Systematic Review of the Impact of Behavioral Health Homes on Cardiometabolic Risk Factors for Adults With Serious Mental Illness
Abstract
Objective:
Methods:
Results:
Conclusions:
Methods
Search Strategy
Study Selection Criteria
Participants.
Intervention.
Comparisons.
Outcomes.
Study design.
Data Extraction
Methodological Quality Assessment
Results
Methodological Quality Assessment
Demographic characteristics | ||||||
---|---|---|---|---|---|---|
Study | Setting/type | Description of BHH model | Intervention group | Comparison group | Comparison | Outcomes |
Low level of bias (good quality) | ||||||
Breslau et al., 2018 (18) | OP/observational and secondary data analysis | PBHCI program; implementation of the PBHCI program varied across the clinics | Wave 1, PBHCI group (N=6,712): age, 43.41±10.94; male, N=2,385 (35.5%); white, N=1,965 (29.2%); African American, N=2,272 (33.8%); Latino, N=1,733 (25.8%); Asian, N=61 (.9%); other race-ethnicity, N=681 (10.1%); serious mental illness, N=2,197 (32.7%). Wave 2, PBHCI group (N=1,881): age, 45.93±10.91; male, N=707 (37.6%); white, N=484 (25.7%); African American, N=664 (35.3%); Latino, N=410 (21.8%); Asian, N=26 (1.4%); other race-ethnicity, N=297 (15.8%); serious mental illness, N=895 (47.6%) | Wave 1, no IC group (N=13,012): age, 43.28±11.09; male, N=4,120 (31.6%); white, N=4,241 (32.5%); African American, N=4,214 (32.6%); Latino, N=2,725 (20.9%); Asian, N=278 (2.1%); other race-ethnicity, N=1,554 (11.9%); serious mental illness, N=3,794 (29.2%). Wave 2, no IC group (N=11,514): age, 44.81±11.14; male, N=3,847 (33.4%); white, N=3,637 (31.5%); African American, N=3,888 (33.7%); Latino, N=2,357 (20.4%); Asian, N=250 (2.1%); other race-ethnicity, N=1,382 (12.0%); serious mental illness, N=3,691 (32.1%) | Propensity score–matched PBHCI group and no IC group (persons with serious mental illness who were never enrolled in the intervention) | Wave 1: hospital stays due to chronic health conditions increased significantly in the intervention group compared with the control group (odds ratio [OR]=1.21). Emergency room visits for behavioral health conditions decreased significantly compared with the control condition (OR=.89). Wave 2: hospital stays due to chronic health conditions increased significantly in the intervention group compared with the control group (OR=1.33). No additional significant differences in utilization in the intervention and control groups were identified in waves 1 or 2. |
Breslau et al., 2018 (19) | OP/observational and secondary data analysis | Same as Breslau et al., 2018 (18) | Same as Breslau et al., 2018 (18) | Same as Breslau et al., 2018 (18) | Same as Breslau et al., 2018 (18) | The PBHCI program showed statistically significant improvement in LDL/cholesterol screening (OR=.21, 95% confidence interval [CI]=.12–.30, p<.05) for participants taking antipsychotics in one of the two research waves. Wave 1: the PBHCI program showed statistically significant improvement in glucose/HbA1c screening (OR=.22, 95% CI=.12–.33, p<.05). HbA1c monitoring was not affected in either wave. |
Druss et al., 2001 (16) | VA OP/RCT | Primary care services provided within a VA mental health clinic by a multidisciplinary team colocated within the VA mental health clinic. Team: full-time nurse practitioner and nurse case manager and part-time family practitioner and administrative assistant. Staff provided education, preventive services, and communication and coordination between primary care and mental health providers. | IC (N=59): age, 45.7±8.4; male, 59±100; white, N=45 (76.3%); schizophrenia, N=13 (22.0); posttraumatic stress disorder, N=19 (32.2%); major affective disorder, N=7 (11.9%); substance use disorder, N=15 (25.4%); other psychiatric diagnosis, N=5 (8.5%); severe psychiatric illness, N=47 (79.7%) | Usual care (N=61): age, 44.8±8.0; male, N=60 (98.4%); white, N=39 (63.9%); schizophrenia, N=12 (19.7%); posttraumatic stress disorder, N=16 (26.2%); major affective disorder, N=9 (14.8%); substance use disorder, N=18 (29.5%); other psychiatric diagnosis, N=6 (9.8%); severe psychiatric illness, N=44 (72.1%) | Usual care participants were provided referral to VA general medicine, located adjacent to the mental health clinic | Participants in the health home intervention group clinic were significantly more likely to have had a primary care visit and also had a greater average number of primary care visits compared with participants in usual care. Participants in the health home were significantly more likely to receive preventive health care. |
