Systems-Based Approaches to Cardiometabolic and Chronic Disease Management in Adult Clinical Practice: A Systematic Review

Cardiometabolic and chronic diseases frequently coexist in adult clinical practice, creating complex care needs across hypertension, type 2 diabetes, cardiovascular disease, chronic kidney disease, dyslipidemia, obesity, and multimorbidity. This systematic review evaluated systems-based approaches for adult cardiometabolic and chronic disease management, including integrated care, multidisciplinary teams, chronic care management, shared medical appointments, telemonitoring, pharmacist- and nurse-supported care, and technology-assisted models. A structured search identified 252 records; after duplicate removal, title and abstract screening, and full-text eligibility assessment, 11 studies were included. Because the studies differed in design, setting, population, intervention components, follow-up duration, and outcome reporting, findings were synthesised narratively. The strongest and most consistent effects were observed for intermediate clinical outcomes, especially systolic blood pressure and HbA1c, particularly when interventions incorporated structured monitoring, medication optimisation, patient education, multidisciplinary input, and coordinated follow-up. Several studies also reported improvements in quality of life, anxiety symptoms, medication safety, provider workload, reimbursement feasibility, and care coordination. Findings for lipid control, body mass index, behavioural outcomes, and major cardiovascular, renal, or mortality endpoints were less consistent. Risk of bias varied, with randomised trials generally showing fewer concerns than retrospective, nonrandomized, and quality-improvement studies. Overall, systems-based care may improve risk-factor control and care processes in adults with cardiometabolic multimorbidity, but larger pragmatic trials with longer follow-up are needed to determine whether these benefits translate into durable reductions in complications, hospitalisation, and mortality.