Towards systematic reviews that inform health care management and policy-making Primary care practice-based care management for chronically ill patients (PraCMan): study protocol for a cluster randomized controlled trial [ISRCTN56104508] Effects of case management in community aged care on client and carer outcomes: a systematic review of randomized trials and comparative observational studies Systematic review of evidence on the impact of nursing workload and staffing on establishing healthy work environments Impact of patient-reported outcomes in oncology: a longitudinal analysis of patient-physician communication. Involvement of patients or their representatives in quality management functions in EU hospitals: implementation and impact on patient-centred care strategies Using logic model methods in systematic review synthesis: describing complex pathways in referral management interventions A new model of integrated primary-secondary care for complex diabetes in the community: study protocol for a randomised controlled trial Design of a Randomised Controlled Trial (RCT) on the effectiveness of a Dutch patient advocacy case management intervention among severely disabled Multiple Sclerosis patients Clinical Management and Burden of Prostate Cancer: A Markov Monte Carlo Model A randomized, controlled trial of outpatient geriatric evaluation and management in a large public hospital. Helping patients help themselves: A systematic review of self-management support strategies in primary health care practice Impact of population management with direct physician feedback on care of patients with type 2 diabetes. The effect of community-based health management on the health of the elderly: a randomized controlled trial from China Seeing the forests and the trees—innovative approaches to exploring heterogeneity in systematic reviews of complex interventions to enhance health system decision-making: a protocol Estimating the Horizon of Articles to Decide When to Stop Searching in Systematic Reviews: An Example Using a Systematic Review of RCTs Evaluating Osteoporosis Clinical Decision Support Tools Outcome evaluation of a randomized trial of the PhoenixCare intervention: program of case management and coordinated care for the seriously chronically ill.
Objectives To identify ways to improve the usefulness of systematic review s for health care managers and policy-makers that could then be evaluated prospect ively . Methods We systematic ally review ed studies of decision-making by health care managers and policy-makers , conducted interviews with a purposive sample of them in Canada and the United Kingdom ( n=29 ) , and review ed the websites of research funders , producers/purveyors of research , and journals that include them among their target audiences ( n=45 ) . Results Our systematic review identified that factors such as interactions between research ers and health care policy-makers and timing/timeliness appear to increase the prospect s for research use among policy-makers . Our interviews with health care managers and policy-makers suggest that they would benefit from having information that is relevant for decisions highlighted for them ( e.g. context ual factors that affect a review 's local applicability and information about the benefits , harms/risks and costs of interventions ) and having review s presented in a way that allows for rapid scanning for relevance and then grade d entry ( such as one page of take-home messages , a three-page executive summary and a 25-page report ) . Managers and policy-makers have mixed views about the helpfulness of recommendations . Our analysis of websites found that context ual factors were rarely highlighted , recommendations were often provided and grade d entry formats were rarely used . Conclusions Research ers could help to ensure that the future flow of systematic review s will better inform health care management and policy-making by involving health care managers and policy-makers in their production and better highlighting information that is relevant for decisions . Research funders could help to ensure that the global stock of systematic review s will better inform health care management and policy-making by supporting and evaluating local adaptation processes such as developing and making available online more user-friendly ‘ front ends ’ for potentially relevant systematic review Background Care management programmes are an effective approach to care for high risk patients with complex care needs result ing from multiple co-occurring medical and non-medical conditions . These patients are likely to be hospitalized for a potentially " avoidable " cause . Nurse-led care management programmes for high risk elderly patients showed promising results . Care management programmes based on health care assistants ( HCAs ) targeting adult patients with a high risk of hospitalisation may be an innovative approach to deliver cost-efficient intensified care to patients most in need . Methods / Design PraCMan is a cluster r and omized controlled trial with primary care practice s as unit of r