Druss et al., 2010 (15) | CMHC/RCT | Registered nurse provided medical education, information on medical care providers, and information on appointments. Motivational interviewing was used to monitor participants’ readiness to change, support self-management skills, coach participants to interact more effectively with providers, and develop action plans to promote health behavior change. Registered nurses also enrolled uninsured participants in entitlement programs and coordinated care between primary and mental health care providers. | Health home intervention group (N=205): age, 47.0±8.1; male, N=302 (74.2%); African American, N=156 (76.5%); Latino, N=4 (2.0%); schizophrenia or schizoaffective disorder, N=75 (36.6%); bipolar disorder, N=22 (10.7%); posttraumatic stress disorder, N=11 (5.4%); depression, N=94 (45.9%); co-occurring substance use disorder, N=50 (24.4%) | Usual care (control) (N=202): age, 46.3±8.1; male, N=110 (54.4%); African American, N=159 (78.7%); Latino, N=2 (1.0%); schizophrenia or schizoaffective disorder, N=69 (34.2%); bipolar disorder, N=30 (14.9%); PTSD, N=9 (4.5%); depression, N=85 (42.1%); other psychiatric diagnosis, N=1 (.5%); co-occurring substance use disorder, N=53 (26.2%) | Usual care participants were provided with a list with contact information to contact local primary care medical clinics | At 12-month follow-up, the health home intervention group received 58.7% of recommended preventive services (i.e., physical examinations, screening tests, vaccinations, and education), compared with 21.8% in the usual care group (p<.001). Specifically for screening, individuals in the health home intervention group had more than twice as many screening tests (50.4% versus 21.6%, F=105.93, df=1 and 361, p<.001). The health home intervention group had a higher likelihood of having a primary care provider (71.2% versus 51.9%, p=.003). Among participants with laboratory data (N=100), Framingham Cardiovascular Risk Scores were significantly better for intervention group (6.9%) than the control group (9.8%) (p=.02). |
Druss et al., 2017 (17) | CMHC and FQHC/RCT | Clinic staff included a part-time nurse practitioner with prescribing authority and a full-time nurse care manager, both supervised by an FQHC medical director. A treat-to-target approach was used for the cardiometabolic risk factors, with weekly supervision meetings focusing on patients whose test results were not within the normal range for blood pressure, glucose level, or cholesterol level. The care manager provided health education for lifestyle factors (e.g., smoking, diet) and logistical support to ensure that participants were able to attend their medical appointments. Both providers attended weekly rounds at the CMHC to facilitate integration with the mental health team. | Behavioral health home (N=224): age, 47.3±9.7; male, N=80 (36%); white, N=122 (54%); African American, N=95 (42%); other race-ethnicity, N=7 (3%); schizophrenia or schizoaffective disorder, N=49 (22%); bipolar disorder, N=108 (48%); depression, N=66 (29%); anxiety, N=1 (0%) | Usual care (N=223): age, 47.1±9.6; male, N=81 (39%); white, N=129 (58%); African American, N=84 (38%); other race-ethnicity, N=10 (4%); schizophrenia or schizoaffective disorder, N=40 (18%); bipolar disorder, N=122 (55%); depression, N=58 (26%); anxiety, N=2 (1%); substance use disorder, N=1 (0%) | Usual care participants provided with summary of findings from laboratory tests and were encouraged to make follow-up appointment with a medical provider. | Compared with usual care, primary care visits in the health home intervention group increased from a mean of .93 to a mean of 1.73 (.65 to .86 in the usual care group). The group × time interaction was statistically significant (p<.001). Compared with usual care, the health home intervention was associated with significant improvements in use of preventive services (p<.001; Cohen's d=1.2, large effect). For most cardiometabolic outcomes, both groups demonstrated improvement, although there were no statistically significant differences between the two groups over time on diastolic blood pressure, total and LDL cholesterol levels, blood glucose level, and HbA1c level or on the Framingham risk score. There were modest, statistically significant differential improvements in systolic blood pressure (improvements of 4.9 points [intervention] and 3.1 [usual care] points, p=.04). |
