Dr Sarah Dennis Project: Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales Funding: Australian Primary Health Care Research Institute Stream Funding

Chronic diseases will soon account for about 80% of the total burden of ill health in Australia and a solid evidence base is needed to ensure policies and programs support comprehensive quality care.
Previous research examined specific diseases or elements of care, but this new project took a ‘big picture’ approach to identifying the evidence for effective chronic disease management in primary care.

A collaboration of primary care and chronic disease experts undertook a systematic review of the evidence - a total of 141 studies and 23 published systematic reviews – and used the Chronic Care Model as a framework for analysis. This model is used widely in policy forums and comprises six elements: self-management support, delivery system design, decision support, clinical information systems, community resources, and health care organisation.

The project found that self-management support – such as patient education and motivational counselling – improved disease control as well as quality of life and this was particularly effective when delivered by a multidisciplinary team. Decision support in the form of evidence-based guidelines, education materials and meetings, and audit and feedback were found to improve clinical practice and patients’ disease control, and were often supported by clinical information systems to facilitate recall and feedback.

The advantage of this review is that it presents the evidence for a wide range of interventions to manage chronic disease in the primary care setting. The use of the Chronic Care Model as the framework for the analysis means that the results are presented simply and clearly and within a policy context because of the widespread use of the model in both the national and international policy forums.

View the project abstract on ROAR