y Y Y NA NA Y Y N Y Y Y Y Y Good
Borenstein et al., 2003 [45] U U Y NA NA U Y N Y Y Y U Y Fair
Bosanquet et al., 2017 [46] Y Y Y NA NA Y Y Y Y Y Y Y Y Good
Boult et al., 2008 [47] U U Y NA NA Y Y Y Y Y Y Y Y Good
Boult et al., 2011 [48] U U Y NA NA Y Y Y Y Y Y Y Y Good
Callahan et al., 2005 [49] U U Y NA NA U Y N Y Y Y Y Y Fair
Camacho et al., 2018 [13] Y Y Y NA NA Y Y N Y Y Y Y Y Good
Campins et al., 2017 [20] Y Y Y NA NA N Y N Y Y Y Y Y Good
Chaney et al., 2011 [50] U U Y NA NA U Y Y Y Y Y Y Y Good
Cooper et al., 2013 [51] Y Y Y NA NA N Y U Y Y Y Y Y Good
Coventry et al., 2015 [14] Y Y Y NA NA N Y Y Y Y Y Y Y Good
Dobscha et al., 2009 [53] Y Y Y NA NA Y Y Y Y Y Y Y Y Good
Dorr et al., 2008 [54] U U Y NA NA U Y N U Y Y Y Y Fair
Edelman et al., 2010 [16] Y Y Y NA NA Y Y U U Y Y Y Y Fair
Engel et al., 2016 [55] Y Y Y NA NA N Y N Y Y Y Y Y Good
Fihn et al., 2011 [56] U U Y NA NA N Y N Y Y Y Y Y Fair
Gilbody et al., 2017 [57] Y Y Y NA NA Y Y Y Y Y Y Y Y Good
Green et al., 2014 [59] U U Y NA NA N Y N Y Y Y Y Y Fair
Hirsch et al., 2014 [61] Y Y Y NA NA N Y N Y Y Y Y Y Good
Hsu et al., 2014 [62] U U N NA NA U Y N U Y Y Y U Poor
Huijbregts et al., 2013 [63] Y Y Y NA NA U Y Y Y Y Y Y Y Good
Ip et al., 2013 [64] U U Y NA NA U Y N Y Y Y Y Y Fair
Katon et al., 2012 [66] U U Y NA NA Y Y Y Y Y Y Y Y Good
Katon et al., 1999 [67] Y Y Y NA NA Y Y Y Y Y Y Y Y Good
Katon et al., 2010 [68] Y Y Y NA NA Y Y Y Y Y Y Y Y Good
Katon et al., 2004 [70] Y Y Y NA NA Y Y Y Y Y Y Y Y Good
Konnopka et al., 2016 [22] U U Y NA NA N Y N Y Y Y Y Y Fair
Krein et al., 2004 [71] Y Y Y NA NA Y Y Y Y Y Y Y Y Good
Kruis et al., 2014 [72] Y Y Y NA NA Y Y Y Y Y Y Y Y Good
Lin et al., 2000 [76] Y Y Y NA NA Y Y Y Y Y U Y Y Fair
Lin et al., 2006 [74] U U U NA NA U Y N Y Y Y Y Y Fair
Lin et al., 2012 [75] Y Y Y NA NA N Y N Y Y Y Y Y Good
Maislos et al., 2004 [77] U U Y NA NA U Y N Y Y Y Y Y Fair
Menchetti et al., 2013 [78] Y Y Y NA NA U Y Y Y Y Y Y Y Good
Muntingh et al., 2013 [19] Y Y N NA NA Y Y U Y Y Y Y Y Fair
Ramli et al., 2016 [82] Y Y Y NA NA U Y Y Y Y Y Y Y Good
Richards et al., 2013 [83] Y Y Y NA NA U Y Y Y Y Y Y Y Good
Richards et al., 2008 [84] Y Y Y NA NA Y Y Y Y Y Y Y Y Good
Rollman et al., 2005 [86] Y Y Y NA NA Y Y Y Y Y Y Y Y Good
Rollman et al., 2017 [85] Y Y Y NA NA Y Y Y Y Y Y Y Y Good
Rollman et al., 2018 [87] Y Y Y NA NA Y Y Y Y Y Y Y Y Good
Rost et al., 2001 [88] N N Y NA NA U Y N Y Y Y Y Y Fair
Salisbury et al., 2018 [89] Y Y Y NA NA Y Y Y Y Y Y Y Y Good
Scherpbier-de Haan et al., 2013 [90] U U Y NA NA N Y Y Y Y Y Y Y Good
Schnurr et al., 2013 [91] Y Y Y NA NA Y Y Y Y Y Y Y Y Good
Simon et al., 2004 [93] Y Y Y NA NA Y Y Y Y Y Y Y Y Good
Simpson et al., 2011 [94] Y Y Y NA NA Y Y Y Y Y Y Y Y Good
Smith et al., 2004 [95] Y Y Y NA NA U Y Y Y Y Y Y Y Good
Tang et al., 2013 [96] Y Y Y NA NA Y Y Y Y Y Y Y Y Good
Taylor et al., 2005 [97] Y Y Y NA NA N Y N Y Y U Y Y Good
Uijen et al., 2012 [99] Y Y Y NA NA Y Y Y Y Y Y Y Y Good
Unutzer et al., 2002 [100] Y Y Y NA NA Y Y Y Y Y Y Y Y Good
van Orden et al., 2009 [102] Y Y Y NA NA N Y N Y Y Y Y Y Good
Vera et al., 2010 [103] Y Y Y NA NA Y Y N Y Y Y Y Y Good
Von Korff et al., 2011 [105] Y Y Y NA NA N Y N Y Y Y Y Y Good
Zwar et al., 2016 [106] Y Y Y NA NA Y Y Y Y Y Y Y Y Good