Kilbourne et al., 2011 (20) | VA OP/observational and cross-sectional study | The health home intervention group colocated general medical care within the mental health clinic. | N=40,600. Age, 55±11.6; male, 91%; African American, 26%; no report of specific serious mental illness diagnosis or general medical diagnosis | VA participants who did not receive care at a colocated facility. Detailed description of sample in non-colocated sites was not included in the published article. | Health home participants and comparison group were compared. | Participants in the health home intervention group were more likely to receive all cardiometabolic tests, including diabetes, blood pressure, BMI, and cholesterol screening (OR=1.26, 95% CI=1.18–1.35, p<.001). |
Kilbourne et al., 2011 (21) | VA OP/observational and cross-sectional study | Same as Kilbourne et al., 2011 (20) | N=7,514, all with serious mental illness. Age, gender, and race not reported | Same as Kilbourne et al., 2011 (20) | Same as Kilbourne et al., 2011 (20) | Participants in the health home intervention group were more likely than those without colocation to receive foot exams (OR=1.87, p<.05), colorectal cancer screening (OR=1.54, p<.01), and alcohol misuse screening (OR=2.92, p<.01). They were also more likely to have their blood pressure controlled (<140/90 mmHg; OR=1.32, p<.05) but less likely to have an HbA1c level <9% (OR=.69, p<.05). |
Krupski et al., 2016 (22) | CMHC/observational and secondary data analysis | A primary care physician and nurse care managers were embedded within a CMHC. Staff screening and referral services for prevention and treatment, care management, and additional prevention and wellness services | Clinic 1, PBHCI (N=373): Age, 47.60±11.12; male, N=256 (68%); American Indian/Alaska Native, N=6 (2%); Asian, N=18 (5%); African American, N=137 (37%); Hispanic, N=10 (3%); multiracial, N=9 (2%); Native Hawaiian, N=1 (<1%); other, N=5 (1%); white, N=184 (49%); serious mental illness (100%). Clinic 2, PBHCI (N=389): age, 46.00±10.18; male, N=265 (68%); American Indian/Alaska Native, N=9 (2%); Asian, N=12 (3%); African American, N=110 (28%); Hispanic, N=15 (4%); multiracial, N=6 (2%); Native Hawaiian, N=1 (<1); white, N=229 (59%); serious mental illness (100%) | Clinic 1, comparison (N=373): Age, 47.55±13.15; male, N=270 (72%); American Indian/Alaska Native, N=6 (2%); Asian, N=20 (5%); African American, N=152 (41%); Hispanic, N=7 (2%); multiracial, N=11 (3%); other, N=6 (2%); white, N=168, (45%); serious mental illness (100%). Clinic 2, comparison (N=373): age, 47.00±11.31; male, N=261 (67%); American Indian/Alaska Native, N=10 (3%); Asian, N=10 (3%); African American, N=124 (32%); Hispanic, N=22 (6%); multiracial, N=5 (1%); white, N=208 (53%); serious mental illness (100%) | Propensity score–matched persons with serious mental illness who were never enrolled in the intervention (clinic 1, N=746; clinic 2, N=778) | A higher proportion of participants in the health home intervention group engaged in outpatient medical services following program enrollment (p<.003, clinic 1; p<.001, clinic 2) compared with the control condition. Health home intervention group clinic 1 was associated with a decrease in the proportion of participants with an inpatient hospital admission (p=.04). |
