The rise of ‘chronic disease management’

New thinking about the management of chronic diseases has resulted in several terms being used in the literature to refer to similar concepts. These terms include ‘chronic disease management’ (CDM), ‘chronic care management’, ‘chronic condition management’ and ‘integrated care’. These terms reflect different stakeholder epistemological perspectives, and there has been a trend over time to move away from terms that focus on disease (considered potentially disempowering) towards more neutral terminology that focusses on the process of care experience (e.g., ‘integrated’, ‘collaborative’ or ‘co-ordinated care’). Acknowledging these terminology issues, the term ‘CDM’ will be used in this paper as it is likely to be more familiar to health professionals.

There are also many different definitions of what constitutes CDM, although the common elements of CDM definitions include the following:

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  a systematic approach to planning care;

  
  
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  utilisation of potentially multiple treatment modalities with a focus on patient self-management support (SMS);

  
  
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  use of coordinated care across health-care providers and sectors; and/or

  
  
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  use of multidisciplinary teams.

Increasingly, policymakers are formalising CDM aims and components to assist service planning. For instance, the Institute of Medicine (IOM), in developing a policy document to address identified gaps in provision of high-quality health-care, recommended that health-care reform and redesign should be based on six specific quality improvement aims, such that care is designed to be safe, effective, patient-centred, timely, efficient and equitable .

CDM models of care

In the health system, it may be useful to conceptualise CDM models as a bridge between policy and practice, frameworks that provide information on planning, implementation, evaluation and ongoing improvement. Confusion arises in CDM as the term ‘CDM model’ can be used to describe high-level broad conceptual frameworks (for instance, the Chronic Care Model , Expanded Chronic Care Model and the World Health Organisation Innovative Care for Chronic Conditions Model ) or to describe organisation and practice-level service delivery models. In this paper, we focus on meso-/micro-level CDM service models, of which there are many thousands in operation worldwide. Some models consider tiered or step-wise management across a broad disease severity spectrum, based on risk assessment, whilst others focus only on populations with more advanced disease that are high users of health-care resources. Although the target population may differ, CDM service models often share key operational design elements based on the broader CDM frameworks described above, including health-care organisation and planning, decision support, delivery system design, SMS, clinical information systems and community resource partnerships ( Table 1 ).

Are CDM models of care effective?

Appraising research about CDM for all chronic conditions is challenging due to the lack of common terminology relating to the definition of CDM as well as the use of different components of broad CDM frameworks and different service model strategies. Evaluations commonly cite marked heterogeneity between studies and inconsistencies in reported impacts, although positive impacts on patient health outcomes including hospital utilisation, quality of life (QoL), functional health, patient satisfaction and process outcomes have now been documented for a number of chronic conditions .

One systematic review has reported on the impacts of osteoarthritis-chronic disease management (OA-CDM) service models as part of a broader review of chronic disease programmes . Zwar and colleagues classified CDM studies focussed on primary care service delivery by their inclusion of CDM components ( Table 1 ) and assessed effectiveness in relation to patient outcomes and adherence to guidelines by health professionals . Of the 145 included studies, only eight (5.5%) were OA-focussed. There were 12 interventions investigated within the eight studies, five/eight included one intervention, two/eight included two interventions and one/eight included three interventions. Overall, 11/12 interventions were SMS. The review found that across all studies, the most effective intervention was SMS, specifically, patient education and motivational counselling. Further, the most effective combination of CDM components was SMS and delivery system design, although OA studies did not include interventions in the latter category. Similar to earlier research , the number of CDM elements included in the studies (overall conditions) was not associated with improved outcomes, although strong conclusions could not be made given the relatively small number of model components. It is now pertinent to examine studies that have been published since this systematic review, in particular to identify if researchers have extended their scope of interest to other CDM domains, whether reported models are cost effective and what barriers exist to their implementation and sustainability.

Aims of the review

In this paper, we aim to update and review the evidence about the use and effectiveness of CDM models of care for OA and develop recommendations for future research and practice. In addressing this aim, we focussed on the following questions:

• 1.
  

  What evidence is there that OA-CDM service models are effective and cost effective?

  
  
• 2.
  

