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Method of the Review
A three-step search strategy was used in this review. An initial limited search of MEDLINE and CINAHL was undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second keywords and index term search was then undertaken across Embase, Informit Online, PsycINFO, Scopus, and Web of Science. Duplications were then identified and the most complete record retained for subsequent review on inclusion criteria. Additional file 1 http://www.biomedcentral.com/1471-2296/16/102/additional provides an example of the Medline search strategy.
Inclusion Criteria
Population and Context. This review considered studies that focused on patients with one or more of the more prevlant major chronic diseases as defined by the World Health Organisation - cardiovascular disease, chronic kidney disease, chronic respiratory disease, type 2 diabetes mellitus and depression - receiving care in primary healthcare settings, as well as all primary healthcare providers such as doctors, nurses and administrators.
Primary healthcare is generally defined as first-contact, accessible, continued, comprehensive and coordinated healthcare provided by a single practitioner (e.g. GP, nurse practitioner) or a multidisciplinary team of professionals in a community practice. For the purposes of this review however, primary healthcare is first-contact, accessible, continued, comprehensive and coordinated care. First-contact care is accessible at the time of need; ongoing care focuses on the long-term health of a person rather than the short duration of the disease comprehensive care is a range of services appropriate to the common problems in the respective population and coordination is the role by which primary care acts to coordinate other specialists that the patient may need. Primary healthcare also includes primary care settings that have only one health professional, i.e. a general practitioner (GP).
Phenomena of Interest/Intervention. The phenomena of interest were the attitudes, beliefs, expectations, understandings, perceptions, experiences, resources and knowledge of healthcare providers and patients about what supports (facilitators) or inhibits (barriers) the implementation of CCMs within a primary healthcare setting. To be included studies must have also referred to a CCM which included at least two of the following elements:
Facilitated community support (CS) to meet the needs of patients
Facilitated unpaid/informal family support (FS) to meet the needs of patients
Enhanced health care professional case management (CM) support to meet the needs of patients
Self-management support (SMS) to meet the needs of patients
Health organisational change (OC) to meet the needs of health-care providers
Delivery system design (DSD) to meet the needs of health-care providers
Decision support (DS) to meet the needs of health-care providers
Clinical information systems (CIS) to meet the needs of health-care providers
Outcome. Finally, this review only considered studies that included attitudes, beliefs, expectations, understandings, perceptions, experiences, resources and knowledge according to healthcare providers support (facilitators) or inhibit (barriers) the implementation of CCMs.
Types of Studies
This review focused on both qualitative and quantitative studies (e.g. randomised and non-randomised control trials, cross-sectional and cohort studies, case studies and case series). Papers were limited to those published in English between 1998 and 2013.
Data Collection
Data was extracted from primary studies and included in the review using a set of pre-defined tables. The extracted data included specific details about the chronic care model, populations, study methods and outcomes of significance to the review questions and objectives. Extracted data included:
Study type
Chronic disease
Study setting (country and region)
Chronic care elements
These data on the included studies are presented in an additional file [see Additional file 2] http://www.biomedcentral.com/1471-2296/16/102/additional.
Critical Appraisal
Two reviewers independently assessed the quality of the papers prior to inclusion in this review. The Cochrane Handbook for Systematic Reviews of Interventions was used to assess bias for randomised and non-randomised control trials, cross-sectional and cohort studies. The Joanna Briggs critical appraisal tool was used to measure the quality of case studies and case series. As the objective of this review was to facilitators and barriers to implementing CCMs, studies were not excluded based on these critical appraisals.
Data Extraction
Data was extracted where possible by themes identified by the authors of each study. Where themes were not identified within the study, findings were extracted from the narrative discussion by a reviewer (CD) in the form of a definitive statement made by the authors and supported by the presentation of data. Qualitative findings and the quantiative findings presented in narrative form were pooled. Findings were first inductively grouped into categories that were created on the basis of similarity of meaning; categories were then subjected to a meta-aggregation in order to produce a single comprehensive set of synthesized findings that could be used as a basis for evidence-based practice which would inform policy makers and practitioners on the facilitators and barriers associated with implementing a CCM.
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