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Examining health promotion interventions for patients with chronic conditions using a novel patient-centered complexity model: protocol for a systematic review and meta-analysis

Amy E Bodde12, Nathan D Shippee3, Carl R May4, Frances S Mair5, Patricia J Erwin1, M Hassan Murad16 and Victor M Montori17*

Author Affiliations

1 Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA

2 Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA

3 Division of Health Policy and Management, Mayo Building A302, MMC 197 420 Delaware Street SE, Minneapolis, MN, 55455, USA

4 Health Sciences, University of Southampton, University Road, Southampton, SO17 1BJ, UK

5 General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, 1055 Great Western Road, Glasgow, G12 0XH, UK

6 Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, MN, USA

7 Division of Endocrinology, Diabetes, Metabolism, Nutrition, Mayo Clinic, Rochester, MN, USA

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Systematic Reviews 2013, 2:29  doi:10.1186/2046-4053-2-29

Published: 11 May 2013



Successful chronic care self-management requires adherence to healthy lifestyle behaviors, but many healthcare-based health promotion interventions have resulted in small and unsustainable changes in patient behavior. Patients with chronic conditions may already be overwhelmed by burdensome illnesses and treatments, and not have the capacity to respond well to the additional work required of behavior modifications. To explore this phenomenon, we will apply the cumulative complexity model (CCM), a patient-centered model of patient complexity, to a systematic review and meta-analysis of healthcare-based health behavior interventions.


This systematic review will include randomized trials published between 2002 and 2012 that compared healthcare-based interventions aimed at improving healthy diet and physical activity in community dwelling adult patients with chronic conditions. After extracting study and risk of bias features from each trial, we will classify the interventions according to the conceptual model. We will then use meta-analysis and subgroup analysis to test hypotheses based on the conceptual model.


Healthcare providers need evidence of successful health promoting interventions for patients with chronic conditions who display common behavioral risk factors. To better understand how patients respond to interventions, we will apply the CCM, which accounts for both the capacity of patients with chronic conditions and their treatment-related workload, and posits that a balance between capacity and workload predicts successful enactment of self-care. Analysis will also include whether patients with multiple chronic conditions respond differently to interventions compared to those with single chronic conditions. The results of this review will provide insights as to how patients with chronic conditions respond to health-promoting interventions.

Review registration

PROSPERO registration number: CRD42012003428

Health behavior; Comorbidities; Multimorbidity; Chronic conditions; Patient complexity; Cumulative complexity model; Physical activity; Diet