and omisation . The study evaluates a complex primary care practice -based care management of patients at high risk for future hospitalizations . Eligible patients either suffer from type 2 diabetes mellitus , chronic obstructive pulmonary disease , chronic heart failure or any combination . Patients with a high likelihood of hospitalization within the following 12 months ( based on insurance data ) will be included in the trial . During 12 months of intervention patients of the care management group receive comprehensive assessment of medical and non-medical needs and re sources as well as regular structured monitoring of symptoms . Assessment and monitoring will be performed by trained HCAs from the participating practice s. Additionally , patients will receive written information , symptom diaries , action plans and a medication plan to improve self-management capabilities . This intervention is addition to usual care . Patients from the  control group  receive usual care . Primary outcome is the number of all-cause hospitalizations at 12 months follow-up , assessed by insurance cl aims data . Secondary outcomes are health-related quality of life ( SF12 , EQ5D ) , quality of chronic illness care ( PACIC ) , health care utilisation and costs , medication adherence ( MARS ) , depression status and severity ( PHQ-9 ) , self-management capabilities and clinical parameters . Data collection will be performed at baseline , 12 and 24 months ( 12 months post-intervention ) . Discussion Practice -based care management for high risk individuals involving trained HCAs appears to be a promising approach to face the needs of an aging population with increasing care dem and s . Trial registration Current Controlled Trials IS RCT Background Case management has been applied in community aged care to meet frail older people ’s holistic needs and promote cost-effectiveness . This systematic review aims to evaluate the effects of case management in community aged care on client and carer outcomes . Methods We search ed Web of Science , Scopus , Medline , CINAHL ( EBSCO ) and PsycINFO ( CSA ) from inception to 2011 July . Inclusion criteria were : no restriction on date , English language , community-dwelling older people and /or carers , case management in community aged care , published in refereed journals , r and omized control trials ( RCTs ) or comparative observational studies , examining client or carer outcomes . Quality of studies was assessed by using such indicators as quality control , r and omization , comparability , follow-up rate , dropout , blinding assessors , and intention-to-treat analysis . Two review ers independently screened potentially relevant studies , extracted information and assessed study quality . A narrative summary of findings were presented . Results Ten RCTs and five comparative observational studies were identified . One RCT was rated high quality . Client outcomes included mortality ( 7 studies ) , physical or cognitive functioning ( 6 studies ) , medical conditions ( 2 studies ) , behavioral problems ( 2 studies ) , unmet service needs ( 3 studies ) , psychological health or well-being ( 7 studies ) , and satisfaction with care ( 4 studies ) , while carer outcomes included stress or burden ( 6 studies ) , satisfaction with care ( 2 studies ) , psychological health or well-being ( 5 studies ) , and social consequences ( such as social support and relationships with clients ) ( 2 studies ) . Five of the seven studies reported that case management in community aged care interventions significantly improved psychological health or well-being in the intervention group , while all the three studies consistently reported fewer unmet service needs among the intervention participants . In contrast , available studies reported mixed results regarding client physical or cognitive functioning and carer stress or burden . There was also limited evidence indicating significant effects of the interventions on the other client and carer outcomes as described above . Conclusions Available evidence showed that case management in community aged care can improve client psychological health or well-being and unmet service needs . Future studies should investigate what specific components of case management are crucial in improving clients and their carers ’ outcomes Background This systematic review set out to examine the impact , if any , of  nursing workload and staffing  on creating and maintaining healthy work environments . For the purpose s of this review , the term ‘ healthy work environment ’ was defined as ‘ … a practice setting that maximizes the health and well‐being of nurses , quality patient outcomes and organizational performance ’ . This definition identifies nurse , patient and organisational outcomes as indicators of the establishment and maintenance of a healthy work environment . Objectives The review sought to determine the impact of : Patient characteristics , nurse characteristics , system characteristics and system processes on workload , scheduling and concepts of productivity and utilisation Workload , scheduling