NA—Most did not blind participants or personnel as it was not practical. Therefore, we did not downgrade for these risks/uncertainties.

Table A6.

Quality assessment of non-randomised controlled studies using JBI critical appraisal checklist.

Author and Year Q 1 Q 2 Q 3 Q 4 Q 5 Q 6 Q 7 Q 8 Q 9 Quality
Bray et al., 2013 [17] Y Y Y Y Y Y Y Y Y Good
Kravertz et al., 2016 [107] Y Y Y Y Y U Y U U Fair
Petersen et al., 2019 [109] Y Y Y Y Y Y Y Y Y Good
Ruikes et al., 2016 [21] Y Y Y Y Y Y Y Y Y Good
Seidu et al., 2017 [110] Y Y Y Y Y U Y U U Fair
Sommers et al., 2000 [111] Y Y Y Y Y U Y Y Y Good
Vestjens et al., 2019 [108] Y Y Y Y Y Y Y Y Y Good

Table A7.

Quality assessment of studies on economic evaluation using JBI critical appraisal checklist.

Author and Year Q 1 Q 2 Q 3 Q 4 Q 5 Q 6 Q 7 Q 8 Q 9 Q 10 Q 11 Quality
Aragonès et al., 2014 (Cost-effectiveness) [37] Y Y Y Y Y Y Y Y Y Y Y Good
Boland et al., 2015 [44] Y Y Y Y Y Y Y Y Y Y N Good
Dickinson et al., 2010 [52] Y Y Y Y U U Y Y U Y U Fair
Goorden et al., 2015 [58] Y Y Y Y Y Y Y Y Y Y U Good
Grochtdreis et al., 2019 [60] Y Y Y Y Y Y Y Y Y Y N Good
Johnson et al., 2016 [65] Y Y Y Y Y Y Y Y Y Y Y Good
Katon et al., 2005 [69] Y Y Y Y Y Y Y Y Y Y U Good
Leeuwen et al., 2015 [73] Y Y Y Y Y Y Y Y Y Y Y Good
Metzelthin et al., 2015 [79] Y Y Y Y Y Y Y Y Y Y U Good
Morgan et al., 2015 [80] Y Y Y Y U U Y N N Y U Fair
Pyne et al., 2003 [81] Y Y Y Y Y Y Y Y Y Y U Good
Simon et al., 2001 [92] Y Y Y Y Y Y Y Y Y Y U Good
Thorn et al., 2020 [98] Y Y Y Y Y Y Y Y Y Y U Good
Unutzer et al., 2008 [101] Y Y Y Y U U Y N N U Y Fair
Von Korff et al., 1998 [104] Y Y Y Y U U U N N Y U Poor

Table A8.

Quality assessment of non-randomised controlled studies using Risk of Bias In Non-randomised Studies of Interventions (ROBINS-I) tool.

Author and Year Q 1 Q 2 Q 3 Q 4 Q 5 Q 6 Q 7 Overall
Bray et al., 2013 [17] Low Low Low Low Low Low Low Good
Kravertz et al., 2016 [107] Moderate Low Low Low Low Low Moderate Fair
Petersen et al., 2019 [109] Low Low Low Low Low Low Low Good
Ruikes et al., 2016 [21] Low Low Low Low Low Low Low Good
Seidu et al., 2017 [110] Moderate Low Low Low Low Low Moderate Fair
Sommers et al., 2000 [111] Low Low Low Low Low Low Low Good
Vestjens et al., 2019 [108] Low Low Low Low Low Low Low Good

Author Contributions

Conceptualization, J.R.J.; methodology, J.R.J. and K.A.; formal analysis, J.R.J. and K.A.; investigation, J.R.J., K.P., and H.J.; data curation, J.R.J., K.P., and H.J.; writing—original draft preparation, J.R.J.; writing—review and editing, J.R.J., W.K.T., and K.A.; and supervision, W.K.T. and K.A. All authors have read and agreed to the published version of the manuscript.

Funding

J.R.J.’s PhD scholarship was provided by Capital Markets Cooperative Research Centre (Now Rozetta Institute). The funders did not have any role in the design, methods, analysis, or preparation of this manuscript.

Conflicts of Interest

The authors declare no conflict of interest.

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