Journal of

Personalized
Medicine

Review
Interprofessional Collaboration and Diabetes Management in
Primary Care: A Systematic Review and Meta-Analysis of
Patient-Reported Outcomes
Mario Cesare Nurchis 1,2,† , Giorgio Sessa 1,† , Domenico Pascucci 1,2, * , Michele Sassano 1,3 , Linda Lombi 4
and Gianfranco Damiani 1,2

1 Università Cattolica del Sacro Cuore, 00168 Rome, Italy; [email protected] (M.C.N.);
[email protected] (G.S.); [email protected] (M.S.); [email protected] (G.D.)
2 Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
3 Università di Bologna, 40126 Bologna, Italy
4 Università Cattolica del Sacro Cuore, 20123 Milan, Italy; [email protected]
* Correspondence: [email protected]
† These authors contributed equally to this work.

Abstract: The global spread of diabetes poses serious threats to public health requiring a patient-
centered approach based both on interprofessional collaboration (IPC) given by the cooperation of
several different health professionals, and patients’ perspective through the assessment of Patient-
Reported Outcomes (PROs). The aim of the present study is to evaluate the impact of interprofessional



collaboration interventions, for the management of type 2 diabetes in primary care settings, through

 PROs. A systematic review and meta-analysis was conducted querying the PubMed, Scopus and
Citation: Nurchis, M.C.; Sessa, G.; Embase databases. Out of the 1961 papers initially retrieved, 19 met the inclusion criteria. Inter-
Pascucci, D.; Sassano, M.; Lombi, L.; professional collaboration is significantly associated with an increase in both patient’s satisfaction
Damiani, G. Interprofessional
(SMD 0.32 95% CI 0.05–0.59) and in the mental well-being component of the HRQoL (SMD 0.18;
Collaboration and Diabetes
95% CI 0.06–0.30), and there was also promising evidence supporting the association between an
Management in Primary Care: A
interprofessional approach and an increase in self-care and in generic and specific quality-of-life. No
Systematic Review and
statistical differences were found, supporting the positive impact on IPC interventions on the physical
Meta-Analysis of Patient-Reported
Outcomes. J. Pers. Med. 2022, 12, 643.
component of the HRQoL, depression, emotional distress, and self-efficacy. In conclusion, the effect
https://doi.org/10.3390/ of IPC impacts positively on the few areas assessed by PROMs. Policymakers should promote the
jpm12040643 widespread adoption of a collaborative approach as well as to endorse an active engagement of
patients across the whole process of care.
Academic Editor: José Carmelo
Adsuar Sala
Keywords: type 2 diabetes; patient-reported outcomes; primary care; interprofessional collaboration
Received: 16 March 2022
Accepted: 13 April 2022
Published: 15 April 2022

Publisher’s Note: MDPI stays neutral

1. Background
with regard to jurisdictional claims in Non communicable diseases have spread all over the world as a pandemic and are
published maps and institutional affil- threatening healthcare system sustainability [1]. Among these, diabetes mellitus can be
iations. considered to be one of the biggest problems. In 2019 [2], 463 million people have diabetes
mellitus worldwide, and this is expected to increase by 51% by 2045, with more than
90% of cases being type 2 diabetes mellitus (T2DM) [3]. Older adults have the highest
prevalence of T2DM of any age group, and comorbidities are common, with more than
Copyright: © 2022 by the authors.
40% of individuals with T2DM having 3 or more comorbidities. T2DM combined with
Licensee MDPI, Basel, Switzerland.
comorbidity is linked to higher mortality, poorer functionality and greater health service
This article is an open access article
use [4–7] than T2DM alone [8]. Above all, a huge public health problem is represented
distributed under the terms and
by the co-presence of T2DM and psychological comorbidity, such as depression and/or
conditions of the Creative Commons
diabetes-specific emotional distress [9], as it is associated with poorer treatment outcomes
Attribution (CC BY) license (https://
because both depression and diabetes distress have been shown to negatively affect type
creativecommons.org/licenses/by/
4.0/).
2 diabetes through poor adherence and reduced self-care [10–12]. Furthermore, diabetes

