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Cited by 592Chronic Disease Management StrategiesDiabetes Management and EducationPatient-Provider Communication in Healthcare

Personalised care planning for adults with chronic or long-term health conditions

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Coulter, Angela, Entwistle, Vikki A, Eccles, Abi, Ryan, Sara, Shepperd, Sasha, Perera, Rafael·2015·Cochrane Database of Systematic Reviews
DOI 10.1002/14651858.cd010523.pub2PMC PMC6486144
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Abstract

BACKGROUND: Personalised care planning is a collaborative process used in chronic condition management in which patients and clinicians identify and discuss problems caused by or related to the patient's condition, and develop a plan for tackling these. In essence it is a conversation, or series of conversations, in which they jointly agree goals and actions for managing the patient's condition. OBJECTIVES: To assess the effects of personalised care planning for adults with long-term health conditions compared to usual care (i.e. forms of care in which active involvement of patients in treatment and management decisions is not explicitly attempted or achieved). SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, ProQuest, clinicaltrials.gov and WHO International Clinical Trials Registry Platform to July 2013. SELECTION CRITERIA: We included randomised controlled trials and cluster-randomised trials involving adults with long-term conditions where the intervention included collaborative (between individual patients and clinicians) goal setting and action planning. We excluded studies where there was little or no opportunity for the patient to have meaningful influence on goal selection, choice of treatment or support package, or both. DATA COLLECTION AND ANALYSIS: Two of three review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. The primary outcomes were effects on physical health, psychological health, subjective health status, and capabilities for self management. Secondary outcomes included effects on health-related behaviours, resource use and costs, and type of intervention. A patient advisory group of people with experience of living with long-term conditions advised on various aspects of the review, including the protocol, selection of outcome measures and emerging findings. MAIN RESULTS: We included 19 studies involving a total of 10,856 participants. Twelve of these studies focused on diabetes, three on mental health, one on heart failure, one on end-stage renal disease, one on asthma, and one on various chronic conditions. All 19 studies included components that were intended to support behaviour change among patients, involving either face-to-face or telephone support. All but three of the personalised care planning interventions took place in primary care or community settings; the remaining three were located in hospital clinics. There was some concern about risk of bias for each of the included studies in respect of one or more criteria, usually due to inadequate or unclear descriptions of research methods. Physical healthNine studies measured glycated haemoglobin (HbA1c), giving a combined mean difference (MD) between intervention and control of -0.24% (95% confidence interval (CI) -0.35 to -0.14), a small positive effect in favour of personalised care planning compared to usual care (moderate quality evidence).Six studies measured systolic blood pressure, a combined mean difference of -2.64 mm/Hg (95% CI -4.47 to -0.82) favouring personalised care (moderate quality evidence). The pooled results from four studies showed no significant effect on diastolic blood pressure, MD -0.71 mm/Hg (95% CI -2.26 to 0.84).We found no evidence of an effect on cholesterol (LDL-C), standardised mean difference (SMD) 0.01 (95% CI -0.09 to 0.11) (five studies) or body mass index, MD -0.11 (95% CI -0.35 to 0.13) (four studies).A single study of people with asthma reported that personalised care planning led to improvements in lung function and asthma control. Psychological healthSix studies measured depression. We were able to pool results from five of these, giving an SMD of -0.36 (95% CI -0.52 to -0.20), a small effect in favour of personalised care (moderate quality evidence). The remaining study found greater improvement in the control group than the intervention group.Four other studies used a variety of psychological measures that were conceptually different so could not be pooled. Of these, three found greater improvement for the personalised care group than the usual care group and one was too small to detect differences in outcomes. Subjective health statusTen studies used various patient-reported measures of health status (or health-related quality of life), including both generic health status measures and condition-specific ones. We were able to pool data from three studies that used the SF-36 or SF-12, but found no effect on the physical component summary score SMD 0.16 (95% CI -0.05 to 0.38) or the mental component summary score SMD 0.07 (95% CI -0.15 to 0.28) (moderate quality evidence). Of the three other studies that measured generic health status, two found improvements related to personalised care and one did not.Four studies measured condition-specific health status. The combined results showed no difference between the intervention and control groups, SMD -0.01 (95% CI -0.11 to

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  • Current guidelines and literature inadequately address the complexity of managing MLTCiD, with a tendency for a single-disease focus; only one of 13 NICE guidance documents acknowledged the impact of dementia on care management.

    “Current guidelines and literature inadequately addresses the complexity of managing MLTCiD with a tendency for a single-disease focus (i.e., only one of 13 NICE guidance documents acknowledged the impact of dementia on care management [20]) [21–24].”

    From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [23]

    The Background (Description of the condition; page unavailable) describes most medical care as organised around a single-disease framework, and the Participants section says no included study focused explicitly on multimorbidity. This supports the broad concern about single-disease care and gaps in the literature, but the review does not establish that guidelines inadequately address people with multiple long-term conditions including dementia. The NICE-document count is attached to a separate citation [20], not this source. (LLM, conf=0.84)

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Authors
Coulter, A., Entwistle, V. A., Eccles, A., Ryan, S., Shepperd, S., & Perera, R.
Affiliations
  • University of Oxford (GB)
  • University of Aberdeen (GB)
ORCID
Venue
Cochrane Database of Systematic Reviews
Publisher
Wiley
Published
2015-03-03
Volume
2015
Issue
3
Pages
CD010523-CD010523
ISSN
  • 1361-6137 (ISSN-L)
  • 1465-1858
DOI
10.1002/14651858.cd010523.pub2
PMC
PMC6486144
OpenAlex
W1944172539
Cited by
592
References
201
Citations by year
2026: 26 · 2025: 47 · 2024: 40 · 2023: 59 · 2022: 58 · 2021: 64 · 2020: 83 · 2019: 57 · 2018: 55 · 2017: 46 · 2016: 39 · 2015: 15 · 2013: 2
FWCI
6.68
Type
journal article
Language
en
Open access
Locations
  • Cochrane Database of Systematic Reviews (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • Aberdeen University Research Archive (Aberdeen University) (submittedVersion)
Funders
National Institute for Health and Care Research (SPCR-029, 13/89/04)
Topics
  • Health Sciences › Medicine › Epidemiology › Chronic Disease Management Strategies
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
  • Health Sciences › Health Professions › General Health Professions › Patient-Provider Communication in Healthcare
Keywords
personalised care planning, patient-clinician collaboration, goal setting, action planning, chronic disease, chronic disease management, diabetes mellitus, self-management, behavior change, telephone support, primary care, health-related quality of life, resource utilization (health care), cost-effectiveness, patient participation in treatment decisions, mental health, heart failure, end-stage renal disease, asthma, risk of bias, patient advisory group, patient-centered care
MeSH terms
Adult, Asthma, Mental Disorders, Chronic Disease, Diabetes Mellitus, Health Status, Heart Failure, Glycated Hemoglobin, Humans, Kidney Failure, Chronic, Patient Care Planning, Patient Participation, Self Care, Randomized Controlled Trials as Topic

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