and concepts of productivity and utilisation on the quality of outcomes for clients , nurses and the system/organisation Search strategy The search strategy sought to find both published and unpublished studies and papers written in the English language . A three‐step search strategy approach was used . An initial limited search of MEDLINE and CINAHL data bases was undertaken to identify optimal search terms followed by an analysis of the text words contained in the title and abstract , and of the index terms used to describe the article . A second extensive search using all identified keywords and index terms was then undertaken . The third step consisted of a search of the reference lists of all identified reports and articles for additional studies . Selection criteria Types of studies : This review considered research papers that addressed the appropriateness and effectiveness of workload and staffing concepts in fostering a healthy work environment in healthcare . The types of papers to be considered included : meta‐ analysis , r and omised controlled trials , quasi‐r and omised controlled trials , cohort studies , case‐control studies , descriptive studies and correlational studies . Types of participants : The review considered all participants involved or affected by workload and staffing concepts within the nursing workforce in a healthcare environment , including staff and patients . System and policy issues were also considered . Types of interventions : All workload and staffing strategies that impact on the work environment , patient and nurse outcomes were considered in this review . Types of outcome measures : Outcomes of interest were categorised into four groups : nursing staff outcomes , patient outcomes , organisational outcomes and system outcomes . Data collection and analysis Following assessment of method ological quality , data were extracted using data extraction tools based on the work of the Cochrane Collaboration and the Centre for Review s and Dissemination . Statistical pooling was not possible and findings were presented in narrative form . Results Of the 2162 papers identified in the search , 171 were selected for full paper retrieval and assessed independently by two review ers for method ological quality . A total of 40 papers were included in the review : one systematic review ; one cohort study ; and 38 correlational descriptive studies . Results were summarised in narrative form . The evidence suggests strong correlations between patient characteristics and work environments ; and workload and staffing and the quality of outcomes for clients , nurses and the system/organisation . This gave rise to a number of recommendations for practice and for further research , such as : A greater proportion of regulated staffing ( i.e. registered nurses , enrolled nurses , practical or vocational nurses ) is associated with improved outcomes related to the Functional Independence Measure score , the Short Form Health Survey ( SF‐36 ) vitality score , patient satisfaction with nursing care , patient adverse events ( including atelectasis , decubitus ulcers , falls , pneumonia , postsurgical and treatment infection and urinary tract infections ) An increase in the number of registered nurse hours available is associated with improved patient outcomes in relation to falls , pneumonia , pressure ulcers , urinary tract infection , length of stay and postoperative infection PURPOSE Regularly collecting patient-reported outcomes ( PROs ) of health-related quality of life with feedback to oncologists may assist in eliciting and monitoring patients ' problems during cancer treatment . This study examined how PRO feedback had an impact on patient-physician communication over time to gain a better underst and ing of how it may influence patient care . PATIENTS AND METHODS Exploratory analyses were performed on a data set from a previous study . Patients were r and omly assigned to intervention ( regular completion of European Organisation for Research and Treatment of Cancer Quality of Life Question naire-Core 30 and Hospital Anxiety and Depression Scale with feedback to oncologists ) , attention-control ( completion of same question naires without feedback ) , and control ( st and ard care ) arms . The content of consultation audio recordings between 28 oncologists and 198 patients over four consecutive visits ( 792 consultations ) was analyzed . Mixed-effects models and multivariate regressions were used to examine the longitudinal impact of the intervention on patient-physician communication , dynamics of patient-physician interaction , and the association between PROs and the content of clinic discussion . RESULTS Patients in the intervention arm discussed more symptoms over time compared with patients in the attention-control ( P = .008 ) and control ( P = .04 ) arms . No study arm effect was observed for function discussion s. Discussion topics were predominantly raised by patients /relatives , regardless of arm allocation . Clinic discussion s were associated with severity of patient-reported symptoms but not with