Factors influencing the implementation of chronic care models: A systematic literature review.

BACKGROUND: The increasing prevalence of chronic disease faced by both developed and developing countries is of considerable concern to a number of international organisations. Many of the interventions to address this concern within primary healthcare settings are based on the chronic care model (CCM). The implementation of complex interventions such as CCMs requires careful consideration and planning. Success depends on a number of factors at the healthcare provider, team, organisation and system levels. METHODS: The aim of this systematic review was to systematically examine the scientific literature in order to understand the facilitators and barriers to implementing CCMs within a primary healthcare setting. This review focused on both quantitative and qualitative studies which included patients with chronic disease (cardiovascular disease, chronic kidney disease, chronic respiratory disease, type 2 diabetes mellitus, depression and HIV/AIDS) receiving care in primary healthcare settings, as well as primary healthcare providers such as doctors, nurses and administrators. Papers were limited to those published in English between 1998 and 2013. RESULTS: The search returned 3492 articles. The majority of these studies were subsequently excluded based on their title or abstract because they clearly did not meet the inclusion criteria for this review. A total of 226 full text articles were obtained and a further 188 were excluded as they did not meet the criteria. Thirty eight published peer-reviewed articles were ultimately included in this review. Five primary themes emerged. In addition to ensuring appropriate resources to support implementation and sustainability, the acceptability of the intervention for both patients and healthcare providers contributed to the success of the intervention. There was also a need to prepare healthcare providers for the implementation of a CCM, and to support patients as the way in which they receive care changes. CONCLUSION: This systematic review demonstrated the importance of considering human factors including the influence that different stakeholders have on the success or otherwise of the implementing a CCM.

Effectiveness of chronic care models: opportunities for improving healthcare practice and health outcomes: a systematic review.

BACKGROUND: The increasing prevalence of chronic disease and even multiple chronic diseases faced by both developed and developing countries is of considerable concern. Many of the interventions to address this within primary healthcare settings are based on a chronic care model first developed by MacColl Institute for Healthcare Innovation at Group Health Cooperative. METHODS: This systematic literature review aimed to identify and synthesise international evidence on the effectiveness of elements that have been included in a chronic care model for improving healthcare practices and health outcomes within primary healthcare settings. The review broadens the work of other similar reviews by focusing on effectiveness of healthcare practice as well as health outcomes associated with implementing a chronic care model. In addition, relevant case series and case studies were also included. RESULTS: Of the 77 papers which met the inclusion criteria, all but two reported improvements to healthcare practice or health outcomes for people living with chronic disease. While the most commonly used elements of a chronic care model were self-management support and delivery system design, there were considerable variations between studies regarding what combination of elements were included as well as the way in which chronic care model elements were implemented. This meant that it was impossible to clearly identify any optimal combination of chronic care model elements that led to the reported improvements. CONCLUSIONS: While the main argument for excluding papers reporting case studies and case series in systematic literature reviews is that they are not of sufficient quality or generalizability, we found that they provided a more detailed account of how various chronic care models were developed and implemented. In particular, these papers suggested that several factors including supporting reflective healthcare practice, sending clear messages about the importance of chronic disease care and ensuring that leaders support the implementation and sustainability of interventions may have been just as important as a chronic care model's elements in contributing to the improvements in healthcare practice or health outcomes for people living with chronic disease.

Sociodemographic characteristics of New Zealand adult smokers, ex-smokers, and non-smokers: results from the 2006 Census.

AIM: To analyse adult smoking rates in New Zealand using 2006 Census data METHODS: Data from the 2006 Census of Population and Dwellings were analysed for smoking status against various demographic variables. Data were compared against 1996 Census data to identify changes in smoking prevalence. Age standardised rates were calculated for gender and ethnicity using the WHO Population Standard. RESULTS: The prevalence of regular smokers aged 15 years and over in New Zealand in 2006 was 20.7%, a 3% decrease since 1996. People identifying with Maori and Pacific ethnic groups as well as people who reside in areas of greater deprivation, who earn less, and who are unemployed continue to have the highest rates of smoking. The prevalence of never having smoked regularly has increased among 15 to 19 year olds; increases are not reflected to the same extent among 20 to 24 year olds, however, thus suggesting a possible increase in the age of initiation over the last 10 years. CONCLUSION: While the prevalence of smoking in New Zealand continues to decline, the decrease is gradual--3% over 10 years, largely due to a reduction in initiation rather than increased cessation--and significant ethnic and socioeconomic inequalities in smoking persist. These findings are being used to inform policy and practice in tobacco control, including ensuring that programmes and initiatives are accessible and reliably delivered to groups with the highest smoking rates.