Investigators: Mr Geoff Barnden, Mr Peter Brandt, Mr Zoran Bolevich, Dr Yiqun Chen, Mr Bennett Durham, Dr Richard Matthews (CI), Mrs Helen Moore, Mr Allan Went.

A Chronic Disease Management Program that aims to reduce avoidable hospital admissions and to improve outcomes has been established by the NSW Department of Health. The program specifically targets five chronic conditions including diabetes, congestive heart failure (CHF), coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), and hypertension.

For an effective program implementation, patients who are at the highest risk and who can benefit most from participation in the program should be identified and enrolled. Previous studies have assumed that patients identified at high risk on the basis of their previous admissions would continue to be at high risk of admission in the absence of the intervention. Evidence has proved this assumption may not be true and that identification of high risk patients should consider factors other than or in addition to hospital admissions.

Through the use of data linkage this study aims to:

  • Investigate factors associated with hospital admissions (planned/ unplanned) and re-admissions of older patients diagnosed with the five chronic diseases in NSW
  • Investigate the influence of healthcare utilisation on disease outcomes, taking into account the patients’ risk characteristics.