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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