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.