McGuire et al., 2009 (23) | VA OP/observational study and pre-post analysis | Participants were screened and referred to the health home intervention group (i.e., primary and mental health care services colocated within the VA mental health outpatient center) within the same day. Case managers provided short-term assistance for participants. Primary care providers included a primary care physician and three advanced-practice registered nurses. | Homeless veterans (N=260): age, 45.8±7.0; male, N=259 (99%); African American, N=130 (50%); bipolar disorder, 20%; depression, 42%; PTSD, 17%; schizophrenia, 13%; substance abuse (drug), 48%; alcohol use disorder, 45% | Same as original sample | Preintegration of primary care services within the VA mental health outpatient center. Medical center was .5 miles from mental health facility and the wait for appointments was approximately 2 months. | Compared with the demonstration (control) group, the health home intervention group had fewer days to primary care enrollment (.3±1.8 compared with 53.2 ±1.7) and received significantly more prevention services (including tobacco use screening, depression screening, colorectal cancer screening, breast cancer screening, and alcohol abuse screening) (.57±.1 compared with .44 ±.1) and primary care visits (2.3 more visits over 18-months of follow-up) and significantly fewer emergency department visits (4.3±7 compared with 5.0±6 mean visits). |
O'Toole et al., 2011 (24) | VA PCMH/quasi-experimental study | Traditional patient-centered medical home model with the addition of a special clinic team to manage participants with serious mental illness. Clinic team tailored access and care to address population-specific needs, and provided intensive registered nurse and social work case management with small caseloads. Staff were also trained on specific cultural competencies. | Total N=457. Mean age, not reported; ages ≥65, N=167 (36.5%); male, N=312 (68.2%); race-ethnicity, not reported; serious mental illness, N=74 (16.1%) | Same as original sample | Preimplementation versus full implementation of the patient-centered medical home | For participants with serious mental illness, primary care visits increased from 64.9% (1.30 visits per participant) to 82.4% (3.04 visits per participant) from preimplementation to full implementation of the patient-centered medical home. Average length of hospital stay decreased from 8.75 days to 6.0 days. However, there was also an increase in emergency department use among people with serious mental illness (p<.05). |
Tepper et al., 2017 (25) | CMHC/quasi-experimental and secondary data analysis | Health home services included on-site medical care and chronic disease screening, health promotion, support for care coordination and transitions, and opportunities for peers to engage with one another (such as social functions and educational workshops). Electronic health records included alerts for patient transitions through emergency departments or inpatient units and provided a registry for monitoring patients' health status, service delivery, and discharge. | Behavioral health home (N=424): mean age, 48; male, N=224 (53%); white (64%); African American (22%); Hispanic (2%); Asian (2%); psychotic disorder (87%); bipolar disorder (13%) | Control (N=1,521): mean age, 50; male, N=745 (49%); white (59%); African American (18%); Hispanic (8%); Asian (2%); psychotic disorder (63%); bipolar disorder (37%) | Usual care included psychopharmacology, individual or group psychotherapy, and use of primary care or specialty services. Electronic health records offered modest information to track health care utilization. | Psychiatric hospitalizations declined for health home participants (.22 to .10) and remained stable for participants in the control group (.145 and .147) (p=.002 between groups); no differences between groups in medical hospitalizations. Health home participants were more likely to receive HbA1c screening; however, there were no differences between groups in lipid monitoring. No significant differences between groups in metabolic monitoring among participants with diabetes. |
Medium level of bias (medium quality) | ||||||