patient-reported functional concerns . CONCLUSION A positive longitudinal impact of the intervention on symptom discussion was observed , but not for function discussion , suggesting that potentially serious problems may remain unaddressed . Training oncologists in responding to patient-reported functional concerns may increase the impact of this intervention Objective The objective of this study was to describe the involvement of patients or their representatives in quality management ( QM ) functions  and to assess associations between levels of involvement and the implementation of patient-centred care strategies . Design A cross-sectional , multilevel study design that surveyed quality managers and department heads and data from an organizational audit . Setting R and omly selected hospitals ( n = 74 ) from seven European countries ( The Czech Republic , France , Germany , Pol and , Portugal , Spain and Turkey ) . Participants Hospital quality managers ( n = 74 ) and heads of clinical departments ( n = 262 ) in charge of four patient pathways ( acute myocardial infa rct ion , stroke , hip fracture and deliveries ) participated in the data collection between May 2011 and February 2012 . Main Outcome Measures Four items reflecting essential patient-centred care strategies based on an on-site hospital visit : ( 1 )  formal survey seeking views of patients and carers , ( 2 ) written policies on patients ' rights , ( 3 ) patient information literature including guidelines and ( 4  ) fact sheets for post-discharge care .  The main predictors were patient involvement in QM  at the ( i ) hospital level and ( ii ) pathway level . Results Current levels of involving patients and their representatives in QM functions in European hospitals are low at hospital level ( mean score 1.6 on a scale of 0 to 5 , SD 0.7 ) , but even lower at departmental level ( mean 0.6 , SD 0.7 ) . We did not detect associations between levels of involving patients and their representatives in QM functions and the implementation of patient-centred care strategies ; however , the smallest hospitals were more likely to have implemented patient-centred care strategies . Conclusions There is insufficient evidence that involving patients and their representatives in QM leads to establishing or implementing strategies and procedures that facilitate patient-centred care ; however , lack of evidence should not be interpreted as evidence of no effect Background There is increasing interest in innovative methods to carry out systematic review s of complex interventions . Theory-based approaches , such as logic models , have been suggested as a means of providing additional insights beyond that obtained via conventional review methods . Methods This paper reports the use of an innovative method which combines systematic review processes with logic model techniques to synthesis e a broad range of literature . The potential value of the model produced was explored with stakeholders . Results The review identified 295 papers that met the inclusion criteria . The papers consisted of 141 intervention studies and 154 non-intervention quantitative and qualitative articles . A logic model was systematic ally built from these studies . The model outlines interventions , short term outcomes , moderating and mediating factors and long term dem and management outcomes and impacts . Interventions were grouped into typologies of practitioner education , process change , system change , and patient intervention . Short-term outcomes identified that may result from these interventions were changed physician or patient knowledge , beliefs or attitudes and also interventions related to changed doctor-patient interaction . A range of factors which may influence whether these outcomes lead to long term change were detailed . Dem and management outcomes and intended impacts included content of referral , rate of referral , and doctor or patient satisfaction . Conclusions The logic model details evidence and assumptions underpinning the complex pathway from interventions to dem and management impact . The method offers a useful addition to systematic review method ologies . Trial registration number PROSPERO registration number : CRD42013004037 Background A new model of complex diabetes care is provided by a multidisciplinary team which incorporates general practitioner ( GP ) Clinical Fellows supported by an Endocrinologist and diabetes educator within a community-based general practice setting . This study evaluates the health and clinical benefits of the new model of care , assesses the acceptability of the model to patients , GPs and other health professionals , and examines the cost-effectiveness of the model . Methods / Design The study is an open , non-inferiority r and omised controlled trial with data collected at baseline , 6 and 12 months . Participants are identified from new patients on hospital-based diabetes outpatient clinic waiting lists and new GP referrals . Eligible consenting patients are r and omised to either a community practice site ( intervention ) or a hospital site ( usual