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Table 3 Combination of elements of Chronic Care Model and outcome measures

From: A systematic review of chronic disease management interventions in primary care

Single or combination CCM elements OUTCOME CATEGORY
Professional-level Patient-level Other
Adherence to guidelines Change in medication Quality of care Adherence to treatment Service use PMOD Risk behaviour Quality of life Health status Satisfaction Functional status Knowledge level Costs
DSD overall o Overall 3 (5) 6 (7)   1 (5) 4 (7) 18(22) 0 (4) 6 (13) 3 (8) 4 (5) 1 (3) 4 (6) 2 (2)
DSD       0 (1)    1 (1)     
DSD + CIS         1 (1) 0 (1)     
DSD + CIS + DS     1 (1)          
DSD + CIS + SMS      0 (1) 1 (1)   0 (1)     0 (1)  
DSD + DS   2 (2)     4 (4)    1 (1)     
DSD + DS + CIS 1 (1)      1 (1)    1 (1)     
DSD + DS + HCO 1 (1)          0 (1)    
DSD + DS + SMS 0 (1) 1 (1)    1 (1) 1 (2) 0 (1) 0 (1)     1 (1)  
DSD + SMS   2 (3)   0 (2) 2 (3) 4 (5) 0 (1) 3 (5) 0 (1) 2 (2) 1 (2) 3 (3)  
DSD + SMS + CIS 0 (1)    0 (1) 0 (1) 1 (1)   0 (2) 0 (1) 1 (1)    1 (1)
DSD + SMS + DS 1 (1) 1 (1)   0 (1) 1 (1) 6 (7) 0 (2) 2 (3) 0 (2) 1 (1) 0 (1) 0 (1) 1 (1)
DS overall 6 (13) 8 (13)   1 (3) 5 (9) 8 (22) 2 (3) 1 (5) 2 (9) 1 (3) 2 (10) 1 (1) 1 (2)
DS 2 (3) 3 (8)   1 (2) 3 (6) 3 (7)   1 (3) 2 (2) 0 (1) 2 (4)   0 (1)
DS + CIS 1 (3) 2 (2)     0 (3) 1 (1)   0 (1)   0 (1)   1 (1)
DS + CIS + DSD 1 (1)         0 (1)   0 (1)   
DS + CIS + SMS 0 (1)             
DS + DSD 0 (1) 2 (2)   0 (1)   3 (4)    0 (1) 0 (1) 0 (1)   
DS + DSD + SMS 0 (1)     1 (1) 1 (4)   0 (2) 0 (3) 1 (1) 0 (1)   
DS + HCO 1 (1)           0 (1)   
DS + SMS 1 (2) 1 (1)    1 (2) 1 (4) 1 (2)   0 (1)   0 (1) 1 (1)  
CIS overall 4 (5) 2 (2) 1 (1)   1 (2) 5 (8) 0 (1)    1 (1) 4 (5)   1 (2)
CIS + DS 4 (4) 1 (1) 1 (1)   1 (1) 1 (3) 0 (1)    1 (1) 4 (4)   1 (1)
CIS + DSD       1 (1)        
CIS + SMS 0 (1)     0 (1) 1 (2)      0 (1)   0 (1)
CIS + SMS + DSD   1 (1)     2 (2)        
SMS overall 5 (7) 5 (6)   6 (13) 1 (7) 32(52) 11 (20) 10(25) 5 (13) 3 (5) 5 (5) 16 (23) 5 (5)
SMS   1 (1)   0 (3) 0 (3) 8 (14) 4 (5) 6 (10) 3 (5)   1 (2) 7 (9) 1 (1)
SMS + CIS 1 (1)    2 (2) 0 (1) 2 (5) 1 (1) 0 (2) 0 (1) 1 (1) 1 (1) 1 (1)  
SMS + CIS + DSD   1 (1)     1 (1) 0 (1)       
SMS + CR     1 (1)   1 (1)        
SMS + CR + DSD       0 (1)        
SMS + DS 1 (1) 1 (1)    0 (1) 5 (6) 2 (2) 1 (2)     1 (1) 1 (1)
SMS + DS + CIS 1 (1) 1 (1)     2 (2)   0 (1) 0 (1)     2 (2)
SMS + DS + DSD 0 (1)     1 (1) 0 (1) 0 (1)    0 (1)    
SMS + DSD 2 (2) 1 (2)   3 (5) 0 (1) 9 (14) 4 (8) 3 (8) 1 (5) 1 (2) 3 (3) 5 (9) 1 (1)
SMS + DSD + CIS       1 (1)   0 (1) 1 (1) 1 (1)   0 (1)  
SMS + DSD + CR       1 (1)       1 (1)  
SMS + DSD + DS 0 (1)    0 (2)   2 (5) 0 (2) 0 (1)     1 (1)  
HCO + CIS 1 (1)      1 (1)        
HCO + DSD     1 (1)   0 (1)        
CR + DSD   0 (1)    1 (1) 1 (1)        
  1. Numbers in cells: number of studies reporting at least one significant outcome (number of studies reporting at least one outcome)
  2. Bold font in cells is where 50% or more of studies reported a significant difference for that category of outcome
  3. CCM Chronic Care Model, CIS clinical information systems, COPD chronic obstructive pulmonary disease, CR community resources, DS decision support, DSD delivery system design, HCO health care organization, PMOD physiological measure of disease, SMS self-management support