Context, mechanisms and outcomes of integrated care for diabetes mellitus type 2: a systematic review.

backgroundIntegrated care interventions for chronic conditions can lead to improved outcomes, but it is not clear when and why this is the case. This study aims to answer the following two research questions: First, what are the context, mechanisms and outcomes of integrated care for people with type 2 diabetes? Second, what are the relationships between context, mechanisms and outcomes of integrated care for people with type 2 diabetes?

methodsA systematic literature search was conducted for the period 2003-2013 in Cochrane and PubMed. Articles were included when they focussed on integrated care and type 2 diabetes, and concerned empirical research analysing the implementation of an intervention. Data extraction was performed using a common data extraction table. The quality of the studies was assessed with the Mixed Methods Appraisal Tool. The CMO model (context + mechanism = outcome) was used to study the relationship between context factors (described by the barriers and facilitators encountered in the implementation process and categorised at the six levels of the Implementation Model), mechanisms (defined as intervention types and described by their number of Chronic Care Model (sub-)components) and outcomes (the intentional and unintentional effects triggered by mechanism and context).

resultsThirty-two studies met the inclusion criteria. Most reported barriers to the implementation process were found at the organisational context level and most facilitators at the social context level. Due to the low number of articles reporting comparable quantitative outcome measures or in-depth qualitative information, it was not possible to make statements about the relationship between context, mechanisms and outcomes.

conclusionsEfficient resource allocation should entail increased investments at the organisational context level where most barriers are expected to occur. It is likely that investments at the social context level will also help to decrease the development of barriers at the organisational context level, especially by increasing staff involvement and satisfaction. If future research is to adequately inform practice and policy regarding the impact of these efforts on health outcomes, focus on the actual relationships between context, mechanisms and outcomes should be actively incorporated into study designs.