care ) . In the intervention model , medical care is led by a GP Clinical Fellow in partnership with an Endocrinologist . Quantitative measures include clinical indicators with HbA1c as the primary outcome ; patient-reported outcomes include health-related quality of life , mental health and satisfaction with care . Qualitative methods will be used to explore the perspectives and experiences of patients and providers regarding the new model of care . An economic evaluation will also be undertaken . Discussion This model of care seeks to improve the quality and safety of healthcare at the interface between the hospital and primary care sectors for patients with complex diabetes . The study will provide empirical evidence about the impact of the model of care on health outcomes , patient and clinician satisfaction , as well as any economic impacts . Trial registration Clinical Trials Registry Number : Background Case management has been suggested as an innovative strategy that facilitates the improvement of a patient 's quality of life , reduction of hospital length of stay , optimization of self-care and improvement of satisfaction of patients and professionals involved . However , there is little evidence about the effectiveness of the patient advocacy case management model in clinical practice .Therefore , the objective of our study was to examine the effects of the Dutch patient advocacy case management model for severely disabled Multiple Sclerosis ( MS ) patients and their caregivers compared to usual care . Methods / design In this r and omized controlled trial the effectiveness of casemanagement on quality of life of patients and their caregivers  , quality of care , service use and economic aspects were evaluated . The primary outcomes of this study were quality of life of MS- patients and caregiver burden of caregivers . Furthermore , we examined quality of life of caregivers , quality of care , service use and costs . Discussion This is a unique trial in which we examined the effectiveness of case management from a broad perspective . We meticulously prepared this study and applied important features and created important conditions for both intervention and research protocol to increase the likelihood of finding evidence for the effectiveness of patient advocacy case management . Concerning the intervention we anticipated to five important conditions : 1 ) the contrast between the case management intervention compared to the usual care seems to be large enough to detect intervention effects ; 2 ) we included patients with complex care situations and /or were at risk for critical situations ; 3 ) the case managers were familiar with disease specific health-problems and a broad spectrum of solutions ; 4 ) case managers were competent and authorized to perform a medical neurological examination and worked closely with neurologists specialized in MS ; and 5 ) the case managers had a regional network of professionals and health care organisations at their disposal , and were accepted as a coordinator of care . We also put a lot of effort on the selection of eligible patients , r and omization and statistical methods , but also on power analysis , selection of reliable , vali date d and sensitive outcome measures , and ( statistical ) control of confounders . Trial registration Dutch Trial Register http://www.trialregister.nl . Trial ID : NTR762 Background Prostate cancer ( PCa ) is the most common non-skin cancer among men in developed countries . Several novel treatments have been adopted by healthcare systems to manage PCa . Most of the observational studies and r and omized trials on PCa have concurrently evaluated fewer treatments over short follow-up . Further , preceding decision analytic models on PCa management have not evaluated various contemporary management options . Therefore , a contemporary decision analytic model was necessary to address limitations to the literature by synthesizing the evidence on novel treatments thereby forecasting short and long-term clinical outcomes . Objectives To develop and vali date a Markov Monte Carlo model for the contemporary clinical management of PCa , and to assess the clinical burden of the disease from diagnosis to end-of-life . Methods A Markov Monte Carlo model was developed to simulate the  management  of  PCa in men 65 years and older from diagnosis to end-of-life . Health states modeled were : risk at diagnosis , active surveillance , active treatment , PCa recurrence , PCa recurrence free , metastatic castrate resistant prostate cancer , overall and PCa death . Treatment trajectories were based on state transition probabilities derived from the literature . Validation and sensitivity analyses assessed the accuracy and robustness of model predicted outcomes . Results Validation indicated model predicted rates were comparable to observed rates in the published literature . The simulated distribution of clinical outcomes for the base case was consistent with sensitivity analyses . Predicted rate of clinical outcomes and mortality varied across risk groups . Life expectancy and