J. Pers. Med. 2022, 12, 643. https://doi.org/10.3390/jpm12040643 https://www.mdpi.com/journal/jpm

J. Pers. Med. 2022, 12, 643 2 of 12

is one of the most relevant causes of economic loss, morbidity, and early mortality in the
world [13]. The per capita cost burden associated with diabetes is two to four-fold greater
than that of non-diabetic patients [14].
Chronic conditions follow an unpredictable trajectory over a prolonged period and
commonly do not achieve a cure, so to provide effective care for people with chronic
conditions and to facilitate the shift from a reactive health care system to one which proac-
tively involves patients has been developed in the Chronic Care Model [15,16]. Extensive
evidence has shown that the Chronic Care Model improves patient care and provides
a framework for improved efficiency and outcomes [17,18], especially in a primary care
setting [19]. The Chronic Care Model is based on “patient-centeredness”, requiring an
interprofessional collaboration approach and taking into account the patients perspectives.
There is extensive evidence to support the benefits of team-based care [20]. Interprofes-
sional collaborative (IPC) practice [21] can be defined as the cooperation of several health
professionals, belonging to different health or social care professions, with the shared goal
of increasing collaboration and patient-related care quality. Therefore, IPC is an additional
key aspect of caring for patients with multiple chronic conditions [15,22]. Individuals
affected by chronic conditions require continued interactions with the health care system
and must make ongoing adjustments in daily life. In addition, many chronic diseases are
preventable or modifiable through alterations of risky behaviors, lifestyle changes, and
self-care practices [23]. Patients, their families, and their caregivers are called upon to
manage difficult care and adopt significant behavior changes requiring “a complex and
diverse set of skills” [24]. To provide effective care, it is important for health professionals
to understand all these aspects in managing chronic illnesses and gain skills to apply these
concepts in clinical practice.
As stated by the Chronic Care Model, the patients’ perspective could be elicited
through the adoption of the “patient-reported outcomes” (PROs).
A PRO can be defined as “any report of the status of a patient’s health condition
that comes directly from the patient, without interpretation of the patient’s response by a
clinician or anyone else” [25]. The PROs can be measured though generic and/or disease-
specific questionnaires [26,27], defined as PROMs, aimed at measuring functional status,
health related quality of life, symptoms burden, personal experience of care, and health-
related behaviors such as anxiety and depression.
The routine collection of e-PROs by healthcare providers in their clinical practice may
help them to improve the quality of care through the monitoring of patient symptoms [28] to
promote the identification of their unmet needs, and to foster a patient-centred approach by
tailored treatment [29] to increase patient involvement and the individualization of patient
care trajectories [30]. Assessing the reports coming directly from patients is integral to
delivering high-value patient-centered care. The PROs have the potential to systematically
incorporate patient input for improvement in both quality and cost of care.
Therefore, the aim of the present study is to assess the impact of interprofessional
collaboration interventions for the management of type 2 diabetes in primary care settings,
through PROs.

2. Materials and Methods

2.1. Study Design and Literature Search
A systematic review of the literature was carried out querying the following electronic
databases: EMBASE, ISI Web of Knowledge, MEDLINE, from their inception to October
2021, without language restrictions. The Population, Intervention, Comparator, Outcome
(PICO) model was used to frame the following guiding question of the systematic review:
What is the impact of IPC intervention on PROs, in a primary care setting, among patients
with type 2 diabetes? Each PICO domain corresponded to the following elements: (P)
Patients with type 2 diabetes mellitus in primary care, (I) IPC, (C) usual care and (O)
patients reported outcomes (PROs) [31]. To ensure the systematic review quality, the
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist
J. Pers. Med. 2022, 12, 643 3 of 12

and flow-diagram was used [32]. Taking into account the search strategy conducted by
Reeves et al. [21], the search string was constructed combining keywords such as “diabetes
mellitus type 2”, “interprofessional collaboration”, “interprofessional team”, “patient
reported outcome measures”, “patient reported outcomes”, “health related quality of life”,
“primary health care”, “primary care” and their synonyms through Boolean operators
“AND” and “OR” (Document S1). Finally, additional studies were identified by “hand
search” of references from articles included in the review (i.e., snowball searching).