  What are the barriers to developing and implementing effective OA-CDM service models?

Literature search

To identify evidence for CDM in OA and the impact on patient outcomes, a systematic literature search was undertaken in July/August 2013, using the Ovid Medline, PubMed and EBSCO CINAHL databases. Our comprehensive search strategy was informed by the search terms used by Zwar et al. , but modified to focus on arthritis and OA. The search strategy specifically excluded the terms ‘rheumatoid arthritis’, ‘fibromyalgia’, ‘osteoporosis’, ‘juvenile arthritis’, ‘low back pain’, ‘neck pain’, ‘child’ and ‘adolescent’. We also searched the Cochrane Database of Systematic Reviews using the terms ‘osteoarthritis’, ‘chronic disease, chronic disease management’, ‘improving care’, ‘quality of care’, ‘barriers’ and ‘delivery of healthcare’. Full details of our search strategy can be obtained from the authors upon request. Additional papers of potential relevance were identified from our existing resource libraries and Google searches. The search results were pooled, and after removing duplicate publications, all retrieved titles and abstracts were screened according to our eligibility criteria. To be included in this review, studies had to:

• •
  

  involve care for OA (excluding studies limited to neck pain and/or low back pain);

  
  
• •
  

  involve human adults; and

  
  
• •
  

  include CDM interventions that addressed the organisation and coordination of care for OA between health-care providers and/or across health-care sectors.

There was no restriction on study type, but papers were excluded if they:

• •
  

  dealt with only one aspect of OA care,

  
  
• •
  

  involved a pharmacological intervention only,

  
  
• •
  

  were published in a language other than English, or

  
  
• •
  

  were published prior to January 2006 to avoid duplication of previous work ,

  
  
• •
  

  tested a patient education programme (±an exercise component) that did not include SMS strategies such as individual problem solving support, goal setting and regular assessment of progress , or

  
  
• •
  

  assessed care pathways for total hip or knee replacement surgery, where the focus was solely on inpatient care efficiency.

All titles and abstracts were initially screened by one assessor (INA); those which did not meet the eligibility criteria were excluded. Where eligibility was unclear, it was discussed with the other authors. All papers considered to meet the eligibility criteria were reviewed by a second assessor (JT) to confirm their inclusion in the review. If required, the full paper was reviewed by a third assessor (CAB) and discussed in order to reach consensus. Similar to previous methods , each included paper was classified according to the CDM elements covered ( Table 1 ). Studies were also grouped by the setting in which interventions were delivered; primary care (general practice/primary care physician settings), community care (allied health professional or pharmacy settings) and secondary care (including specialist acute care/hospital settings). While OA is the most common form of arthritis, the specific terminology used to describe joint disease in each paper (arthritis or OA) was used when summarising the studies.

The Physiotherapy Evidence Database (PEDro) scale was used to evaluate the methodological quality of all randomised controlled trials (RCTs) included in our review . This scale contains 11 criteria and produces a scale from zero to ten (the first item is not used for scoring purposes), with higher scores indicating higher trial quality. Prior to scoring the studies, we searched PEDro to determine whether any of the included RCTs had previously been rated . Where PEDro scores were available, we reported these in our paper, as all studies published in PEDro have been scored by at least two raters . Where scores were not available from the PEDro database, each RCT was assessed independently by two of the authors (CAB and INA) using the PEDro scale, with any scoring disagreements resolved by consensus.

Information on barriers to developing and implementing effective CDM in OA was obtained from eligible papers, as well as from papers sourced from additional searches and our existing resources.

Aims of the review

In this paper, we aim to update and review the evidence about the use and effectiveness of CDM models of care for OA and develop recommendations for future research and practice. In addressing this aim, we focussed on the following questions:

• 1.
  

  What evidence is there that OA-CDM service models are effective and cost effective?

  
  
• 2.
  

  What are the barriers to developing and implementing effective OA-CDM service models?

