Understanding the Chronic Disease Management Programs: A Comprehensive Literature Review
Main Article Content
Abstract
Chronic diseases, such as diabetes, heart disease, and chronic obstructive pulmonary disease (COPD), persist over a year and necessitate ongoing medical attention or limit daily activities, posing significant challenges to global healthcare systems and economies. Chronic disease management programs (CDMPs) aim to provide comprehensive, patient- centered care worldwide. This review synthesizes evidence from diverse studies, including observational research, systematic reviews, randomized trials, and retrospective analyses, to evaluate CDMP effectiveness across different populations and settings. Positive impacts include Chronic Disease Self- Management Education workshops reducing loneliness among older adults, eHealth interventions enhancing self- management skills and quality of life for chronic kidney disease patients, and lifestyle interventions benefiting cardiovascular health in low-income women. Technological innovations, such as personalized messaging systems, have improved engagement in diabetes prevention. CDMPs are pivotal in enhancing clinical outcomes, patient satisfaction, and reducing healthcare utilization through tailored, multidisciplinary approaches integrating technology. Challenges include ensuring consistent implementation and addressing access disparities. Future research should refine strategies, assess long-term sustainability, and explore innovative approaches to optimize chronic disease management globally. Continuous evolution of CDMPs is essential to mitigate chronic disease impacts, improving health outcomes and quality of life globally.
Keywords:
Chronic diseases, CDMPs, patient-centered care, effectiveness evaluation, multidisciplinary approaches, global health
Article Details
How to Cite
GBIGBI-JACKSON, Grace A. et al.
Understanding the Chronic Disease Management Programs: A Comprehensive Literature Review.
Medical Research Archives, [S.l.], v. 12, n. 7, july 2024.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/5647>. Date accessed: 21 dec. 2024.
doi: https://doi.org/10.18103/mra.v12i7.5647.
Section
Review Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
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23. Rodriguez DV, Chen J, Viswanadham RVN, Lawrence K, Mann D. Leveraging Machine Learning to Develop Digital Engagement Phenotypes of Users in a Digital Diabetes Prevention Program: Evaluation Study. JMIR AI. 2024;3:e47122. Published 2024 Mar 1. doi:10.2196/47122
24. Daniels J, Leypoldt M, Dillon C, Sweazy A, Crane J. Outcome Evaluation of a Public Health Intervention on Cardiovascular Disease (CVD) Prevention Among Women Aged 40-64 with Low Incomes in Nebraska. J Public Health Manag Pract. 2024;30:S62-S70. doi:10.1097/PHH.0000000000001925
25. Calvert B, Bayakly R, Newsome T. Stroke Prevention and Management in Rural Georgia: Evaluating the Effectiveness of a Community Paramedicine Program. J Public Health Manag Pract. 2024;30:S32-S38. doi:10.1097/PHH.0000000000001951
26. Barragan NC, Wu C, Ly A, Oh SM, Kuo T. Testing an Innovative Approach to Improve Hypertension Management at a Federally Qualified Health Center. J Public Health Manag Pract. 2024;30:S46-S51. doi:10.1097/PHH.0000000000001901
27. Shen H, van der Kleij R, van der Boog PJM, Chavannes NH. Developing a Tailored eHealth Self-Management Intervention for Patients With Chronic Kidney Disease in China: Intervention Mapping Approach. JMIR Form Res. 2024;8:e48605. Published 2024 Jun 13. doi:10.2196/48605
28. Steinman L, Chadwick K, Chavez Santos E, et al. Remote Evidence-Based Programs for Health Promotion to Support Older Adults During the COVID-19 Pandemic and Beyond: Mixed Methods Outcome Evaluation. JMIR Aging. 2024;7:e52069. Published 2024 Jun 13. doi:10.2196/52069