2.2. Study Selection

Two investigators independently screened titles and abstracts of all records to identify
potentially relevant publications. The inclusion criteria for this review were: randomized
clinical trials, published in English or in Italian, assessing, through PROs, IPC interventions
on DM2 management compared to usual care in the primary care setting.
Technically, IPC implies a set of different interventions usually taking place in health-
care settings as well as by specific tools such as interprofessional checklists and meetings,
pathways, and forms [21,33]. Scientific evidence showed a conceptual skepticism regarding
the wide number of terms referring to IPC given the great amount of manuscripts written
by expert health professionals rather than scholars. However, as a whole, IPC’s main
characteristic is the interactive effort and the support of professionals deemed to be of
paramount importance to achieving the outcome implying high levels of communication,
mutual planning, collective decisions and common responsibilities [21]. “Usual care” was
defined as the care the targeted patient population would be expected to receive as part of
the normal practice without explicitly stressing any degree of collaboration [34]. Articles
were excluded if they did not meet the inclusion criteria or if they met at least one of the
following exclusion criteria: not peer-reviewed studies, studies including students in the
IPC teams, and studies reporting PROMs assessing any construct that was not present in
other manuscripts. The evaluation of the eligibility criteria was performed independently
by the two authors and, in case of divergence, a third researcher was consulted.

2.3. Quality Assessment

Two investigators independently assessed the quality of the studies using the National
Institute of Health’s Quality Assessment of Controlled Intervention Studies [35]. If dis-
agreements occurred, the final decision was reached by team consensus. The tool assesses
14 parameters for evaluating the internal validity of a study. For each item, the investigator
could select “yes”, “no”, or “cannot determine/not reported/not applicable” [35]. A po-
tential risk of bias was considered if the item was rated as “no” or “cannot determine/not
reported/not applicable” were selected for the items by the reviewer. If the “yes” answers
were ≥75% of the total, an article was considered to be of “good” quality; if they were
<75% but ≥50%, an article was scored as “fair”; if they were <50%, the article was scored
as “poor”.

2.4. Data Extraction and Data Analysis

Two reviewers independently performed data extraction and a standardized form
was used to tabulate the following data: bibliographic details, country, intervention team,
setting, intervention, population, PROMs, main results. Considering the variety of different
PROMs investigating the same area, we grouped them in order to conduct a meta-analysis.
For each study, standardized mean differences (SMD) between compared groups were
computed using Hedge’s g statistics [36]. Thus, pooled estimates were obtained using
the Paule-Mandel random-effects model [37,38], and between-study heterogeneity was
assessed using I2 statistics, which describes the percentage of variability in estimates across
studies due to chance rather than sample error [39,40].
All meta-analyses were performed using statistical software STATA (version 14.0;
College Station, TX, USA) and two-sided p values < 0.05 were considered statistically
significant.
 was assessed using I2 statistics, which describes the percentage of variability in estimates
across studies due to chance rather than sample error [39,40].
All meta-analyses were performed using statistical software STATA (version 14.0;
J. Pers. Med. 2022, 12, 643 College Station, TX, USA) and two-sided p values < 0.05 were considered statistically4 of 12
sig-
nificant.

3. Results
3.1. Study Selection
The
The literature
literaturesearch
searchresulted
resultedin in
1961 studies.
1961 After
studies. eliminating
After duplicates,
eliminating the research
duplicates, the re-
team reviewed a total of 1725 manuscript titles and abstracts. A total of 48
search team reviewed a total of 1725 manuscript titles and abstracts. A total of 48 fullfull articles were
ar-
considered potentially relevant and were reviewed by two independent
ticles were considered potentially relevant and were reviewed by two independent re- researchers. After
full text examination,
searchers. 29examination,
After full text of 48 articles29
were
of 48excluded as they
articles were did notasfulfill
excluded they didthe not
selection
fulfill
criteria. The remaining
the selection criteria. The19remaining
studies [41–59] were[41–59]
19 studies included in the
were systematic
included in thereview and
systematic
studies werestudies
review and considered
werefor the meta-analysis
considered (Figure 1). (Figure 1).
for the meta-analysis

Figure 1.
Figure 1. Flow
Flow diagram.
diagram.