Boardman, 2006 (26) | OP/quasi-experimental study | Primary care was colocated within a mental health outpatient clinic. Primary health care was provided by a nurse practitioner (including a physical examination, laboratory tests, referral for additional tests, and ongoing follow-up). Mental health and substance abuse counseling, psychopharmacology, and case management were also provided on-site. The nurse practitioner communicated with other care providers. | Experimental group (N=39): mean age not reported; age range 20–69; male, N=14 (37%); race-ethnicity not reported; serious mental illness (100%) | Usual care (control) (N=37): mean age not reported; age range 20–69; male, N=9 (25%); race-ethnicity not reported; serious mental illness (100%) | Usual care vs. experimental group (N=76) | The health home intervention group reported a 42% lower number of emergency department visits, 50% increased routine medical care, 70% greater incidence of physical examinations, and notable increases in health care screens (i.e., diabetes, hypertension) compared with the usual care group. |
Scharf et al., 2016 (28) | CMHC and FQHC/ quasi-experimental study | PBHCI clinic include screening and referral for general medical illness prevention and treatment, registry and tracking system for general medical needs and outcomes, care management, and prevention and wellness support. | PBHCI clinics (N=322): age, 42±12; male, N=601 (75.9%); white, N=231 (71%); African American, N=51 (16%); Latino, N=15 (5%); other, N=25 (8%); anxiety, N=33 (10%); bipolar disorder, N=79 (25%); schizophrenia, N=91 (28%); major depressive disorder, N=85 (26%) | Control (N=469): age, 45±12; male, N=162 (34.5%); white, N=393 (84%); African American, N=21 (4%); Latino, N=17 (4%); other, N=38 (8%); anxiety, N=54 (12%); bipolar disorder, N=97 (21%); schizophrenia, N=120 (26%); major depressive disorder, N=143 (30%) | PBHCI vs. usual care (N=791) | Participants in the intervention group had better outcomes for cholesterol: mean reductions in total cholesterol were greater by 36 mg/dL (p<.01), mean reductions in LDL cholesterol were greater by 35 mg/dL (p<.001), and mean increases in HDL cholesterol were greater by 3 mg/dL (p<.05). |
Tatreau et al., 2016 (29) | IP/observational study and cross-sectional analysis | A locked inpatient unit included an embedded medical team. The team included a physician’s assistant supervised by a physician. | IC group (N=220): age, 36.1±14.3; male, N=146 (66%); white, N=93 (42%); black, N=109 (50%); Asian, N=2 (1%); other race-ethnicity, N=16 (7%); Hispanic, N=6 (3%); schizophrenia spectrum disorder, N=144 (65%); bipolar disorder N=69 (31%); depression, N=35 (16%); autism, N=11 (5%) | TAU group (N=232): age, 38.8±14.5; male, N=150 (65%); white, N=141 (61%); black, N=67 (29%); Asian, N=1 (.4%); other race-ethnicity, N=23 (10%); Hispanic, N=6 (3%); schizophrenia spectrum disorder, N=187 (81%); bipolar disorder, N=101 (44%); depression, N=58 (25%); autism, N=2 (1%) | A locked inpatient unit that provided treatment as usual medical care. In this model medical care is provided by resident psychiatrists supervised by attending psychiatrist. A hospitalist is available as needed for consultation regarding medical issues. | Significantly more health screening tests were ordered for the control group compared with the health home intervention group (i.e., HbA1c, 56% versus 16%, p<.001; glucose, 99% versus 66%, p<.001; and lipids, 61% versus 20%, p<.001). |
Pirraglia et al., 2012 (30) | VA, OP/observational study and pre-post analysis | A primary care clinic staffed by one primary care physician and patient care assistant and colocated and integrated in the VA mental health outpatient program. The integrated clinic uses open-access scheduling, and primary care visits are scheduled to co-occur with mental health care visits. | Veterans (N=97): age, 55.3±10; male, N=92 (95%); white, N=83 (86%); schizophrenia, N=23 (24%); schizoaffective disorder, N=24 (25%); psychosis, not otherwise specified, N=4 (4%); bipolar disorder, N=14 (14%); major depressive disorder, N=36 (37%); alcohol abuse/dependence, N=41 (42%); substance abuse/dependence, N=28. | Same as original sample | 1-year pre-enrollment in the integrated clinic compared with 1-year postenrollment. | Compared with the control group, participants in the health home intervention group had significantly improved goal attainment for blood pressure, LDL cholesterol, triglycerides, and body mass index; there were no statistically significant changes for HDL cholesterol or HbA1c. |