29. Tang M, Zhao R, Lv Q. Status and influencing factors of frailty in hospitalized patients with chronic heart failure: A cross-sectional study. J Clin Nurs. Published online June 13, 2024. doi:10.1111/jocn.17324
30. Woods-Giscombe CL, Gaylord S, Bradford AB, et al. Protocol of the HARMONY study: A culturally relevant, randomized-controlled, stress management intervention to reduce cardiometabolic risk in African American women. Contemp Clin Trials. Published online June 10, 2024. doi:10.1016/j.cct.2024.107604
31. Mathews M, Lyons R, Harris S, et al. Evaluation of a unique and innovative diabetes care model in primary care in Ontario, Canada: protocol for a multiple-methods study with a convergent parallel design. BMJ Open. 2024;14(6):e088737. Published 2024 Jun 10. doi:10.1136/bmjopen-2024-088737
32. Hong HC, Kim YM. Multimorbidity and its Associated Factors in Korean Shift Workers: Population-Based Cross-Sectional Study. JMIR Public Health Surveill. 2024;10:e55014. Published 2024 Jun 10. doi:10.2196/55014
33. Dalakoti M, Wong S, Lee W, et al. Incorporating AI into cardiovascular diseases prevention-insights from Singapore. Lancet Reg Health West Pac. 2024;48:101102. Published 2024 May 27. doi:10.1016/j.lanwpc.2024.101102
34. Chan JC, Mbanya JC, Chantelot JM, et al. Patient-reported outcomes and treatment adherence in type 2 diabetes using natural language processing: Wave 8 of the Observational International Diabetes Management Practices Study. J Diabetes Investig. Published online June 5, 2024. doi:10.1111/jdi.14228
35. Iyngkaran P, Buhler M, de Courten M, Hanna F. Effectiveness of self-management programmes for heart failure with reduced ejection fraction: a systematic review protocol. BMJ Open. 2024;14(6):e079830. Published 2024 Jun 5. doi:10.1136/bmjopen-2023-079830
36. Ou TY, Huy LD, Mayne J, et al. Global mortality of chronic liver diseases attributable to Hepatitis B virus and Hepatitis C virus infections from 1990 to 2019 and projections to 2030. J Infect Public Health. Published online May 8, 2024. doi:10.1016/j.jiph.2024.04.027
37. Mehta SJ, Volpp KG, Troxel AB, et al. Remote Blood Pressure Monitoring With Social Support for Patients With Hypertension: A Randomized Clinical Trial. JAMA Netw Open. 2024;7(6):e2413515. Published 2024 Jun 3. doi:10.1001/jamanetworkopen.2024.13515
38. Roche N, Caron A, Emery C, et al. Évaluation médicoéconomique du PRADO-BPCO, programme d’accompagnement post-exacerbation [Medico-economic evaluation of the PRADO-BPCO post-exacerbation support program]. Rev Mal Respir. 2024;41(6):409-420. doi:10.1016/j.rmr.2024.05.001
39. Hearn R, Selfe J, Cordero MI, Dobbin N. The effects of person-centred active rehabilitation on symptoms of suspected Chronic Traumatic Encephalopathy: A mixed-methods single case design. PLoS One. 2024;19(5):e0302260. Published 2024 May 30. doi:10.1371/journal.pone.0302260
40. Burke JF, Sussman JB, Yaffe K, et al. Effect of Population-Level Blood Pressure Treatment Strategies on Cardiovascular and Cognitive Outcomes. Circ Cardiovasc Qual Outcomes. 2024;17(6):e010288. doi:10.1161/CIRCOUTCOMES.123.010288
41. Peytremann-Bridevaux I, Staeger P, Bridevaux PO, Ghali WA, Burnand B. Effectiveness of chronic obstructive pulmonary disease-management programs: systematic review and meta-analysis. Am J Med. 2008;121(5):433-443.e4. doi:10.1016/j.amjmed.2008.02.009
42. Reilly R, Evans K, Gomersall J, et al. Effectiveness, cost effectiveness, acceptability and implementation barriers/enablers of chronic kidney disease management programs for Indigenous people in Australia, New Zealand and Canada: a systematic review of mixed evidence. BMC Health Serv Res. 2016;16:119. Published 2016 Apr 6. doi:10.1186/s12913-016-1363-0
