Rejuvenating chronic disease management in Malaysian private general practice – a global perspective

  • AS Ramli
  • S Wijesinha
  • L Piterman
Keywords: Chronic disease management, chronic care model, private general practice, Malaysia


Rapid epidemiological transition globally has witnessed a rising prevalence of major chronic diseases such as hypertension,diabetes, hyperlipidaemia, obesity, chronic respiratory diseases and cancers over the past 30 years. In Malaysia, theseconditions are commonly managed in primary care and published evidence has consistently shown suboptimal managementand poor disease control. This in turn, has led to the massive burden of treating complications in secondary care, burden tothe patients and their families with regards to morbidity and premature death, and burden to the country with regards topremature loss of human capital. The crushing burden and escalating health care costs in managing chronic diseases posea daunting challenge to our primary care system, as we remain traditionally oriented to care for acute, episodic illnesses.This paper re-examines the current evidence supporting the implementation of Wagner Chronic Care Model in primary careglobally; analyses the barriers of implementation of this model in the Malaysian private general practice through SWOT(strengths, weaknesses, opportunities and threats) analysis; and discusses fundamental solutions needed to bridge the gapto achieve better outcomes.


World Health Organization (WHO). Preventing chronic diseases: a vital investment. Geneva: World Health Organization; 2005.

Wagner EH, Austin BT, Davis C, et al. Improving chronic illness care: translating evidence into action. Health Aff. 2001;20(6):64-78.

Ramli AS, Taher SW. Managing chronic diseases in the Malaysian primary health care – a need for change. Malaysian Family Physician. 2008;3(1):7-13.

Yach D, Hawkes C, Gould CL, et al. The global burden of chronic diseases: overcoming impediments to prevention and control. JAMA. 2004;291(21):2616-22.

Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002; 288(14):1775-9.

Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model,Part 2. JAMA. 2002;288(15):1909-14.

Nolte E, Knai C, McKee M. Managing chronic conditions: experience in eight countries. Europian Observatory on Health Systems and Policies, World Health Organization; 2008.

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):S53-6.

Ham C. Chronic care in the English National Health Service: progress and challenges. Health Aff. 2009;28(1):190-201.

Minkman M, Ahaus K, Huijsman R. Performance improvement based on integrated quality management models: what evidence do we have? A systematic literature review. Int J Qual Health Care. 2007;19(2):90-104.

Coleman K, Austin BT, Brach C, et al. Evidence on the Chronic Care Model in the new millennium. Health Aff. 2009;28(1):75-85.

Ramli AS. Chronic disease management in primary care – a review of evidence. Medical & Health Review. 2008;1(1):63-80.

Wagner EH. The role of patient care teams in chronic disease management. BMJ. 2000;320(7234):569-72.

Bodenheimer T, Laing BY. The teamlet model of primary care. Ann Fam Med. 2007;5(5):457-61.

Smith SM, Allwright S, O’Dowd T. Effectiveness of shared care across the interface between primary and specialty care in chronic disease management. Cochrane Databse Syst Rev. 2007(3):CD004910.

Schoen C, Osborn R, Huynh PT, et al. On the front lines of care: primary care doctors’ office systems, experiences and views in seven countries. Health Aff. 2006;25(6):w555-71.

Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004;8(6):iii-iv,1-72.

Bodenheimer T, Lorig K, Holman H, et al. Patient selfmanagement of chronic disease in primary care. JAMA. 2002;288(19):2469-75.

Kennedy A, Reeves D, Bower P, et al. The effectiveness and cost-effectiveness of a national lay-led self care support programme for patients with long-term conditions: a pragmatic randomized controlled trial. J Epidemiol Community Health. 2007;61(3):254-61.

Martin CM. Chronic disease and illness care: adding principles of family medicine to address ongoing health system redesign. Can Fam Physician. 2007;53(12):2086-91.

Chambers R, Wakley G. Clinical Audit in Primary Care: Demonstrating quality and outcomes. Radcliffe Publishing; 2005.

Doran T, Fullwood C, Kontopantelis E, et al. Effect of financial incentives on inequalities in the delivery of primary clinical care in England: analysis of clinical activity indicators for the Quality and Outcomes Framework. Lancet. 2008; 372(9640):728-36.

Campbell S, Reeves D, Kontopantelis E, et al. Quality of primary care in England with the introduction of pay for performance. N Engl J Med. 2007;357(2):181-90.

Provan KG, Nakama L, Veazie MA, et al. Building community capacity around chronic disease services through collaborative interorganizational network. Health Educ Behav. 2003;30(6):646-62.

How to Cite
RamliA., WijesinhaS., & PitermanL. (2012). Rejuvenating chronic disease management in Malaysian private general practice – a global perspective. Malaysian Family Physician, 5(1), 4. Retrieved from
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