3.2.
3.2. Characteristics
Characteristics of
of the
the Studies
Studies
The
The included
included studies
studies were
were published
published between
between 1998
1998 and
and 2020,
2020, of
of which
which three
three were
were
from
from Canada
Canada[46,50,54]
[46,50,54]andandthethe
Netherlands [48,59],
Netherlands whilewhile
[48,59], two were
two from
were the USA
from the[42,44],
USA
Brazil [45,57] and the UK [56,58]. Overall, 6273 patients were enrolled in the 19
[42,44], Brazil [45,57] and the UK [56,58]. Overall, 6273 patients were enrolled in the 19 studies
(range:
studies 29–507), nine of which
(range: 29–507), nine ofenrolled fewer than
which enrolled 100than
fewer patients.
100 patients.
The majority of the studies, 18 out of 20, were targeted at improving the role of diabetes’
patients in self-management and modifying lifestyle behaviors. Following the definition of
Ismail et al. [60], 11 studies included educational intervention [43,46–52,54,56,57], 11 studies
were characterized by psychological intervention [42–45,47,50,53–55,58,59], and three were
based on peer support programs [41,43,55]. Other kinds of intervention assessed were
medication control and the retraining of health professionals. The vast majority of the
interventions were provided in outpatient settings, while three interventions were delivered
J. Pers. Med. 2022, 12, 643 5 of 12

through the adoption of telemedicine [44,47] and one intervention occurred directly at the
patient’s home [50].
In many studies, it was clearly reported that an empowerment approach [43,49,56,57],
patient engagement [54,55], and/or community engagement [41,46,54] were adopted. On
the basis of the intervention provision, the target was person-based in 10 studies [44,
45,47,50–53,55,58,59] while in six it was either in groups [42,43,48,49,56,57], community-
based [41,46], or both [54].
“Nurse” was the most represented job category available in the intervention team
in 14 studies [41,42,44,46–51,53,54,56,58,59], followed by “dietician” in eight studies [45,
46,48,49,51,54–56] and “primary care physician” in 10 papers [43,45,47,51–53,55,58,59].
"Psychologist" was present in the intervention team in only five studies [42,43,45,53,59].
Overall, five studies assessed the impact of IPC in diabetes patients who had any kind
of psychological symptoms or emotional distress [42,44,50,54,59].
A summary of the characteristics of each study is reported in Table S1.

3.3. Quality Assessment

A score of ten or greater was indicative of good methodological quality, nine to seven
was fair and studies scoring below seven were deemed to be of poor quality. The overall
methodological quality of all included studies (n = 19) is summarized in Table S2. Thirteen
studies [41,42,44,46–50,52–54,58,59] were deemed of good quality, while five [43,51,55–57]
were rated to be of fair quality, showing a moderate risk of bias. Only one study was rated
as poor [45]. The most frequent quality criteria met were the use of randomization and
the power of study calculation. A number of items were rarely reported, including those
regarding adherence to treatment or avoiding other interventions. The drop-out rate at the
endpoint was 20% or lower in 16 studies [41–44,46–55,57,59].

3.4. Data Synthesis

Different PROMs investigating the same area were grouped into nine categories
(i.e., health-related quality-of-life—physical; Health-related quality-of-life—mental; De-
pression; Emotional distress; Patient’s satisfaction; Self-efficacy; Self-care; Quality of life—
generic; Quality of life—specific), as already highlighted in the scientific literature [61].
Figure 2 depicts the results of the meta-analysis.

3.4.1. Health-Related Quality-of-Life—Physical

Seven [41,42,44–46,49,54] trials assessed the physical component of the health-related
quality of life on generic PROMs. In particular, five [42,44–46,54] were SF-12 questionnaires
while two [41,49] were SF-36 ones. After pooling these studies, no significant difference
between intervention and the usual care was found: SMD 0.05 (95% CI −0.03, 0.14).