Literature search

To identify evidence for CDM in OA and the impact on patient outcomes, a systematic literature search was undertaken in July/August 2013, using the Ovid Medline, PubMed and EBSCO CINAHL databases. Our comprehensive search strategy was informed by the search terms used by Zwar et al. , but modified to focus on arthritis and OA. The search strategy specifically excluded the terms ‘rheumatoid arthritis’, ‘fibromyalgia’, ‘osteoporosis’, ‘juvenile arthritis’, ‘low back pain’, ‘neck pain’, ‘child’ and ‘adolescent’. We also searched the Cochrane Database of Systematic Reviews using the terms ‘osteoarthritis’, ‘chronic disease, chronic disease management’, ‘improving care’, ‘quality of care’, ‘barriers’ and ‘delivery of healthcare’. Full details of our search strategy can be obtained from the authors upon request. Additional papers of potential relevance were identified from our existing resource libraries and Google searches. The search results were pooled, and after removing duplicate publications, all retrieved titles and abstracts were screened according to our eligibility criteria. To be included in this review, studies had to:

• •
  

  involve care for OA (excluding studies limited to neck pain and/or low back pain);

  
  
• •
  

  involve human adults; and

  
  
• •
  

  include CDM interventions that addressed the organisation and coordination of care for OA between health-care providers and/or across health-care sectors.

There was no restriction on study type, but papers were excluded if they:

• •
  

  dealt with only one aspect of OA care,

  
  
• •
  

  involved a pharmacological intervention only,

  
  
• •
  

  were published in a language other than English, or

  
  
• •
  

  were published prior to January 2006 to avoid duplication of previous work ,

  
  
• •
  

  tested a patient education programme (±an exercise component) that did not include SMS strategies such as individual problem solving support, goal setting and regular assessment of progress , or

  
  
• •
  

  assessed care pathways for total hip or knee replacement surgery, where the focus was solely on inpatient care efficiency.

All titles and abstracts were initially screened by one assessor (INA); those which did not meet the eligibility criteria were excluded. Where eligibility was unclear, it was discussed with the other authors. All papers considered to meet the eligibility criteria were reviewed by a second assessor (JT) to confirm their inclusion in the review. If required, the full paper was reviewed by a third assessor (CAB) and discussed in order to reach consensus. Similar to previous methods , each included paper was classified according to the CDM elements covered ( Table 1 ). Studies were also grouped by the setting in which interventions were delivered; primary care (general practice/primary care physician settings), community care (allied health professional or pharmacy settings) and secondary care (including specialist acute care/hospital settings). While OA is the most common form of arthritis, the specific terminology used to describe joint disease in each paper (arthritis or OA) was used when summarising the studies.

The Physiotherapy Evidence Database (PEDro) scale was used to evaluate the methodological quality of all randomised controlled trials (RCTs) included in our review . This scale contains 11 criteria and produces a scale from zero to ten (the first item is not used for scoring purposes), with higher scores indicating higher trial quality. Prior to scoring the studies, we searched PEDro to determine whether any of the included RCTs had previously been rated . Where PEDro scores were available, we reported these in our paper, as all studies published in PEDro have been scored by at least two raters . Where scores were not available from the PEDro database, each RCT was assessed independently by two of the authors (CAB and INA) using the PEDro scale, with any scoring disagreements resolved by consensus.

Information on barriers to developing and implementing effective CDM in OA was obtained from eligible papers, as well as from papers sourced from additional searches and our existing resources.

Search results

Our search identified 2410 papers of potential relevance that were published between January 2006 and July/August 2013. After screening, 13 studies were considered eligible for inclusion in this review. Of these, eight utilised an RCT or cluster RCT design and five/eight were undertaken in primary or community care settings. PEDro scores for the included RCTs ranged from five to eight, indicating moderate to high trial quality .

Evidence for CDM

The included papers reported research into a range of coordinated care programmes for lower limb or generalised OA, such as pre- and post-operative clinical pathways for joint replacement surgery, musculoskeletal screening clinics, collaborative depression care for people with arthritis and pharmacist-led CDM. An overview of the study design, type of service evaluated and primary outcomes for each paper are provided in Table 2 , and a summary of the reported impacts for each of the RCTs can be found in Table 3 . All of the papers reported interventions that could be classified according to at least one element of the CDM. Most covered delivery system design or SMS, with few interventions relating to decision support, clinical information systems or community resources. None of the papers related to the element of health-care organisation.

