What is the project about?

For patients at risk of developing a chronic disease, early diagnosis can enhance quality and length of life through early intervention provided by their general practitioners (GPs). Chronic Disease IMPACT will simplify the process for GPs to earlier identify patients who may be at risk of developing some of the most common chronic diseases which include Chronic Kidney Disease (CKD), Cardio-vascular diseases (CVDs), and Type 2 Diabetes Mellitus (T2DM). In addition, the program will facilitate efficient management of individuals already diagnosed with multiple diseases (i.e. those at most risk of being admitted to hospital).

The program includes provision of a newly designed, tested and implemented chronic disease e-technology which acts as a-one stop shop for the detection and management of CKD, CVD and T2DM and associated risk factors; education and clinical audit planning support for GPs on CKD, CVD and T2DM detection and management. Chronic Disease IMPACT is currently being implemented into a total of 16 Victorian General Practices located across metropolitan and regional Victoria with a total patient population of approximately 120,000.

Who’s involved?

The e-technology and program design is based on input from a team of disease specialists, a population health expert and GPs in collaboration with Kidney Health Australia, Heart Foundation, Stroke Foundation and Diabetes (Vic) and is informed by the latest national chronic disease management and prevention guidelines.

What were the outcomes?

A recent publication with baseline data from this project including 37 946 patients from Victorian general practices shows that general practice electronic medical record data could be used to assess chronic disease risk factor detection and disease testing, diagnosis, monitoring and treatment. It also provides a snapshot of chronic kidney disease, type 2 diabetes and cardiovascular disease and risk factors for these conditions in Victorian general practice patients.

Findings of a stepped wedge trial assessing the outcomes of the electronic tool-based intervention are currently being prepared for publication.

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