3.4.2. Health-Related Quality-of-Life—Mental

This was evaluated in seven trials using the SF-12 questionnaire in five of
them [42,44–46,54] and the SF-36 questionnaire in two [41,49]. After pooling the stud-
ies, statistical analysis supports a significant difference in favor of the IPC intervention
team: SMD 0.18 (95% CI 0.06, 0.30).
J. Pers. Med. 2022, 12, x FOR PEER REVIEW 6 of 13

J. Pers. Med. 2022, 12, 643 6 of 12

Figure 2. Findings of the pooled analysis of the included studies. Abbreviation: SMD, Standardized
Mean Difference.
Figure 2. Findings of the pooled analysis of the included studies. Abbreviation: SMD, Standardized
Mean
3.4.3.Difference.
Depression
Nine studies [42,44–47,50,54–56] investigated the depression scores on itemized scales.
3.4.1.
FourHealth-Related Quality-of-Life—Physical
[42,46,54,55] used the Center for Epidemiologic Studies Depression Tool (CES-D),
twoSeven [41,42,44–46,49,54]
[44,45] trials assessed
used the Beck Depression the physical
Inventory component
(BDI), two used theof[50,56]
the health-related
Hospital
Anxiety
quality ofand
lifeDepression
on genericScale (HADS),
PROMs. and one [47]five
In particular, used the Major Depressive
[42,44–46,54] were SF-12Syndrome
question-
(PHQ-9). The pooled analysis did not show any significant difference between intervention
naires while two [41,49] were SF-36 ones. After pooling these studies, no significant dif-
and usual
ference care: SMD
between −0.19 (95%
intervention andCI the−usual
0.40, 0.02).
care was found: SMD 0.05 (95% CI −0.03, 0.14).
3.4.4. Emotional Distress
3.4.2. Health-Related Quality-of-Life—Mental
This was assessed in four studies [51,55,56,59] adopting the Problem Areas in Diabetes
Thisquestionnaire.
(PAID) was evaluated inpooling
After seven these
trialstrials,
usingthere
thewas
SF-12 questionnaire
no significant in five
difference of them
in either
[42,44–46,54] and the SF-36 questionnaire
group: SMD 0.00 (95% CI −0.18, 0.19). in two [41,49]. After pooling the studies, statis-
tical analysis supports a significant difference in favor of the IPC intervention team: SMD
3.4.5.
0.18 Patient’s
(95% Satisfaction
CI 0.06, 0.30).
Two studies [51,52] assessed the patient’s satisfaction using the Diabetes Satisfaction
3.4.3.
and Depression
Treatment Questionnaire (DTSQ). After analyzing these trials together, a significant
difference was found
Nine studies between intervention
[42,44–47,50,54–56] and usual care:
investigated SMD 0.32 (95%
the depression CI 0.05,
scores on 0.59).
itemized
scales. Four [42,46,54,55] used the Center for Epidemiologic Studies Depression Tool
3.4.6. Self-Efficacy
(CES-D), two [44,45] used the Beck Depression Inventory (BDI), two used the [50,56] Hos-
This was evaluated in six studies [46,47,50,53–55] adopting the Self-Efficacy for Man-
pital Anxiety and Depression Scale (HADS), and one [47] used the Major Depressive Syn-
aging Chronic Disease scale (SEMCD) in two [46,54] of them, the Diabetes Self-Efficacy
drome (PHQ-9). The pooled analysis did not show any significant difference between in-
Scale (DSES) in two [47,50], the Chinese diabetes management self-efficacy scale (CDMSES)
tervention
in one [53],and
andusual care: SMD
the 20-item -0.19Management
Diabetes (95% CI −0.40, 0.02)
Self-Efficacy Scale (DMSES) in the last
J. Pers. Med. 2022, 12, 643 7 of 12

one [55]. The pooled analysis highlighted no significant difference in either group: SMD
0.09 (95% CI −0.02, 0.19).

3.4.7. Self-Care
Four trials [46,53,54,57] analyzed the self-care aspect. Three studies [46,53,54] imple-
mented the Summary of Diabetes Self-Care Activities (SDSCA) scale while one [57] adopted
the Self-care for type 2 diabetes (SLC). The statistical analysis did not show any significant
difference between intervention and standard care: SMD 0.10 (95% CI −0.07, 0.28).