health adjusted life expectancy predicted for the simulated cohort was 20.9 years ( 95%CI 20.5–21.3 ) and 18.2 years ( 95 % CI 17.9–18.5 ) , respectively . Conclusion Study findings indicated contemporary management strategies improved survival and quality of life in patients with PCa . This model could be used to compare long-term outcomes and life expectancy conferred of PCa management paradigms OBJECTIVE To study the effect of outpatient geriatric evaluation and management on physical function , mental status , and subjective well-being . DESIGN Prospect i ve r and omized controlled trial with a 1-year study period . SETTING Large medical school-affiliated public hospital in an urban community . SUBJECTS Patients at least 70 years old admitted to the medicine service were screened , r and omized , and completed a 1-year follow-up interview . INTERVENTIONS Comprehensive geriatric evaluation and an outpatient care management program . MAIN OUTCOME MEASURES Mental status ( SPMSQ ) , ADL ( Katz Index ) , IADL ( Five-Item OARS Scale ) , Life satisfaction ( LSI-Z ) , and self-perception of health status ( physical health section of OARS ) . RESULTS No significant differences were found for cognitive status , ADL functioning , life satisfaction , nursing home placement , or mortality . The experimental patients reported significantly higher function in IADL and more favorable self-perception of health status compared with controls . CONCLUSION Outpatient comprehensive geriatric evaluation and management appears to be a useful model for providing care to medically frail elderly patients Background Primary health professionals are well positioned to support the delivery of patient self-management in an evidence -based , structured capacity . A need exists to better underst and the active components required for effective self-management support , how these might be delivered within primary care , and the training and system changes that would subsequently be needed . Objectives ( 1 ) To examine self-management support interventions in primary care on health outcomes for a wide range of diseases compared to usual st and ard of care ; and ( 2 ) To identify the effective strategies that facilitate positive clinical and humanistic outcomes in this setting . Method A systematic review of r and omized controlled trials evaluating self-management support interventions was conducted following the Cochrane h and book & PRISMA guidelines . Published literature was systematic ally search ed from inception to June 2019 in PubMed , Scopus and Web of Science . Eligible studies assessed the effectiveness of individualized interventions with follow-up , delivered face-to-face to adult patients with any condition in primary care , compared with usual st and ard of care . Matrices were developed that mapped the evidence and components for each intervention . The method ological quality of included studies were appraised . Results 6,510 records were retrieved . 58 studies were included in the final qualitative synthesis . Findings reveal a structured patient-provider exchange is required in primary care ( including a one-on-one patient-provider consultation , ongoing follow up and provision of self-help material s ) . Interventions should be tailored to patient needs and may include combinations of strategies to improve a patient ’s disease or treatment knowledge ; independent monitoring of symptoms , encouraging self-treatment through a personalized action plan in response worsening symptoms or exacerbations , psychological coping and stress management strategies , and enhancing responsibility in medication adherence and lifestyle choices . Follow-up may include tailored feedback , monitoring of progress with respect to patient set healthcare goals , or honing problem-solving and decision-making skills . Theoretical models provided a strong base for effective SMS interventions . Positive outcomes for effective SMS included improvements in clinical indicators , health-related quality of life , self-efficacy ( confidence to self-manage ) , disease knowledge or control . An SMS model has been developed which sets the foundation for the design and evaluation of practical strategies for the construct of self-management support interventions in primary healthcare practice . Conclusions These findings provide primary care professionals with evidence -based strategies and structure to deliver SMS in practice . For this collaborative partnership approach to be more widely applied , future research should build on these findings for optimal SMS service design and upskilling healthcare providers to effectively support patients in this collaborative process OBJECTIVE Population -level strategies may improve primary care for diabetes . We design ed a controlled study to assess the impact of population management versus usual care on metabolic risk factor testing and management in patients with type 2 diabetes . We also identified potential patient-related barriers to effective diabetes management . RESEARCH DESIGN AND METHODS We used novel clinical software to rank 910 