43. Adamopoulos S, Bonios M, Ben Gal T, et al. Right heart failure with left ventricular assist devices: Preoperative, perioperative and postoperative management strategies. A clinical consensus statement of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. Published online June 10, 2024. doi:10.1002/ejhf.3323
44. Harvey AR, Meehan E, Merrick N, et al. Comprehensive care programmes for children with medical complexity. Cochrane Database Syst Rev. 2024;5(5):CD013329. Published 2024 May 30. doi:10.1002/14651858.CD013329.pub2
45. Golabi P, Owrangi S, Younossi ZM. Global perspective on nonalcoholic fatty liver disease and nonalcoholic steatohepatitis - prevalence, clinical impact, economic implications and management strategies. Aliment Pharmacol Ther. 2024;59 Suppl 1:S1-S9. doi:10.1111/apt.17833
2. Bernell S, Howard SW. Use Your Words Carefully: What Is a Chronic Disease?. Front Public Health. 2016;4:159. Published 2016 Aug 2. doi:10.3389/fpubh.2016.00159
3. NCACCH: Chronic disease management program. Accessed on: June 10, 2024. Chronic Disease Management Program (CDMP) – NCACCH
4. New directions in healthcare for resource limited settings: managing chronic conditions optimizing health throughout life. Accessed on: June 10, 2024. Managing Chronic Conditions Optimizing Health Throughout Life (fhi360.org)
5. Fortin, M., Chouinard, MC., Bouhali, T. et al. Evaluating the integration of chronic disease prevention and management services into primary health care. BMC Health Serv Res 13, 132 (2013). https://doi.org/10.1186/1472-6963-13-132
6. Airhihenbuwa CO, Tseng TS, Sutton VD, Price L. Global Perspectives on Improving Chronic Disease Prevention and Management in Diverse Settings. Prev Chronic Dis. 2021;18:E33. Published 2021 Apr 8. doi:10.5888/pcd18.210055
7. Goodridge D, Bandara T, Marciniuk D, et al. Promoting chronic disease management in persons with complex social needs: A qualitative descriptive study. Chron Respir Dis. 2019;16:1479973119832025. doi:10.1177/1479973119832025
8. Primary Care pages: Chronic disease management programme. Accessed on: June 10, 2024. Chronic Disease Management Programme (CDMP) (primarycarepages.sg)
9. Chen Z, Liang N, Zhang H, et al. Harnessing the power of clinical decision support systems: challenges and opportunities. Open Heart. 2023;10(2):e002432. Published 2023 Nov 28. doi:10.1136/openhrt-2023-002432
10. Goorts K, Dizon J, Milanese S. The effectiveness of implementation strategies for promoting evidence informed interventions in allied healthcare: a systematic review. BMC Health Serv Res. 2021;21(1):241. Published 2021 Mar 18. doi:10.1186/s12913-021-06190-0
11. Paone D. Factors Supporting Implementation among CDSMP Organizations. Front Public Health. 2015;2:237. Published 2015 Apr 27. doi:10.3389/fpubh.2014.00237
12. Powell BJ, Fernandez ME, Williams NJ, et al. Enhancing the Impact of Implementation Strategies in Healthcare: A Research Agenda. Front Public Health. 2019;7:3. Published 2019 Jan 22. doi:10.3389/fpubh.2019.00003
13. Haleem A, Javaid M, Singh RP, Suman R. Telemedicine for healthcare: Capabilities, features, barriers, and applications. Sens Int. 2021;2:100117. doi:10.1016/j.sintl.2021.100117
14. Hajat C, Stein E. The global burden of multiple chronic conditions: A narrative review. Prev Med Rep. 2018;12:284-293. Published 2018 Oct 19. doi:10.1016/j.pmedr.2018.10.008
15. Ansah JP, Chiu CT. Projecting the chronic disease burden among the adult population in the United States using a multi-state population model. Front Public Health. 2023;10:1082183. Published 2023 Jan 13. doi:10.3389/fpubh.2022.1082183
16. WHO: Management of noncommunicable diseases (2024). Accessed on: June 10, 2024. Management of noncommunicable diseases (who.int)
