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INFLUENTIAL PUBLICATIONS   |    
Comparative Effectiveness of Collaborative Chronic Care Models for Mental Health Conditions Across Primary, Specialty, and Behavioral Health Care Settings: Systematic Review and Meta-Analysis
Emily Woltmann, Ph.D.; Andrew Grogan-Kaylor, Ph.D.; Brian Perron, Ph.D.; Hebert Georges, M.D.; Amy M. Kilbourne, Ph.D.; Mark S. Bauer, M.D.
FOCUS 2013;11:552-567. doi:10.1176/appi.focus.11.4.552
Abstract

Objective  Collaborative chronic care models (CCMs) improve outcome in chronic medical illnesses and depression treated in primary care settings. The effect of such models across other treatment settings and mental health conditions has not been comprehensively assessed. The authors performed a systematic review and meta-analysis to assess the comparative effectiveness of CCMs for mental health conditions across disorders and treatment settings.

Method  Randomized controlled trials comparing CCMs with other care conditions, published or in press by August 15, 2011, were identified in a literature search and through contact with investigators. CCMs were defined a priori as interventions with at least three of the six components of the Improving Chronic Illness Care initiative (patient self-management support, clinical information systems, delivery system redesign, decision support, organizational support, and community resource linkages). Articles were included if the CCM effect on mental health symptoms or mental quality of life was reported. Data extraction included analyses of these outcomes plus social role function, physical and overall quality of life, and costs. Meta-analyses included comparisons using unadjusted continuous measures.

Results  Seventy-eight articles yielded 161 analyses from 57 trials (depression, N=40; bipolar disorder, N=4; anxiety disorders, N=3; multiple/other disorders, N=10). The meta-analysis indicated significant effects across disorders and care settings for depression as well as for mental and physical quality of life and social role function (Cohen's d values, 0.20–0.33). Total health care costs did not differ between CCMs and comparison models. A systematic review largely confirmed and extended these findings across conditions and outcome domains.

Conclusions  CCMs can improve mental and physical outcomes for individuals with mental disorders across a wide variety of care settings, and they provide a robust clinical and policy framework for care integration.
(Reprinted with permission The American Journal of Psychiatry 2012; 169:790–804) 

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Figure 1. Meta-Analysis of Clinical Outcomesa

a The individual comparisons extracted for these meta-analyses reflect data from the longest time interval for a given trial (see the Method section). The individual comparisons at these longest time points may or may not have been significantly different but were extracted for meta-analyses as the most rigorous test of the model. In complementary fashion, the systematic review results (see Table 2; also see the online data supplement) report the planned analyses as reported in each given trial, which typically included repeated-measures analyses that incorporated tests of change over time between the chronic care model and the control condition.

b Weights are from random-effects analysis.

Figure 2. Meta-Analysis of Economic Outcomes

a Weights are from random-effects analysis.

Figure 3. Comprehensive Analysis Displays (CADgrams) for Specific Outcome Domains Across Diagnosesa

a The bar graphs depict comprehensive analysis displays, which summarize chronic care model (CCM) significance across outcome domains. These comprehensive analysis displays appear in an order consistent with that of Table 2 for domains with four or more informative analyses, with each outcome categorized by disorder. The horizontal axis represents the raw count of informative analyses according to the number of analyses that favored the CCM, revealed no significant difference between the CCM and control condition, or favored the control condition. The dimension of the horizontal axis varies by the number of informative analyses in order to accommodate the length of the bars, ranging from 4 (overall quality of life) to 133 (total clinical outcomes).

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Table 1.Collaborative Chronic Care Model (CCM) Core Elementsa
Table Footer Note

a Adapted from references 10 and 118.

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Table 2.By-Diagnosis Tabulation of Systematic Review Clinical Analyses Comparing the Chronic Care Model (CCM) With the Control Condition
Table Footer Note

a Each qualifying analysis from each trial was categorized as favoring the CCM, favoring the control condition, or exhibiting no difference between the CCM and the control condition. Percentages reflect the proportion of total informative analyses (e.g., for depressive disorders, 41 of 88 informative analyses [46.6%] favored the CCM).

Table Footer Note

b Percentages reflect the proportion of analyses that were informative compared with those that were indeterminate (trials that did report the significance level explicitly compared with those that did not) (e.g., 88 of 92 analyses [95.7%] for depressive disorders reported significance).

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Table 3.Tabulation By Outcome of Systematic Review Analysis Comparing the Chronic Care Model (CCM) With the Control Condition
Table Footer Note

a Each qualifying analysis from each trial was categorized as favoring the CCM, favoring the control condition, or exhibiting no difference between the CCM and the control condition. Percentages reflect the proportion of total informative analyses (e.g., for anxiety disorders, five of five informative analyses [100.0%] favored the CCM).

Table Footer Note

b Percentages reflect the proportion of analyses that were informative compared with those that were indeterminate (trials that did report the significance level explicitly compared with those that did not).

+

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