Chronic Disease Management

The Research Question:

"Is there reliable scientific evidence to support team-based management of chronic disease and, if so, given the NL context (in terms of geography, demography, fiscal resources and health system capacities) what is the most effective and efficient way to organize, implement, and sustain team-based care for individuals with diabetes and chronic obstructive pulmonary disease (COPD) so as to derive the best possible outcomes for patients, providers and the health system?"


As in other parts of Canada and the world, the prevalence of chronic disease in Newfoundland and Labrador (NL) is growing due to the combined impact of our aging population and other persistent lifestyle risk factors.

It has been argued that a team approach to chronic disease management may improve patient health outcomes and may also ease the financial burden on the healthcare system.

Adopting an interprofessional team-based approach to chronic disease management in NL would, however, require rethinking the current healthcare delivery system and would have implications for both patients and providers of healthcare in this province.

In order to justify the potential increments in human and financial resources associated with such a change, decision makers would, before making such significant investments, require reliable research-based evidence on whether team-based management of chronic disease works and, if so, how such teams are best designed, implemented and sustained.

Given the mounting health and economic burdens associated with chronic disease in this province, our decision-making partners in the provincial health system asked the Contextualized Health Research Synthesis Program (CHRSP) team to synthesize and contextualize the evidence on interprofessional teams for the management of chronic disease.

The research team chose to focus their study on the management of individuals with diabetes and chronic obstructive pulmonary disease (COPD) for several reasons:

  • In 2006-7, NL had the highest age-standardized prevalence of diabetes of all provinces and territories in Canada (PHAC, 2009) and incidence rates are steadily increasing. The complications associated uncontrolled diabetes place a considerable burden on patients and the healthcare system.
  • COPD is a chronic, debilitating disease and is the leading cause of hospital admissions and readmissions for chronic disease across Canada (Canadian Thoracic Society, 2010). If managed incorrectly, the disease affects the quality of life of patients, and places considerable burden on the healthcare system.
  • Lastly, in keeping with CHRSP methodologies, the availability of systematic reviews and HTAs for these two chronic diseases was thought to be sufficient to support a synthesis of research evidence.

The CHRSP Project Team:

  • Dr. Anne Sales, Professor, School of Nursing, University of Michigan; Research Scientist, Centre for Clinical Management Research, Veteran's Affairs, Ann Arbour, MI, VA Inpatient Evaluation Center (IPEC) and Canadian Research Chair in Interdisciplinary Healthcare Teams (Team Leader)
  • Dr. Daria O’Reilly, PATH Program, McMaster University (Health Economist)
  • Dr. Stephen Bornstein, Director, NLCAHR (CHRSP Program Director)
  • Janice Butler, Senior Research Officer, NLCAHR (CHRSP Project Coordinator)
  • Robert Kean, CHRSP Research Officer
  • Meagan Mackenzie, CHRSP Research Assistant

Project Consultants:

  • Dr. Susan Gillam, CEO, Western Health, (Health System Partner)
  • Michelle House, V.P., Population Health, Western Health (Health System Partner)
  • Dr. Brendan Barrett, Professor of Medicine, Memorial University; Nephrologist, Eastern Health
  • Dr. Nigel Duguid, Clinical Professor of Medicine, Memorial University; Respirologist, Eastern Health
  • Lisa Hoddinott, VP, Quality Management and Research, Western Health
  • Dr. Anne Kearney, Associate Professor, School of Nursing and Division of Community Health and Humanities, Memorial University; Director, Centre for Nursing Studies, Memorial University
  • Linda Carter, Director, Chronic Disease Prevention, Department of Health and Community Services
  • Karen Oldford, Primary Healthcare Nurse-Practitioner, Labrador-Grenfell Health
  • Karen Milley, Regional Manager, Community Health Services, Chronic Disease Prevention and Management, Eastern Health
  • Dr. Sandra Small, Associate Professor, School of Nursing, Memorial University
  • Kaitryn Campbell, Assistant Professor, McMaster University (Information Scientist)



Newfoundland & Labrador Centre for Applied Health Research

230 Elizabeth Ave, St. John's, NL, CANADA, A1B 3X9

Postal Address: P.O. Box 4200, St. John's, NL, CANADA, A1C 5S7

Tel: (709) 864-8000