17. WHO IRIS: How can chronic disease management programmes operate across care settings and providers? How can chronic disease management programmes operate across care settings and providers? (who.int)
18. CDC: Fast facts: Health and economic costs of chronic conditions. Accessed on: June 15, 2024. Fast Facts: Health and Economic Costs of Chronic Conditions | Chronic Disease | CDC
19. Smith ML, Chen E, Lau CA, Davis D, Simmons JW, Merianos AL. Effectiveness of chronic disease self-management education (CDSME) programs to reduce loneliness. Chronic Illn. 2023;19(3):646-664. doi:10.1177/17423953221113604
20. Hisashige A. The effectiveness and efficiency of disease management programs for patients with chronic diseases. Glob J Health Sci. 2012;5(2):27-48. Published 2012 Nov 26. doi:10.5539/gjhs.v5n2p27
21. Solanes I, Bolíbar I, Llauger MA, et al. ¿Es útil la implantación de programas de gestión clínica de los pacientes con enfermedad pulmonar obstructiva crónica? Comparación de la efectividad de dos intervenciones sobre la evolución clínica y la atención recibida [Is the introduction of clinical management programs for patients with chronic obstructive pulmonary disease useful? Comparison of the effectiveness of two interventions on the clinical progress and care received]. Aten Primaria. 2018;50(3):184-196. doi:10.1016/j.aprim.2017.01.014
22. Nica AE, Rusu E, Dobjanschi CG, et al. Sudoscan's Effectiveness in Identifying Chronic Kidney Disease in Patients With Type 2 Diabetes. Cureus. 2024;16(5):e60344. Published 2024 May 15. doi:10.7759/cureus.60344
23. Rodriguez DV, Chen J, Viswanadham RVN, Lawrence K, Mann D. Leveraging Machine Learning to Develop Digital Engagement Phenotypes of Users in a Digital Diabetes Prevention Program: Evaluation Study. JMIR AI. 2024;3:e47122. Published 2024 Mar 1. doi:10.2196/47122
24. Daniels J, Leypoldt M, Dillon C, Sweazy A, Crane J. Outcome Evaluation of a Public Health Intervention on Cardiovascular Disease (CVD) Prevention Among Women Aged 40-64 with Low Incomes in Nebraska. J Public Health Manag Pract. 2024;30:S62-S70. doi:10.1097/PHH.0000000000001925
25. Calvert B, Bayakly R, Newsome T. Stroke Prevention and Management in Rural Georgia: Evaluating the Effectiveness of a Community Paramedicine Program. J Public Health Manag Pract. 2024;30:S32-S38. doi:10.1097/PHH.0000000000001951
26. Barragan NC, Wu C, Ly A, Oh SM, Kuo T. Testing an Innovative Approach to Improve Hypertension Management at a Federally Qualified Health Center. J Public Health Manag Pract. 2024;30:S46-S51. doi:10.1097/PHH.0000000000001901
27. Shen H, van der Kleij R, van der Boog PJM, Chavannes NH. Developing a Tailored eHealth Self-Management Intervention for Patients With Chronic Kidney Disease in China: Intervention Mapping Approach. JMIR Form Res. 2024;8:e48605. Published 2024 Jun 13. doi:10.2196/48605
28. Steinman L, Chadwick K, Chavez Santos E, et al. Remote Evidence-Based Programs for Health Promotion to Support Older Adults During the COVID-19 Pandemic and Beyond: Mixed Methods Outcome Evaluation. JMIR Aging. 2024;7:e52069. Published 2024 Jun 13. doi:10.2196/52069
29. Tang M, Zhao R, Lv Q. Status and influencing factors of frailty in hospitalized patients with chronic heart failure: A cross-sectional study. J Clin Nurs. Published online June 13, 2024. doi:10.1111/jocn.17324
30. Woods-Giscombe CL, Gaylord S, Bradford AB, et al. Protocol of the HARMONY study: A culturally relevant, randomized-controlled, stress management intervention to reduce cardiometabolic risk in African American women. Contemp Clin Trials. Published online June 10, 2024. doi:10.1016/j.cct.2024.107604
31. Mathews M, Lyons R, Harris S, et al. Evaluation of a unique and innovative diabetes care model in primary care in Ontario, Canada: protocol for a multiple-methods study with a convergent parallel design. BMJ Open. 2024;14(6):e088737. Published 2024 Jun 10. doi:10.1136/bmjopen-2024-088737
