Yiu Kristy C, Rohwer Anke, Young Taryn
McMaster University, 1280, Hamilton, ON, L8S 4L8, Canada.
Centre of Evidence Based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa.
BMC Health Serv Res. 2018 Jun 20;18(1):481. doi: 10.1186/s12913-018-3290-8.
With the rise in pre-mature mortality rate from non-communicable disease (NCD), there is a need for evidence-based interventions. We evaluated existing systematic reviews on effectiveness of integration of healthcare services, in particular with focus on delivery of care designed to improve health and process outcomes in people with multi-morbidity, where at least one of the conditions was diabetes or hypertension.
We searched MEDLINE, EMBASE, Cochrane Library, and Health Evidence to November 8, 2016 and consulted experts. One review author screened titles, abstracts and two review authors independently screened short listed full-texts and selected reviews for inclusion. We considered systematic reviews evaluating integration of care, compared to usual care, for people with multi-morbidity. One review author extracted data and another author verified it. Two review authors independently evaluated risk of bias using ROBIS and AMSTAR. Inter-rater reliability was analysed for ROBIS and AMSTAR using Cohen's kappa and percent agreement. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was used to assess reporting.
We identified five systematic reviews on integration of care. Four reviews focused on comorbid diabetes and depression and two covered hypertension and comorbidities of cardiovascular disease, depression, or diabetes. Interventions were poorly described. The health outcomes evaluated included risk of all-cause mortality, measures of depression, cholesterol levels, HbA1c levels, effect of depression on HbA1c levels, symptom improvement, systolic blood pressure, and hypertension control. Process outcomes included access and utilisation of healthcare services, costs, and quality of care. Overall, three reviews had a low and medium risk of bias according to ROBIS and AMSTAR respectively, while two reviews had high risk of bias as judged by both ROBIS and AMSTAR. Findings have demonstrated that collaborative care in general resulted in better health and process outcomes when compared to usual care for both depression and diabetes and hypertension and diabetes.
Several knowledge gaps were identified on integration of care for comorbidities with diabetes and/or hypertension: limited research on this topic for hypertension, limited reviews that included primary studies based in low-middle income countries, and limited reviews on collaborative care for communicable and NCDs.
随着非传染性疾病（NCD）导致的过早死亡率上升，需要有循证干预措施。我们评估了关于整合医疗服务有效性的现有系统评价，尤其关注旨在改善患有多种疾病人群的健康和诊疗过程结局的医疗服务提供情况，其中至少有一种疾病为糖尿病或高血压。
我们检索了截至2016年11月8日的MEDLINE、EMBASE、Cochrane图书馆和健康证据库，并咨询了专家。一名综述作者筛选标题、摘要，两名综述作者独立筛选入围的全文，并选择纳入的综述。我们纳入了评估针对患有多种疾病人群的整合医疗服务（与常规医疗服务相比）的系统评价。一名综述作者提取数据，另一名作者进行核实。两名综述作者使用ROBIS和AMSTAR独立评估偏倚风险。使用Cohen's kappa系数和百分比一致性分析ROBIS和AMSTAR的评分者间信度。使用系统评价和Meta分析的首选报告项目（PRISMA）清单评估报告情况。
我们确定了五项关于整合医疗服务的系统评价。四项综述关注糖尿病合并抑郁症，两项涵盖高血压以及心血管疾病、抑郁症或糖尿病的合并症。干预措施描述不佳。评估的健康结局包括全因死亡率风险、抑郁测量指标、胆固醇水平、糖化血红蛋白（HbA1c）水平、抑郁对HbA1c水平的影响、症状改善情况、收缩压和高血压控制情况。诊疗过程结局包括医疗服务的可及性和利用情况、成本以及医疗质量。总体而言，根据ROBIS和AMSTAR评估，分别有三项综述存在低和中度偏倚风险，而根据ROBIS和AMSTAR判断，有两项综述存在高偏倚风险。研究结果表明，与针对抑郁症和糖尿病以及高血压和糖尿病的常规医疗服务相比，协作式医疗总体上能带来更好的健康和诊疗过程结局。
在糖尿病和/或高血压合并症的整合医疗服务方面发现了几个知识空白：针对高血压这一主题的研究有限，纳入中低收入国家初级研究的综述有限，以及关于传染病和非传染性疾病协作式医疗的综述有限。
