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Table 4 Elements of Chronic Care Model and positive outcome measures by disease

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

Primary CCM element

Disease

OUTCOME CATEGORY

Professional

Patient

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

3 (5)

6 (7)

 

1 (5)

4 (7)

18 (22)

0 (4)

6 (13)

3 (8)

4 (5)

1 (3)

4 (6)

2 (2)

Arthritis

       

1 (2)

0 (1)

 

1 (1)

  

Asthma

             

COPD

0 (1)

   

1 (4)

0 (1)

0 (1)

1 (5)

0 (1)

  

2 (3)

 

Diabetes

3 (3)

3 (4)

 

0 (2)

2 (2)

12 (14)

0 (2)

4 (4)

1 (2)

3 (4)

0 (1)

2 (2)

1 (1)

Heart disease

0 (1)

  

0 (2)

 

0 (1)

0 (1)

0 (1)

1 (3)

1 (1)

  

1 (1)

Hypertension

 

3 (3)

  

1 (1)

5 (5)

 

0 (1)

1 (1)

 

0 (1)

0 (1)

 

Lipid disorders

     

1 (1)

       

Osteoporosis

   

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)

Arthritis

             

Asthma

1 (1)

1 (2)

 

1 (2)

0 (1)

0 (1)

 

1 (3)

1 (1)

    

COPD

    

0 (1)

  

0 (1)

1 (2)

1 (1)

1 (2)

  

Diabetes

1 (3)

3 (4)

  

2 (3)

4 (11)

2 (2)

0 (1)

0 (3)

0 (2)

0 (2)

1 (1)

1 (2)

Heart disease

1 (3)

2 (3)

  

1 (2)

0 (3)

0 (1)

 

0 (1)

 

0 (2)

  

Hypertension

2 (4)

2 (4)

 

0 (1)

2 (2)

4 (7)

  

0 (2)

 

1 (3)

  

Lipid disorders

1 (2)

         

0 (1)

  

Osteoporosis

             

CIS

Overall

4 (5)

3 (3)

1 (1)

 

1 (2)

5 (8)

0 (1)

  

1 (1)

4 (5)

 

1 (2)

Arthritis

             

Asthma

1 (1)

 

1 (1)

       

1 (1)

  

COPD

             

Diabetes

2 (3)

   

1 (1)

2 (3)

   

1 (1)

2 (3)

 

1 (1)

Heart disease

 

1 (1)

  

0 (1)

1 (1)

       

Hypertension

1 (1)

2 (2)

   

2 (4)

0 (1)

   

1 (1)

 

0 (1)

Lipid disorders

             

Osteoporosis

             

SMS

Overall

5 (7)

5 (6)

 

6 (13)

1 (7)

32 (52)

11 (20)

10 (25)

5 (13)

3 (5)

5 (6)

16 (23)

5 (5)

Arthritis

1 (1)

    

1 (1)

 

3 (5)

  

2 (2)

2 (3)

 

Asthma

 

1 (1)

  

0 (2)

1 (2)

 

1 (3)

1 (2)

    

COPD

 

0 (1)

  

1 (2)

 

1 (1)

2 (4)

1 (1)

1 (2)

1 (1)

3 (5)

 

Diabetes

1 (1)

  

4 (8)

0 (1)

17 (29)

9 (15)

3 (8)

2 (6)

1 (2)

1 (2)

11 (14)

1 (1)

Heart disease

 

1 (1)

  

0 (2)

2 (5)

 

1 (2)

1 (3)

1 (1)

  

1 (1)

Hypertension

3 (5)

3 (3)

 

1 (3)

 

11 (15)

1 (4)

0 (3)

0 (1)

 

1 (1)

0 (1)

3 (3)

Lipid disorders

             

Osteoporosis

   

1 (2)

 

1 (1)

 

0 (1)

1 (1)

    

HCO

Overall

1 (2)

  

1 (1)

 

1 (3)

  

0 (1)

 

0 (1)

  

Arthritis

             

Asthma

             

COPD

             

Diabetes

   

1 (1)

 

0 (1)

       

Heart disease

1 (1)

    

1 (1)

       

Hypertension

0 (1)

    

0 (1)

  

0 (1)

 

0 (1)

  

Lipid disorders

             

Osteoporosis

             

CR

Overall

 

0 (1)

  

1 (1)

1 (1)

       

Arthritis

             

Asthma

             

COPD

             

Diabetes

             

Heart disease

             

Hypertension

 

0 (1)

  

1 (1)

1 (1)

       

Lipid disorders

             

Osteoporosis

             
  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
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