32. Hong HC, Kim YM. Multimorbidity and its Associated Factors in Korean Shift Workers: Population-Based Cross-Sectional Study. JMIR Public Health Surveill. 2024;10:e55014. Published 2024 Jun 10. doi:10.2196/55014
33. Dalakoti M, Wong S, Lee W, et al. Incorporating AI into cardiovascular diseases prevention-insights from Singapore. Lancet Reg Health West Pac. 2024;48:101102. Published 2024 May 27. doi:10.1016/j.lanwpc.2024.101102
34. Chan JC, Mbanya JC, Chantelot JM, et al. Patient-reported outcomes and treatment adherence in type 2 diabetes using natural language processing: Wave 8 of the Observational International Diabetes Management Practices Study. J Diabetes Investig. Published online June 5, 2024. doi:10.1111/jdi.14228
35. Iyngkaran P, Buhler M, de Courten M, Hanna F. Effectiveness of self-management programmes for heart failure with reduced ejection fraction: a systematic review protocol. BMJ Open. 2024;14(6):e079830. Published 2024 Jun 5. doi:10.1136/bmjopen-2023-079830
36. Ou TY, Huy LD, Mayne J, et al. Global mortality of chronic liver diseases attributable to Hepatitis B virus and Hepatitis C virus infections from 1990 to 2019 and projections to 2030. J Infect Public Health. Published online May 8, 2024. doi:10.1016/j.jiph.2024.04.027
37. Mehta SJ, Volpp KG, Troxel AB, et al. Remote Blood Pressure Monitoring With Social Support for Patients With Hypertension: A Randomized Clinical Trial. JAMA Netw Open. 2024;7(6):e2413515. Published 2024 Jun 3. doi:10.1001/jamanetworkopen.2024.13515
38. Roche N, Caron A, Emery C, et al. Évaluation médicoéconomique du PRADO-BPCO, programme d’accompagnement post-exacerbation [Medico-economic evaluation of the PRADO-BPCO post-exacerbation support program]. Rev Mal Respir. 2024;41(6):409-420. doi:10.1016/j.rmr.2024.05.001
39. Hearn R, Selfe J, Cordero MI, Dobbin N. The effects of person-centred active rehabilitation on symptoms of suspected Chronic Traumatic Encephalopathy: A mixed-methods single case design. PLoS One. 2024;19(5):e0302260. Published 2024 May 30. doi:10.1371/journal.pone.0302260
40. Burke JF, Sussman JB, Yaffe K, et al. Effect of Population-Level Blood Pressure Treatment Strategies on Cardiovascular and Cognitive Outcomes. Circ Cardiovasc Qual Outcomes. 2024;17(6):e010288. doi:10.1161/CIRCOUTCOMES.123.010288
41. Peytremann-Bridevaux I, Staeger P, Bridevaux PO, Ghali WA, Burnand B. Effectiveness of chronic obstructive pulmonary disease-management programs: systematic review and meta-analysis. Am J Med. 2008;121(5):433-443.e4. doi:10.1016/j.amjmed.2008.02.009
42. Reilly R, Evans K, Gomersall J, et al. Effectiveness, cost effectiveness, acceptability and implementation barriers/enablers of chronic kidney disease management programs for Indigenous people in Australia, New Zealand and Canada: a systematic review of mixed evidence. BMC Health Serv Res. 2016;16:119. Published 2016 Apr 6. doi:10.1186/s12913-016-1363-0
43. Adamopoulos S, Bonios M, Ben Gal T, et al. Right heart failure with left ventricular assist devices: Preoperative, perioperative and postoperative management strategies. A clinical consensus statement of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. Published online June 10, 2024. doi:10.1002/ejhf.3323
44. Harvey AR, Meehan E, Merrick N, et al. Comprehensive care programmes for children with medical complexity. Cochrane Database Syst Rev. 2024;5(5):CD013329. Published 2024 May 30. doi:10.1002/14651858.CD013329.pub2
45. Golabi P, Owrangi S, Younossi ZM. Global perspective on nonalcoholic fatty liver disease and nonalcoholic steatohepatitis - prevalence, clinical impact, economic implications and management strategies. Aliment Pharmacol Ther. 2024;59 Suppl 1:S1-S9. doi:10.1111/apt.17833