Table 2

Summary of included studies.

Author (year) Country Quality score	Study design CCM elements	Patient population Setting	Type of service/intervention Intensity and complexity	Health-care professionals delivering service Method of communication	Primary outcomes
Brand (2010) Australia	Pre-test/post-test design with program evaluation DSD DS SMS CIS CR	OA hip and knee patients. N = 123 Age in years: median 66.0 (IQR: 58.5–72.5) 76.4% female Hospital rheumatology outpatient clinic (metropolitan tertiary public hospital).	Osteoarthritis-Chronic Disease Management service model; including introduction of a musculoskeletal coordinator (MSC) role. Patients assessed at baseline, 3 months and 6 months. High level of complexity.	MSC – physiotherapist Rheumatologist Face-to-face: individual Telephone: in person	For patients completing 3- and 6-month reviews: Patient Global Pain: 28.0% improved change from baseline to 6 months, p < 0.001; Patient Global Functional Disability: 30.8% improved change from baseline to 6 months, p < 0.001; Patient Global Priority: 36.7% improved change from baseline to 6 months, p < 0.001.
Brosseau (2012a) Canada PEDro score: 6 a (for 2012a)	RCT SMS	People with mild to moderate OA of the knee. N = 222 Age in years: mean 63.4 (SD 8.6) 68.9% female Community based walking clubs.	Walking and behavioural intervention group (WB), compared to walking intervention group (W) and control group (C). The first 12 months were supervised and consisted of: 3 weekly supervised walking sessions; a behavioural intervention including 20 2-h group sessions over a duration of 20 consecutive weeks, monthly individual meetings for the first 6-months and telephone counselling for the last 6 months. A self-directed control group received an educational pamphlet only. Follow-up assessments occurred at 15 and 18 months. Intermediate level of complexity.	Physical activity specialist/exercise therapist/trainer b supervised the walking sessions Trained instructor delivered the educational component of the behavioural intervention Face-to-face: group Face-to-face: individual Telephone: in person	At 12 and 18 months, all groups had improved clinical outcomes. There was no difference in overall WOMAC scores, functional tests, QoL (SF-36) between groups, For SF-36 subscales, the WB intervention group had significant improvements in physical functioning ( p = 0.012 & 0.015), pain index ( p = 0.030 & 0.003) and standardised physical component ( p = 0.009 & 0.002) items of the short form-36 (SF-36) compared to the self-directed control group and the walking intervention group. Adherence was not significantly different at 6 and 12 months between groups.
Dobscha (2009) USA PEDro score: 8 a	Cluster RCT DSD SMS DS	Chronic musculoskeletal pain patients, including patients with OA. N = 401 Age in years (intervention group): mean ± SD, 62.1 ± 11.2 8% female 5 Veterans Affairs primary care clinics; 3 urban and 2 rural.	Collaborative chronic pain intervention. Patients followed up for 12 months. Initial assessment visit followed by contact every 2 months. Participants were also encouraged to attend a 4-session workshop. High level of complexity.	Psychologist care manager Medical internist Physical therapist (co-led workshop) Face-to-face: individual Face-to-face: group workshop Telephone: in person	At 12 months, patients in the intervention group showed significant improvement in pain-related disability as measured by the Roland–Morris Disability Questionnaire for pain, although change in mean score from baseline was moderate (−1.4 (95% CI −2.0, −7.1) for intervention group compared to −0.2 (95% CI: −0.8, 0.4) for control group, p < 0.04). NNT for reduction in pain-related disability was 12.70 (95% CI 12.48–12.74)
Doerr (2013) Australia	Before and after program evaluation DSD DS CIS	OA hip and knee patients. N = 548 procedures Orthopaedic unit of a metropolitan public hospital.	The OA Management System. Initial assessment and patient education session at clinic. Frequency of contact and follow-up was variable for patients receiving conservative management only. Surgical prioritisation tool reassessed every 4 months. High level of complexity.	Orthopaedic surgeon Physiotherapist Clinical nurse Multidisciplinary team run pre-surgery information session Face-to-face: individual Face-to-face: group information session Postal	Reduction in waiting time for initial assessment and for surgery from 10 months to 3 months. Greater surgical throughput from 396 to 548 procedures. Reduction in average length of stay for hip (6.3–5.3 days) and knee arthroplasty (5.8–5.3 days). Reduction in the use of inpatient rehabilitation from 44% to 8%.