patients in a diabetes registry at a single primary care clinic and thereby identify the 149 patients with the highest HbA(1c ) and cholesterol levels . After review of the medical records of these 149 patients , evidence -based guideline recommendations regarding metabolic testing and management were sent via e-mail to each intervention patient 's primary care provider ( PCP ) . Over a 3-month follow-up period , we assessed changes in the evidence -based management of intervention patients compared with a matched cohort of control patients receiving usual care  at a second primary care clinic affiliated with the same academic medical center . RESULTS In the intervention cohort , PCPs followed testing recommendations more often ( 78 % ) than therapeutic change recommendations ( 36 % , P = 0.001 ) . Compared with the usual care control cohort , population management result ed in a greater overall proportion of evidence -based guideline practice s being followed ( 59 vs. 45 % , P = 0.02 ) . Most intervention patients ( 62 % ) had potential barriers to effective care , including depression ( 35 % ) , substance abuse ( 26 % ) , and prior nonadherence to care plans ( 18 % ) . CONCLUSIONS Population management with clinical recommendations sent to PCPs had a modest but statistically significant impact on the evidence -based management of diabetes compared with usual care . Depression and substance abuse are prevalent patient-level adherence barriers in patients with poor metabolic control Background An aging population poses significant challenges to health care in China .  Health management has been implemented to reduce the costs of care , raise health service utilization , increase health knowledge and improve quality of life . Several studies have tried to verify the effectiveness of health management in achieving these goals worldwide . However , there have been insufficient r and omized control trials ( RCTs ) to draw reliable conclusions . The few small-scale studies conducted in China include mostly the general population rather than the elderly . Our study is design ed to evaluate the impact of community-based health management on the health of the elderly through an RCT in Nanjing , China . Methods Two thous and four hundred participants , aged 60 or older and who gave informed consent , were r and omly allocated 1:1 into management and control groups , the r and omization schedule was concealed from community health service center staff until allocation . Community-based health management was applied in the former while the latter was only given usual care . After 18 months , three categories of variables ( subjective grading health indices , objective health indices and health service utilization ) were measured based on a question naire , clinical monitoring and diagnostic measurements . Differences between the two groups were assessed before and after the intervention and analyzed with t-test , χ2-test , and multiple regression analysis . Results Compared with the control group , the management group demonstrated improvement on the following variables ( P<0.01 ) : health knowledge score , self-evaluated psychological conditions , overall self-evaluated health conditions , diet score , physical activity duration per week , regular blood pressure monitoring , waist-to-hip ratio , systolic blood pressure and fasting blood sugar . The number of outpatient clinic visits did not differ significantly ( P=0.60 ) between the two groups before intervention , while after intervention it was smaller in the management group than in the control group ( P<0.01 ) . However , the number of hospital admissions in the preceding 6 months was not different between the two groups even after intervention ( P=0.36 ) . Multiple regression analysis showed that gender , age , education level , chronic disease status and self-evaluated psychological conditions were important factors affecting health knowledge score , BMI , and waist-to-hip ratio .  Conclusion Community-based health management improved both subjective grading health indices , objective health indices and decreased the number of outpatient clinic visits , demonstrating effectiveness in improving elderly health . Trial registration Background To improve quality of care and patient outcomes , health system decision-makers need to identify and implement effective interventions . An increasing number of systematic review s document the effects of quality improvement programs to assist decision-makers in developing new initiatives . However , limitations in the reporting of primary studies and current meta- analysis methods ( including approaches for exploring heterogeneity ) reduce the utility of existing syntheses for health system decision-makers . This study will explore the role of innovative meta- analysis approaches and the added value of enriched and up date d data for increasing the utility of systematic review s of complex interventions . Methods / Design We will use the data set from our recent systematic review of 142 r and omized trials of diabetes quality improvement programs  to