Putz et al., 2015 (31) | CMHC/observational study and pre-post analysis | Participants were referred by their mental health provider to this collaborative care program that included a clinical social worker, physician specializing in metabolic diseases, a family nurse practitioner, two nurse care managers, a peer support specialist, a part-time wellness coach, and an office assistant. Participants received a health assessment, were assigned a medical case manager, and were offered enrollment in one or more wellness programs (e.g., diabetes support, weight-loss support, tobacco cessation, physical activity instruction, stress management, medical self-management, and peer support). | Total (N=169): age 46.3±12.04; male, N=61 (36%); white, N=154 (91.1%); African American, N=11 (6.5%); American Indian, N=4, (2.4%); primary psychotic disorder (42%); primary mood/anxiety disorder (41.4%); borderline personality disorder, ADHD, intermittent explosive disorder, or other (10.7%) | Same as original sample | The control condition was a baseline measurement of study participants. | At 6-month follow-up, significant decreases were found in the following risk factors in the health home intervention group: weight among participants who were overweight and obese at baseline (t=4.19, df=92, p<.001); HDL and LDL cholesterol among at-risk for participants with cardiovascular disease (t=–2.58, df=37, p=.016); significant decrease in cigarette use among baseline cigarette smokers (t=2.65, df=37, p=.012); systolic blood pressure (t=4.997, df=7, p<.002); and diastolic blood pressure (t=3.96, df=15, p<.001). |
Snyder et al., 2008 (27) | VA, PC/ observational and ecological study | Medical school residents provide primary and psychiatric care for participants within a VA medical center | Psychiatry primary medical care (N=23): age, 52.2±7.5; male, N=23 (100%); race-ethnicity, not reported; bipolar disorder, N=12 (52.2%); schizophrenia, N=9 (39.1%); schizoaffective disorder, N=1 (4.3%); delusional disorder, N=1 (4.3%) | Usual care (control) (N=23): age, 51.8±8.5; male, N=23 (100%); race-ethnicity, not reported; bipolar disorder N=12 (52.2%); schizophrenia, N=8 (34.8%); schizoaffective disorder, N=3 (13%) | Usual care defined as treatment in the VA mental health clinics and primary care treatment in a general medical ambulatory clinic by staff or trainees (N=46) | There was no difference between the health home intervention group and control group on preventive health screenings, emergency department visits, or inpatient psychiatry. |
High level of bias (poor quality) | ||||||
Gilmer et al., 2016 (32) | Observational and ecological study/ model 1, mobile health teams; model 2, CMHC and FQHC | Model 1: integrated mobile health teams paired supportive housing with an assertive community treatment model for mental health care and FQHCs for general medical care, provided by mobile team. Model 2: integrated clinics paired CMHCs with FQHCs. | High-integration homes (N=1,292): mean age, gender, race-ethnicity not reported; serious mental illness (100%) | Low-integration homes (N=649): mean age, gender, race-ethnicity not reported; serious mental illness (100%) | Models were compared based on level of integration (high vs. low) (N=1,941) | Highly integrated programs were associated with greater improvement in screening rates for blood pressure, cholesterol, and blood glucose and with reduced risk of hypertension, high-risk cholesterol, and prediabetes/diabetes compared with less integrated programs. In the highly integrated group, there was a significant reduction in hypertension yet an increase in prediabetes or diabetes (p=.01). |
Service Utilization
Psychiatric | Inpatient | ||||||
---|---|---|---|---|---|---|---|
Hospital | hospital | Medical | psychiatry | OP medical | |||
Study | ER visits | PC visits | stays | stays | hospital stay | stay | services |
Low level of bias (good quality) | |||||||
Breslau et al., 2018 (18) | * (+/−) R | * (–) R | |||||
Druss et al., 2001 (16) (VA) | * R | ||||||
Druss et al., 2017 (17) | * R | ||||||
Krupski et al., 2016 (22) | * R | * R | |||||
McGuire et al., 2009 (23) (VA) | * R | * R | |||||
O'Toole et al., 2011 (24) (VA) | * (–) R | ||||||
Tepper et al., 2018 (25) | * R | (o/o) R | |||||
Medium level of bias (medium quality) | |||||||
Boardman, 2006 (26) | R | R | |||||
Snyder et al., 2008 (27) (VA) | (−/−) R | (−/−) R |
Primary care utilization.