Gooch (2012) Canada PEDro score: 5	RCT DSD DS	Patients requiring THR or TKR; majority with severe hip or knee OA. N = 3434 Age in years: mean 67.0. Intervention surgical group: mean ± SD, 69.0 ± 11.1 57.0% female 3 Alberta health service regions (public health system) hip and knee replacement services.	New clinical pathway (NCP) TKR and THR model of care. From patient referral through to 12-months post-operatively; with follow-up at 2 year intervals. During inpatient care, patient–provider interaction occurred multiple times a day. High level of complexity.	Case managers Orthopaedic surgeon Clinical staff working on orthopaedic inpatient wards Face-to-face: individual	12 months post-surgery, patients in the NCP group had significant improvement in their WOMAC overall score (adjusted treatment effect: 2.56; 95% CI 1.10–4.01) compared to the usual care group. Rates of adverse events within 30 days of surgery were similar across both groups.
Hill (2009) UK PEDro score: 6 a	RCT DSD	Patients with OA of any joint. N = 100 Age in years: mean ± SD (intervention group), 60.3 ± 9.4 74% female Rheumatology clinic at a large teaching hospital.	Clinical Nurse Specialist (CNS) delivered care, compared to care delivered by junior hospital doctors (JHD). Patients seen at baseline, with follow-up at 4-months, 8-months and 12-months. Intermediate level of complexity.	Clinical Nurse Specialist Consultant rheumatologist Face-to-face: individual	At 12-months follow-up there were no significant differences between groups in average pain measured by VAS (mean difference after adjustment 1.61 (95% CI: −5.68, 8.90) relating to effect size 0.06 (95% CI: −0.21, 0.33)).
Hoogeboom (2012) Netherlands	Feasibility study SMS	Patients aged 40 years and over with generalised OA. N = 5 Age range 51–76 years 80% female Rheumatology outpatient department of a hospital.	Non-pharmacological multidisciplinary care programme. Patients completed repeated measures at baseline (varying lengths ranging from 2 to 5 weeks pre intervention), during the intervention period and post-intervention period (between 2 and 5 weeks). The intervention consisted of 10 1.5 h sessions over 12 weeks. Baseline and post-intervention periods varied but totalled 7 weeks for each participant. Intermediate level of complexity.	Occupational therapist Physical therapist Face-to-face: group	Feasibility of the intervention: 1 participant dropped out of the study within 2 weeks of commencing There were no adverse events reported although one person reported increase in pain; and there was a 90% adherence rate to attending the intervention. The remarks most frequently made by participants: too many sessions and they were too brief; too much verbal information; there was too little individualisation in the exercise sessions and in setting and monitoring goals.
Marra (2012) Canada PEDro score: 5	Cluster RCT DSD DS CR	Community-dwelling people aged 50 years and over with knee pain or stiffness; undiagnosed knee OA. N = 139 Age in years: mean ± SD (intervention group), 62.7 ± 9.2 57% female Community pharmacies in metropolitan Vancouver.	Pharmacy-led multidisciplinary strategy for knee OA. Patients were followed up for 6 months. Pharmacists followed up with patients each month. Those attending the group exercise program were reassessed by a physiotherapist at 3-weeks and 6-weeks. High level of complexity.	Community pharmacists Primary care physician Physiotherapists Rehabilitation assistant Face-to-face: individual Face-to-face: group	The overall quality indicator pass rate was significantly higher for those in the intervention group compared to the control group (difference of 45.2% (95% CI 34.5, 55.9)).
