Systematic review of chronic disease management in primary care

Project Status

Chief Investigators
Mark Harris, Rhonda Griffiths, Martin Roland, Sarah Dennis

Other Team Members
Iqbal Hasan


The World Health Organization defines chronic diseases as having one or more of the following characteristics: they are permanent, leave residual disability, are caused by non-reversible pathological alteration, require special training of the patient for rehabilitation, or may be expected to require a long period of supervision, observation, or care. This review focussed on those chronic diseases most commonly managed in primary care.

Weingarten’s definition of chronic disease management is “an intervention designed to manage or prevent a chronic condition using a systematic approach to care and potentially employing multiple treatment modalities” . The WHO definition of chronic disease and Weingarten's definition of chronic disease management (CDM) were used in developing our research questions. The review was informed by the Chronic Care Model proposed by Wagner and colleagues which includes the six dimensions of organisation of health care, delivery system design, decision support, self management support and community resources.


Research questions to be investigated were:

1. What is meant by chronic disease management in the primary health care sector in Australia and in comparable countries such as USA, Canada, United Kingdom, Netherlands and New Zealand?
2. How and in what context were the models of chronic disease management developed? Why were they developed?
3. What are the roles of those involved in each of the models identified?
4. What are the key outcomes and impacts of the models? How have they been measured?
5. How effective, efficient and innovative are the models and approaches identified?
6. What are the characteristics of successful (effective, efficient and /or innovative) models and approaches in terms of organisation, service delivery and funding? How applicable are these to the Australian context and health care system?
7. What are the facilitators and barriers to effective interventions for chronic disease in primary
8. In relation to funding, what models of remuneration and incentives encourage improved chronic disease outcomes?
9. How applicable are these to the Australian context and health care system?

Design and Method

Systematic review of the literature

Key Publications


Dennis SM, Zwar NA, Hasan I, Harris MF. Chronic disease self-management programs: challenges ahead. MJA 2007; 186: 103-4.

Dennis S, Zwar N, Griffiths R, Roland M, Hasan I, Powell Davies G, Harris MF. Chronic disease management in Australian primary care: from evidence to policy. MJA. 2008; 188: S53-S56.