Literature Collection

AIMS: To assess the effectiveness, process, and economic outcomes of integrated care for community-dwelling frail older adults. DESIGN: A systematic review and meta-analysis. DATA SOURCES: We searched nine databases, including PubMed, Web of Science, CINAHL, Embase, the Cochrane Library, CNKI, SinoMed, Wanfang, and VIP, three trial registers, grey literature, and reference lists up to April 2024, with an updated search in March 2025. REVIEW METHODS: Randomised controlled trials and non-randomised studies of interventions involving integrated care for community-dwelling frail older adults were included. Data analysis was conducted using the Comprehensive Meta-Analysis software. RESULTS: This review included 12 studies involving 6819 community-dwelling frail older adults from high-income regions. The results indicated that integrated care had significantly positive effects on frailty and functional ability, but not on social function, hospitalisation, nursing home admission, quality of life, and mortality. Outcomes of caregivers and professionals were rarely reported. The cost-effectiveness of integrated care has not been confirmed by limited evidence. Few studies have adopted a systematic approach to designing and conducting comprehensive process evaluations guided by scientific frameworks. CONCLUSION: Integrated care improves frailty and functional ability in community-dwelling frail older adults but lacks consistent benefits for other outcomes. The lack of evidence on cost-effectiveness and the caregiver and professional outcomes highlight critical gaps in current research. The absence of systematic process evaluations underscores the need for future studies to adopt rigorous frameworks to assess them. IMPACT: This implicates that more research, particularly in underserved regions that lack a high standard of usual medical services, should emphasise the outcomes of caregivers and healthcare professionals, process evaluation, and health economics. Policymakers and practitioners must consider these gaps when implementing integrated care programmes to ensure equitable and sustainable healthcare solutions. REPORTING METHOD: PRISMA 2020 Checklist. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution. PROSPERO REGISTRATION NUMBER: CRD42024568811.

OBJECTIVE: Medication for opioid use disorder (MOUD) improves treatment retention and reduces illicit opioid use. A-CHESS is an evidence-based smartphone intervention shown to improve addiction-related behaviors. The authors tested the efficacy of MOUD alone versus MOUD plus A-CHESS to determine whether the combination further improved outcomes. METHODS: In an unblinded parallel-group randomized controlled trial, 414 participants recruited from outpatient programs were assigned in a 1:1 ratio to receive either MOUD alone or MOUD+A-CHESS for 16 months and were followed for an additional 8 months. All participants were on methadone, buprenorphine, or injectable naltrexone. The primary outcome was abstinence from illicit opioid use; secondary outcomes were treatment retention, health services use, other substance use, and quality of life; moderators were MOUD type, gender, withdrawal symptom severity, pain severity, and loneliness. Data sources were surveys comprising multiple validated scales, as well as urine screens, every 4 months. RESULTS: There was no difference in abstinence between participants in the MOUD+A-CHESS and MOUD-alone arms across time (odds ratio=1.10, 95% CI=0.90-1.33). However, abstinence was moderated by withdrawal symptom severity (odds ratio=0.95, 95% CI=0.91-1.00) and MOUD type (odds ratio=0.57, 95% CI=0.34-0.97). Among participants without withdrawal symptoms, abstinence rates were higher over time for those in the MOUD+A-CHESS arm than for those in the MOUD-alone arm (odds ratio=1.30, 95% CI=1.01-1.67). Among participants taking methadone, those in the MOUD+A-CHESS arm were more likely to be abstinent over time (b=0.28, SE=0.09) than those in the MOUD-alone arm (b=0.06, SE=0.08), although the two groups did not differ significantly from each other (∆b=0.22, SE=0.11). MOUD+A-CHESS was also associated with greater meeting attendance (odds ratio=1.25, 95% CI=1.05-1.49) and decreased emergency department and urgent care use (odds ratio=0.88, 95% CI=0.78-0.99). CONCLUSIONS: Overall, MOUD+A-CHESS did not improve abstinence relative to MOUD alone. However, MOUD+A-CHESS may provide benefits for subsets of patients and may impact treatment utilization.

BACKGROUND: In the context of escalating diabetes prevalence worldwide, this study investigates the efficacy of integrating cognitive behavioral therapy (CBT) within primary care visits for managing uncontrolled diabetes. DESIGN: The randomized clinical trial in an integrated health care clinic in Oregon involved 72 adults aged 20-89 with uncontrolled diabetes. Participants were enrolled and randomly assigned to 2 groups: one receiving both cognitive behavioral health (n=36) and the other receiving traditional primary care (n=36). RESULTS: The study primarily measured clinical improvements in hemoglobin A1C levels for a year. Results indicated significant improvements in the cognitive behavioral health group compared with the traditional care group at various intervals up to 51 weeks, with notable enhancements in hemoglobin A1C and secondary outcomes of patient satisfaction scores. During the 36th and 51st weeks, the shared visit group demonstrated significantly lower hemoglobin A1c levels (36 wk: 9.22±0.2 vs. 10.02±0.2, P<0.001; 51 wk: 9.22±0.1 vs. 10.91±0.2, P<0.001), indicating improved long-term glycemic control. CONCLUSIONS: Combining cognitive behavioral health with primary care visits significantly outperformed traditional care in improving clinical outcomes and patient satisfaction among adults with uncontrolled diabetes. The percentage of participants with clinically meaningful improvement in 36 weeks was 22.2% in the CBT versus 0.0% in the traditional primary care visit group. The positive outcomes suggest that integrated cognitive behavioral therapy can effectively contribute to diabetes management strategies, highlighting the importance of innovative approaches in addressing the diabetes epidemic.

This study evaluates the impact of a 6-month care management intervention for 206 children diagnosed with comorbid attention deficit hyperactivity disorder (ADHD) from a sample of 321 five- to 12-year-old children recruited for treatment of behavior problems in 8 pediatric primary care offices. Practices were cluster-randomized to Doctor Office Collaboration Care (DOCC) or Enhanced Usual Care (EUC). Chart reviews documented higher rates of service delivery, prescription of medication for ADHD, and titration in DOCC (vs EUC). Based on complex conditional models, DOCC showed greater acute improvement in individualized ADHD treatment goals and follow-up improvements in quality of life and ADHD and oppositional defiant disorder goals. Medication use had a significant effect on acute and follow-up ADHD symptom reduction and quality of life. Medication continuity was associated with some long-term gains. A collaborative care intervention for behavior problems that incorporated treatment guidelines for ADHD in primary care was more effective than psychoeducation and facilitated referral to community treatment.

Medicare and Medicaid are separate programs that together cover 13 million low-income older adults and people with disabilities, known as dual-eligible individuals. Concern about a lack of coordination across Medicare and Medicaid has prompted the development of Integrated Care Programs (ICPs). Although the primary goal of ICPs is to coordinate financing and care across Medicare and Medicaid, ICPs may also influence whether low-income individuals obtain or keep Medicaid. We evaluated whether the rollout of Medicare-Medicaid Plans (MMPs)-one of the largest ICPs-was associated with changes in Medicaid take-up and retention among Medicare beneficiaries residing in high-poverty zip codes. Using a stacked difference-in-differences design and variation in MMP rollouts across nine states, we found no evidence that MMPs increased monthly or continuous Medicaid enrollment in this population. These findings highlight the need for focused policies to address Medicaid enrollment gaps among low-income Medicare beneficiaries, which could complement broader integration efforts.