Impact on diabetes management of General Practice Management Plans, Team Care Arrangements and reviews

Leelani K Wickramasinghe, Peter Schattner, Marienne E Hibbert, Joanne C Enticott, Michael P Georgeff and Grant M Russell
Med J Aust 2013; 199 (4): 261-265. || doi: 10.5694/mja13.10161


Objectives: To investigate whether General Practice Management Plans (GPMPs), Team Care Arrangements (TCAs) and reviews of these improve the management and outcomes of patients with diabetes when supported by cdmNet, a web-based chronic disease management system; and to investigate adherence to the annual cycle of care (ACOC), as recommended in diabetes guidelines.

Design, participants and setting: A before-and-after study to analyse prospectively collected data on 577 patients with type 1 or 2 diabetes mellitus who were managed with a GPMP created using cdmNet between June 2008 and November 2012.

Main outcome measures: Completion of the clinical tests in the ACOC (process outcome) and values of six of these clinical measurements (clinical outcomes).

Results: Significant improvements were seen after creation of a GPMP in the proportion of ACOC clinical tests completed (57.9% v 74.8%, P < 0.001), total cholesterol level (P < 0.01), low-density lipoprotein (LDL) cholesterol level (P < 0.001) and body mass index (BMI) (P < 0.01). Patients using GPMPs and TCAs also improved their glycated haemoglobin (HbA1c) level (P < 0.05). Patients followed up with irregular reviews had significant improvements in the proportion of ACOC clinical tests completed (59.2% v 77.6%, P < 0.001), total cholesterol level (P < 0.05), and BMI (P < 0.01), but patients with regular reviews had greater improvements in the proportion of ACOC clinical tests completed (58.9% v 85.0%, P < 0.001), HbA1c level (57.7 v 53.0 mmol/mol, P < 0.05), total cholesterol level (4.8 v 4.5 mmol/L, P < 0.05), LDL cholesterol level (2.8 v 2.4 mmol/L, P < 0.01) and diastolic blood pressure (76.0 v 74.0 mmHg, P < 0.05).

Conclusion: There were significant improvements in process and clinical outcomes for patients on a GPMP or a GPMP and TCA, particularly when these were followed up by regular reviews. Patients using cdmNet were four times more likely to have their GPMP or TCA followed up through regular reviews than the national average.

  • Leelani K Wickramasinghe1
  • Peter Schattner1
  • Marienne E Hibbert2
  • Joanne C Enticott3
  • Michael P Georgeff4,5
  • Grant M Russell3

  • 1 Department of General Practice, Monash University, Melbourne, VIC.
  • 2 Department of Medicine, University of Melbourne, Melbourne, VIC.
  • 3 Southern Academic Primary Care Research Unit, Monash University, Melbourne, VIC.
  • 4 Precedence Health Care, Melbourne, VIC.
  • 5 Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC.


This work was supported by funding from the Australian Government under the Digital Regions Initiative and the Department of Health and Ageing and by the Victorian Department of Business and Innovation.

Competing interests:

Michael Georgeff is the CEO and Marienne Hibbert is the clinical integration manager of Precedence Health Care, which developed cdmNet.

  • 1. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996; 74: 511-544.
  • 2. Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic Care Model in the new millennium. Health Aff (Millwood) 2009; 28: 75-85.
  • 3. Improving Chronic Illness Care. The Chronic Care Model: delivery system design. (accessed May 2012).
  • 4. Dennis SM, Zwar N, Griffiths R, et al. Chronic disease management in primary care: from evidence to policy. Med J Aust 2008; 188 (8 Suppl): S53-S56. <MJA full text>
  • 5. Sperl-Hillen JM, Solberg LI, Hroscikoski MC, et al. Do all components of the chronic care model contribute equally to quality improvement? Jt Comm J Qual Saf 2004; 30: 303-309.
  • 6. Shojania KG, Ranji SR, McDonald KM, et al. Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis. JAMA 2006; 296: 427-440.
  • 7. Australian Government Department of Health and Ageing. MBS Primary Care Items. History of key MBS primary care initiatives 1999–2010. (accessed Sep 2012).
  • 8. Australian Government Department of Health and Ageing. MBS Primary Care Items. Chronic Disease Management (CDM) Medicare Items. (accessed Jul 2012).
  • 9. Zwar NA, Hermiz O, Comino EJ, et al. Do multidisciplinary care plans result in better care for patients with type 2 diabetes? Aust Fam Physician 2007; 36: 85-89.
  • 10. Zwar N, Hasan I, Hermiz O, et al. Multidisciplinary care plans and diabetes — benefits for patients with poor glycaemic control. Aust Fam Physician 2008; 37: 960-962.
  • 11. Ralston JD, Hirsch IB, Hoath J, et al. Web-based collaborative care for type 2 diabetes: a pilot randomized trial. Diabetes Care 2009; 32: 234-239.
  • 12. Bond GE, Burr R, Wolf FM, et al. The effects of a web-based intervention on the physical outcomes associated with diabetes among adults age 60 and older: a randomized trial. Diabetes Technol Ther 2007; 9: 52-59.
  • 13. McMahon GT, Gomes HE, Hickson Hohne S, et al. Web-based care management in patients with poorly controlled diabetes. Diabetes Care 2005; 28: 1624-1629.
  • 14. Shea S, Weinstock RS, Starren J, et al. A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus. J Am Med Inform Assoc 2006; 13: 40-51.
  • 15. McCarrier KP, Ralston JD, Hirsch IB, et al. Web-based collaborative care for type 1 diabetes: a pilot randomized trial. Diabetes Technol Ther 2009; 11: 211-217.
  • 16. Georgeff M, Piterman L, Dunning T, et al. CDM-Net: a broadband health network for transforming chronic disease management. Final report. Melbourne: Precedence Health Care, 2010.
  • 17. Jones K, Dunning T, Costa B, et al. The CDM-Net Project: the development, implementation and evaluation of a broadband-based network for managing chronic disease. Int J Family Med 2012; (2012): 453450. doi: 10.1155/2012/453450.
  • 18. Wickramasinghe LK, Schattner P, Enticott J, et al. Care plans for patients with type 2 diabetes: patient variables that contribute to plan formation. Primary Health Care Research Conference; 18-20 July 2012; Canberra, Australia. In: 2012 Primary Health Care Research Conference: program and abstracts. Primary Health Care Research and Information Service. (accessed Jul 2013).
  • 19. Precedence Health Care. Digital Regions Initiative: cdmNet Australia. Final report July 2009 – September 2012. http://precedence (accessed Aug 2013).
  • 20. Australian Government Department of Human Services. Practice Incentives Program. Diabetes incentive guidelines — July 2012. (accessed Jul 2012).
  • 21. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329: 977-986.
  • 22. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998; 352: 837-853.
  • 23. Dekking FM, Kraaikamp C, Lopuhaa HP, Meester LE. A modern introduction to probability and statistics: understanding why and how. London: Springer Verlag, 2005.
  • 24. Lowry R. Chapter 14. One-way analysis of variance for independent samples. In: Concepts and applications of inferential statistics. (accessed Mar 2013).
  • 25. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, NJ; Lawrence Erlbaum Associates, 1988: 284-287.
  • 26. Australian Institute of Health and Welfare. Annual cycle of care. (accessed May 2013).
  • 27. Australian Government Department of Human Services. Medicare item reports. (accessed May 2013).


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