3.4.8. Quality of Life—Generic

Four studies [43,47,48,56] reported the quality of life on generic self-report question-
naires. One [43] study used the Thai version of the World Health Organization Quality
of Life—BREF, (WHOQOL-BREF) while one study [56] adopted the classic version of the
same questionnaire.
Besides, one [54] study used the Assessment of Quality of Life (AQoL) Mark 2 instru-
ment and one [48] study applied the three level EuroQol Five Dimension (EQ-5D-3L) scale.
After pooling these trials, no statistical difference was found in either group: SMD 0.53
(95% CI −0.17, 1.23).

3.4.9. Quality of Life—Specific

This was appraised in three studies [42,58,59] using the Diabetes version of the Ferrans
and Powers Quality of Life Index (QLI) in one [42] of them, the Audit of Diabetes dependent
quality of life (ADDQoL) in one [58], and the Diabetes Symptom Checklist—Revised (DSC-
R) in the final one [59]. The metanalysis did not report any significant difference between
the IPC intervention team and the standard alternative: SMD 0.14 (95% CI −0.03, 0.31).

4. Discussion
This study was intended to investigate, through the PROs, the role of interprofessional
collaboration for the management of type 2 diabetes in primary care settings.
The present systematic review and meta-analysis pointed out that collaborative prac-
tice is significantly associated with an increase in both patient satisfaction and in the mental
well-being component of the health-related quality-of-life.
There was also promising evidence supporting the association between the interpro-
fessional approach and an increase in self-care and in generic and specific quality-of-life.
Disease-specific questionnaires are characterized by a set of questions aimed at inves-
tigating health changes related to a particular pathology, disability or intervention. These
tools have a higher sensitivity, being able to intercept even small modifications in the
analyzed disease. However, different from generic PROMs, specific questionnaires cannot
be adopted to compare the health status among different conditions [62]. Hence, an overall
evaluation should be based on the adoption of both the two types of questionnaires, generic
and specific, which are to be considered complementary rather than in opposition for the
assessment of the reported patients’ outcomes [63].
Moreover, there was a lack of evidence supporting the positive impact on IPC in-
terventions on the physical component of the health-related quality-of-life, depression,
emotional distress, and self-efficacy due to inconsistent findings. There are many possible
reasons for this. One concern is related to the duration, complexity and intensity [64] of
the intervention as well as the length of follow-up that may have been insufficient to see
improvements [46]. Indeed, most of the studies lasted less than thirteen months. On the
other hand, for some of the studies there is the possibility that the evaluation was premature
and that patients had not been exposed to the intervention for long enough to detect any
changes or the maximum change.
Moreover, the lack of consistent effect in some studies may in part be explained by
the lower intensity [47] of intervention, especially in that study that based treatment on
coaching techniques.
J. Pers. Med. 2022, 12, 643 8 of 12

