Review
Integrated care programs for patients with psychological comorbidity: A systematic review and meta-analysis

https://doi.org/10.1016/j.jpsychores.2015.07.013Get rights and content

Highlights

  • Ten integrated care programs for people with psychological co-morbidity were found.

  • Meta-analysis showed a significant positive effect on depression treatment response.

  • There is moderate evidence for better emotional well-being due to integrated care.

  • There is moderate evidence for higher patient satisfaction and cost-effectiveness.

  • Integrated care programs seem promising but more rigorous studies are needed.

Abstract

Objective

Presently, little is known about the characteristics and impact of integrated care programs for patients with psychological comorbidity. The aim was to provide an overview of these integrated care programs and their effectiveness.

Methods

Systematic literature review including papers published between 1995 and 2014. An integrated care program had to consist of interventions related to at least two out of the six components of the Chronic Care Model. Programs had to address patients with psychological comorbidity, which is a psychological disease next to a somatic chronic disease. A meta-analysis was performed on depression treatment response and a best evidence synthesis was performed on other outcomes.

Results

Ten programs were identified, which mostly addressed comorbid depression and consisted of interventions related to three to five components of the Chronic Care Model. Meta-analysis showed significantly higher odds for depression treatment response for patients receiving integrated care (OR: 2.49, 95%CI [1.66–3.75]). Best evidence synthesis suggested moderate evidence for cost-effectiveness and for a beneficial effect on patient satisfaction and emotional well-being. Insufficient evidence was found for a beneficial effect on health-related quality of life, medication adherence, Hb1Ac levels and mortality.

Conclusion

There are few studies evaluating integrated care programs for patients with psychological comorbidity. Although these studies suggest that integrated care programs could positively affect several patient outcomes and could be cost-effective, additional studies are recommended to further assess the value of integrated care for this patient group. This is especially important since the number of people with psychological comorbidity is rising.

Introduction

Over the last decades, life expectancy of the world population has risen. At the same time, an increasing prevalence of chronic diseases has been observed [1]. Recent studies show that psychological disorders are common among patients with a chronic somatic disease; its prevalence is estimated between 24% and 58% [2], [3], [4], [5], [6], [7].

Psychological comorbidity, for this review defined as the existence of psychological disorder in a person that also has a somatic chronic disease, is associated with poor quality of life, disability, poor somatic disease-specific outcomes and higher mortality [8], [9], [10]. Moreover, psychological comorbidity negatively influences the patients' ability to self-manage the somatic chronic disease [11], [12], [13]. As such, patients with psychological comorbidity often have complex treatment demands [14], [15]. However, these needs are often insufficiently met. General practitioners for instance often lack the required knowledge to diagnose and treat psychological diseases [10], [16], [17]. Moreover, there is often insufficient collaboration between health professionals from different disciplines [18], [19]. Patients with psychological comorbidity are therefore prone to receive insufficient, uncoordinated and fragmented care [16], which in turn may lead to unnecessary healthcare utilization (e.g. hospitalizations).

Over the last decades, integrated care has increasingly been implemented to optimize delivery and efficiency of health services to chronically ill patients [20], [21]. Many different terms are being applied to integrated care including comprehensive care, disease management, guided care, transitional care and shared care. In this paper, the umbrella term ‘integrated care programs’ is used. These programs proactively structure and coordinate the complex delivery of health and social care services and consequently aim to improve patient outcomes and restrict healthcare expenditures. Core elements of these programs are: a) a well-coordinated and proactive approach to health and social care needs; b) patient-centeredness by involving patients in decision-making and planning their care process, and by taking their individual needs into account; c) (simultaneous) delivery of multiple interventions; and d) involvement of professionals from multiple disciplines [21], [22], [23]. Since in integrated care programs the complex healthcare needs of chronically ill patients are being acknowledged, it is expected that both treatment demands related to the somatic disease and those related to the psychological disease will be addressed.

So far, little is known about the characteristics of integrated care programs for patients with psychological comorbidity. In addition, it is largely unknown whether these programs are effective in assisting healthcare providers and patients to manage the combination of diseases better and thereby to improve patient outcomes and cost-effectiveness. The aim of this review was therefore twofold: 1. to provide an overview of integrated care programs for patients with psychological comorbidity and 2. to gain insight into the effectiveness of such programs.

Section snippets

Search strategy

We conducted a systematic literature review focusing on English language papers published between January 1995 and March 2014. The year 1995 was chosen, since from that year on integrated care has become an increasingly important focus of attention in medical literature [24]. The search was conducted in the databases Medline, Cochrane, Cinahl, EMBASE, PsycINFO, and SciSearch. The following keywords were used to search these databases: case management, comprehensive healthcare, critical pathways

Search

The literature search yielded 6155 potentially relevant papers. After screening titles and abstracts, 264 full-text articles were selected by the reviewers to be retrieved for in-depth screening. This screening process resulted into thirteen eligible papers and the manual search yielded two additional papers. Reasons for exclusion are given in Fig. 1.

Study designs

The fifteen included papers described ten studies evaluating ten different integrated care programs for patients with psychological comorbidity.

Discussion

This systematic literature review is, to the best of our knowledge, one of few providing an overview of integrated care programs for patients with psychological comorbidity and their effects on patient outcomes. In contrast to two other recent reviews [49], [50], we did not only include studies on depression and diabetes but also on other combinations of psychological and somatic chronic diseases. Furthermore, we used the universally accepted Chronic Care Model to operationalize integrate care

Conclusion

Although it is believed that integrated care programs improve patient outcomes while constraining healthcare expenditures, this review suggests that more evidence is needed. Considering the fact that the number of patients with psychological comorbidity is increasing, it is recommended to enhance evaluation studies of integrated care programs to be able to conclude more validly whether these programs live up to their promise.

Funding source

This study was funded by the Ministry of Health, Welfare and Sport (KV2.2a/2012). The funding source was not involved in the study design, in the collection, analysis and interpretation of data, in the writing of the article and in the decision to submit the article for publication.

Competing interests

The authors have no competing interests to report.

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