ED utilization.
Psychiatric hospitalizations.
Medical hospitalizations.
Outpatient medical services.
Screening for Cardiometabolic Risk Factors
Screen conducted | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|
Diabetes | ||||||||||
Preventive | (HbA1c, glucose, | Colorectal | Alcohol | Tobacco | Physical | |||||
Study | services | foot exam) | BP | BMI | Cholesterol | cancer | misuse | Depression | use | exams |
Low level of bias (good quality) | ||||||||||
Breslau et al. 2018 (18) | ||||||||||
Breslau et al., 2018 (19) | (o/o) R | * (+/−) R | * (+/−) R | |||||||
Druss et al., 2001 (16) (VA) | * R | |||||||||
Druss et al., 2010 (15) | * R | |||||||||
Druss et al., 2017 (17) | * R | * R | ||||||||
Kilbourne et al., 2011 (20) (VA) | * R | * R | * R | * R | ||||||
Kilbourne et al., 2011 (21) (VA) | * R | * R | * R | |||||||
Krupski et al., 2016 (22) | ||||||||||
McGuire et al., 2009 (23) (VA) | * R | * R | * R | * R | ||||||
Tepper et al., 2017 (25) | R | (−/−) R | ||||||||
Medium level of bias (medium quality) | ||||||||||
Boardman, 2006 (26) | R | R | R | |||||||
Tatreau et al., 2016 (29) | * (–) R | * (–) R | ||||||||
Snyder et al., 2008 (27) (VA) | (−/−) R | |||||||||
High level of bias (poor quality) | ||||||||||
Gilmer et al. 2016 (32) | R | R | R |
Cardiometabolic Risk Factor Outcomes
Study | BP control | Diastolic BP | Systolic BP | Heart disease risk | TC | HDL | LDL | Cigarette use | BMI/ weight | Hyper-tension | HbA1c | Blood glucose | Triglycerides | |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Low level of bias (good quality) | ||||||||||||||
Druss et al., 2010 (15) | * R | |||||||||||||
Druss et al., 2017 (17) | (−/−) R | * R | (−/−) R | (−/−) R | (−/−) R | (−/−) R | (−/−) R | |||||||
Kilbourne et al., 2011b (21) (VA) | * R | * (–) R | ||||||||||||
Medium level of bias (medium quality) | ||||||||||||||
Scharf et al., 2016 (28) | * R | * R | * R | |||||||||||
Pirraglia et al., 2012 (30) VA | * R | (−/−) R | * R | * R | (−/−) R | * R | ||||||||
Putz et al., 2015 (31) | * R | * R | * R | * R | * R | * R | ||||||||
High level of bias (poor quality) | ||||||||||||||
Gilmer et al., 2016 (32) | * R | *(–) R |
Strategies to Augment Clinical Improvement
Discussion
Conclusions
Supplementary Material
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