A more intensive telephone counseling intervention with more frequent calls, longer
interaction, or longer duration of follow-up may lead to better outcomes. Also, the role of
training of health professionals on coaching or educational intervention might be a reason
for the results of some inconsistent findings, as most interventions had these characteristics.
For example, motivational interviewing was originally developed for substance abuse,
requiring a single behavioral change, whereas diabetes is a complex chronic illness that
requires multiple behavioral changes [65], thus implying the lack of favorable effects on
patient outcomes.
Another explanation to the lack of statistically significant findings lies in the good
quality of the usual care approach for persons with diabetes in both the intervention and
control groups, thereby avoiding that the training programme hardly added value [65].
In multicentric studies, it is also possible that the background and experience of health-
care providers of diabetes care also differed among the sites, which may have affected
the findings. Another issue [66] that could influence the effect of the intervention is the
Hawthorne effect [67]. On one hand, in an RCT the effect size could be underestimated,
as both the intervention and control groups could improve their performance by virtue of
participation in a study in which both groups were motivated [46] to implement an inter-
vention to improve their performance. On the other hand, the effect could be overestimated
in a controlled before-after study in which the control group provides the usual care and is
not necessarily motivated to implement an intervention and is possibly not (completely)
informed about the intervention and the purpose of this. The intervention group could
improve their delivered care just because they participate in a study aimed at improving
diabetes management.
For what concerns the physical aspect of the health-related quality-of-life, in the
paper taken into the exam, only few interventions were focused on the promotion of the
daily physical activities that represent an essential component of the questionnaire and, as
highlighted by the evidence in the scientific literature [68], they are also fundamental for
the proper management of type 2 diabetes.
The careful reading of the study findings allows for few key implications. The first
suggests that IPC has the potential to ease healthcare processes, improve patient outcomes
and care continuity and coordination as well as to reduce health costs in primary care [69].
Furthermore, given the fragmentation [70] of diabetes services characterizing health
care systems and the high number of specialists involved, the integrated care model
could represent a potential solution to obtaining a continuous multi-organizational assis-
tance [70,71].
Lewis et al. [72] identified four different kinds of integration: organizational, func-
tional, service and clinical. Given that IPC can be configured as both a service and clinical
integration model, therefore it could be important to also focus on the organizational and
functional integration.
The last implication regards the significance of endorsing patient-centeredness [73,74]
for diabetes and other chronic conditions care, through the assessment of PROs and the in-
tegration of PROMs in clinical practice, by allowing a higher degree of patient involvement
in the entire care process and the easing of the communication between health professionals
and patients.
The findings of this systematic review and meta-analysis must be gauged in light of
its strengths and weaknesses. Above all, the comprehensive and rigorous search strategy,
the meticulous quality assessment and the methodological appropriateness in conducting
the meta-analysis are strengths of the study. A limitation is represented by the merging
of different PROMs, as illustrated by the lack of equal questionnaires, on the basis of the
area investigated, thus leading to a potential increase in the heterogeneity. Nonetheless, we
proceeded to standardize the reported estimates to allow a higher comparability during
the meta-analysis process. Another caveat is the significant heterogeneity shown by some
studies used for pooled analysis. However, it could be explained by clinical (i.e., type of
intervention) diversity among the pooled studies. An additional limitation is the follow-up
J. Pers. Med. 2022, 12, 643 9 of 12

time of the selected studies, which may limit the applicability and validity of results and
also may represent a hurdle in the proper identification of the long-term hazards.
Further research is needed to reach a broader consensus and to define a guideline
on which PROMs should be adopted in diabetes management. Additional studies should
define the intensity of the people-centered approach interventions, such as coaching or
education, and which competencies/skills are needed for a productive interprofessional
team in order to deliver an efficient and effective intervention.

5. Conclusions
In brief, this systematic review and meta-analysis brings a new and strong contribution
to the literature debate on the impact of interprofessional collaboration interventions for
the management of type 2 diabetes in primary care settings through PROs.
Currently, in a context characterized by an aging population, resource constraints and
elevated health expenditures for chronic disease management, decision-makers should
promote policies aimed to enhance the widespread adoption of a collaborative approach as
well as to endorse the active engagement of patients across the whole continuum of care.

Supplementary Materials: The following supporting information can be downloaded at: https://
www.mdpi.com/article/10.3390/jpm12040643/s1, Table S1: Summary characteristics of the included
studies, Table S2: Results of quality assessment process of Controlled Intervention studies, Document
S1: Search strategy.
Author Contributions: Conceptualization, M.C.N., D.P. and G.D.; Methodology, M.C.N., D.P. and
M.S.; Validation, L.L. and G.D.; Formal Analysis, M.C.N., G.S. and D.P.; Investigation, M.C.N., G.S.
and D.P.; Resources, M.C.N., G.S. and D.P.; Data Curation, M.C.N., G.S., D.P. and M.S.; Writing—
Original Draft Preparation, M.C.N., G.S. and D.P.; Writing—Review & Editing, M.C.N., G.S., D.P.,
M.S., L.L. and G.D.; Visualization, L.L. and G.D.; Supervision, L.L. and G.D.; Project Administration,
L.L. and G.D. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author.
Conflicts of Interest: The authors declare that they have no conflict of interest.

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