evaluate novel approaches for exploring heterogeneity . These will include exploratory methods , such as multivariate meta-regression analyses and all-subsets combinatorial meta- analysis . We will then up date our systematic review to include new trials and enrich the data set by surveying authors of all included trials . In doing so , we will explore the impact of variables not , reported in previous publications , such as details of study context , on the effectiveness of the intervention . We will use innovative analytical methods on the enriched and up date d data set to identify key success factors in the implementation of  quality improvement interventions  for diabetes . Decision-makers will be involved throughout to help identify and prioritize variables to be explored and to aid in the interpretation and dissemination of results . Discussion This study will inform future systematic review s of complex interventions and describe the value of enriching and updating data for exploring heterogeneity in meta- analysis . It will also result in an up date d comprehensive systematic review of diabetes quality improvement interventions that will be useful to health system decision-makers in developing interventions to improve outcomes for people with diabetes . Systematic review registration PROSPERO registration no. Research ers conducting systematic review s need to search multiple bibliographic data bases such as MEDLINE and EMBASE . However , research ers have no rational search stopping rule when looking for potentially-relevant articles . We empirically tested a stopping rule based on the concept of  capture-mark-recapture ( CMR ) , which was first pioneered in ecology . The principles of CMR can be adapted to systematic review s and meta-analyses to estimate the Horizon of articles in the literature with its confidence interval . We retrospectively tested this Horizon Estimation using a systematic review of r and omized controlled trials ( RCTs ) that evaluated clinical decision support tools for osteoporosis disease management . The Horizon Estimation was calculated based on 4 bibliographic data bases that were included as the main data sources for the review in the following order : MEDLINE , EMBASE , CINAHL , and EBM Review s. The systematic review captured 68 % of known articles from the 4 data sources , which represented 592 articles that were estimated as missing from the Horizon OBJECTIVE To document outcomes of a r and omized trial of the PhoenixCare demonstration program of palliative care and coordinated care/case management for seriously chronically ill individuals who simultaneously received active treatment from managed care organizations ( MCOs ) . DESIGN Patients , continuously enrolled between July 1999 , and March 2001 , were r and omly assigned to the PhoenixCare program  or a control group receiving usual MCO care . SETTING Hospice of the Valley , Phoenix , Arizona . PARTICIPANTS Participants were 192 patients with chronic obstructive pulmonary disease ( COPD ) or chronic heart failure ( CHF ) , who had an estimated 2-year life expectancy . INTERVENTION Intensive home-based case management provided by registered nurse casemanagers , in coordination with patients ' existing source of medical care , comprised the intervention . Program foci included disease and symptom management , patient self-management of illness and knowledge of illness-related re sources , preparation for end-of life , physical and mental functioning , and utilization of medical services . OUTCOME MEASURES Outcomes , assessed every 3 months by telephone interview , included measures related to all program foci ; the SF-36 was used to evaluate physical and mental functioning ; emergency department visits exemplified medical service utilization . RESULTS Compared to controls , PhoenixCare patients exhibited significantly better outcomes on self-management of illness , awareness of illness-related re sources , and legal preparation for end of life . They reported lower symptom distress , greater vitality , better physical functioning and higher self-rated health than r and omized controls . Emergency department utilization was equivalent across groups . Patients with COPD showed stronger responsiveness to the intervention . CONCLUSION A novel model of patient care that combined greatly enhanced palliative carefocused case management with ongoing MCO-based treatment was associated with improved functioning of chronically severely ill patients in the last years of life
Less frequently reported were quality of life , patient satisfaction , self-care , and healthcare utilization .
Most care management modalities were carved out from primary care .
Conclusions Most care management programs for patients with type 2 diabetes are ' carved-out ' , accomplish limited effects on metabolic outcomes , and have unknown effects on patient important outcomes .
Background This systematic review and meta- analysis aims at assessing the composition and performance of care management models evaluated in the last decade and their impact on patient important outcomes .