McKnight (2010) USA PEDro score: 6 a	RCT SMS	Early OA knee; aged 35–64 years. N = 273 (201 completed) Age in years mean ± SD (intervention group), 51.9 ± 7.7 77% female Academic medical centre.	Multidimensional intervention for early OA of the knee. Patients were followed up for 24 months; reassessed at 9-months. Exercise sessions ×3/week for 9 months; followed by fortnightly contact for 6 weeks. Self-management program 12-weekly, 90 min sessions, followed up by weekly contact for 9 months and fortnightly contact for 15 months. Intermediate level of complexity.	Physical trainer Program manager and local health professionals Face-to-face: individual Face-to-face: group Telephone: in person	At 24-months, there were no differences in physical performance tests or self-reported pain and disability between the groups (effect size 0.08 intervention vs strength training alone; effect size 0.22 intervention vs self-management alone). All groups showed significant within-group improvement in all of the outcomes over the study period.
Murphy (2008) USA PEDro score: 7 a	RCT SMS	Older adults with hip or knee OA. N = 54 Age (mean ± SD) of intervention group in years: 75.8 ± 7.1 89% female Community based.	Exercise coupled with activity strategy training (AST). Patients were followed up for 6 weeks. Patients attended 8 exercise sessions of 45-min duration, followed by AST session. Patients visited on one occasion by OT. Intermediate level of complexity.	Occupational therapist Physiotherapist Face-to-face: individual Face-to-face: group	Pain decreased in both groups; there was no significant difference between groups (WOMAC pain: effect size 0.03, p = 0.47). Total physical activity (PA) and objective peak PA increased in the exercise plus AST group; but only peak PA was significantly different compared to the exercise plus education group (effect size 0.30, p = 0.02).
Oldmeadow (2007) Australia	Descriptive program evaluation DSD	Patients with non-urgent knee, shoulder or back musculoskeletal conditions. N = 45, 10 with OA knee Age (mean) 53.3 years 59.6% female Orthopaedic outpatients department of a metropolitan, tertiary hospital.	Musculoskeletal screening clinic provided by physiotherapists. Patients attended 2 separate appointments for assessment by a physiotherapist and an orthopaedic surgeon Details re patient follow-up were not provided. Intermediate level of complexity.	Physiotherapists Orthopaedic surgeon Face-to-face: individual	20% of referrals were eligible for the screening clinic. 45 of 52 eligible patients were seen by the physiotherapist within 2 weeks of referral; 7 did not attend. 63% of new patients were appropriate for non-surgical management. The level of agreement between the surgeon and physiotherapists on the management of 38 patients was 74%.
Rosemann (2007) Germany PEDro score: 5	Cluster RCT DSD SMS	OA hip and knee patients. N = 1021 Age (mean ± SD) of intervention group II in years: 66.3 ± 15.2 66% females 75 Primary care practices.	Case management by a practice nurse combined with general practitioner (GP) guided self-management (intervention group II). Intervention group I involved GP guided self-management only. Patients followed up for 9 months. Follow-up telephone calls to patients by nurse occurred at least every 4-weeks. GPs attended 2 peer group meetings; 8 h each. High level of complexity.	General practitioners Practice nurse Face-to-face: individual Telephone: in person	Post-intervention, significant improvements in QoL Social scale ( p < 0.001), Symptom scale (patients’ perceived pain, p = 0.048) and Lower body scale (patients’ functional ability in the lower limbs, p = 0.049) items were seen among those receiving case management with GP guided self-management (intervention group II) compared to usual care. QoL Affect scale and Upper body scale items were not significantly different between the intervention groups and control group. There were no significant differences in QoL measures between those in intervention group I and the control group.
Unutzer (2008) USA	Pre-test/post-test design DSD SMS	OA patients with depression, aged 60 years and over. N = 14 Age (mean ± SD): 72.2 ± 8.5 85% female Primary care.	Improving Mood, Providing Access to Collaborative Treatment Depression and Pain (IMPACT-DP). Patients followed up for 6 months. Frequency of contact varied, average of 9 follow-up contacts (range 6–13) over the 6 months. Intermediate level of complexity.	Primary care nurse Geriatric psychiatrist Face-to-face: individual Telephone: in person	At 6-months compared to baseline, participants experienced significant improvements in the 2 Depression Severity measures: HSCL-20, effect size 1.27, p = 0.004; and PHQ-9 effect size 1.40, p < 0.001; and the Depression Self Efficacy measure: effect size −0.77, p = 0.029.

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