Table 1

Study selection criteria

Selection criteriaInclusionExclusion
Population – consumer1. General adult (18+ years) population with one or more diagnosed chronic health conditions as classified by the National Public Health Partnership14: ischaemic heart disease (also known as coronary heart disease), stroke, lung cancer, colorectal cancer, depression, type 2 diabetes, arthritis, osteoporosis, asthma, chronic obstructive pulmonary disease, chronic kidney disease and oral disease.
Patients described as having multimorbidity (ie, two or more chronic conditions).
Mixed populations of adult and children unless these groups have been separated as part of the analysis.
Patients with mental health conditions that may impair cognition or understanding, such as dementia and psychosis.
Population – practitioner2. Participants classified as vulnerable based on IMPACT definition and of specific relevance to South West Sydney including: Indigenous/first nation people, culturally and linguistically diverse groups including recently arrived refugee groups, those experiencing socioeconomic hardship and disadvantage (unemployed, low income, those in public housing and homeless); and geographic disadvantage (living in a rural and remote area).
Any health professional providing primary care to a community-based population including general practitioner/family physician, practice nurse or community/clinic nurse, pharmacist, allied health professionals (Aboriginal health workers or Aboriginal and Torres Strait Islander health practitioners, audiologists, chiropractors, diabetes educators, dietitians, exercise, physiologists, mental health workers, occupational therapists, osteopaths, physiotherapists, podiatrists, psychologists and speech pathologists).
e/m/Telehealth interventionsComprehensive (multicomponent) or simple (one component) patient directed or patient-focused tools available via a personal computer, telephone or mobile device (mobile phone or tablet). This includes the provision of instant feedback or SMS reminders that encourage patients to achieve their health goals and interactive programmes that provide ongoing monitoring with self-assessment activities.
Access to the tools should involve an initial direct interaction between a primary healthcare provider (defined above) and the patient (defined above) during which instruction or training is provided to the patient to aid understanding, promote knowledge or increase skills, including coaching and education tools provided over the phone.
The intervention/tool should provide patients with a short to medium term or ongoing interactive method of education, training or skill development that supports self-management and empowerment related to their management of chronic disease and its risk factors.
e/m/Telehealth intervention/s implied but not described.
Devices or programmes used for simple self-monitoring of symptoms related to chronic condition such as sugar or blood pressure except where these are a component of a broader interactive intervention.
Readings recorded via the internet or through devices that allow the download of readings. These may be included if they are one component of a more comprehensive self-management programme.
Telephone triage services where a patient is advised as to what level of care to seek (General Practitioner (GP) or hospital).
Single contact for the provision of simple educational material only without added coaching/skill improvement and ongoing skill development.
Telemedicine for routine consultations with no health education component/intention.
Establishing, utilising or reviewing electronic health record systems within Community Based Primary Health Care (CBPHC).
ComparatorUsual care, enhanced usual care (eg, added counselling or education) or a second intervention arm.
OutcomesPrimary outcomes:
1Health service use:
  • Increased attendance at primary care service.

  • Number of General Practitioner visits per year.

  • Use of the e/m/telehealth intervention by patients and practitioners including practitioner adoption/inclusion in day-to-day practice or negative implications from use reported by patients or providers.

  • Satisfaction with service/practitioner care.

  • Decreased Emergency Department (ED) presentations.

  • Reduction in cost of providing primary care

  • Reduction in medication errors.

  • Reduction in adverse events including drug-related events.

2. Behavioural outcomes
a) Patient behaviour
  • Number of patients with regular monitoring of their clinical parameters.

  • Number of people who self-report improvements in their management of chronic disease or risk factors.

  • Self-reported or measured change in level or risk/engagement in risk behaviour.

  • Levels of motivation.

  • Levels of knowledge and/or understanding.

  • Level of health literacy—self-reported or validated instruments.

  • Level of e-health literacy—self reported or validated instrument.

  • Self-efficacy.

  • Level of confidence with self-management of their condition and associated risk factors.

  • Self-reported or measured changes in communication/interaction with their PC provider.

  • Quality of life.

b) Practitioner behaviour
  • Enhanced use of tools/satisfaction with tools.

  • Self-reported or measured increased patient communication.

2. Secondary outcomes
Health-related outcomes
  • Compliance with treatment/medication.

  • Decreased exacerbation of symptoms.

  • Decreased mortality and morbidity.

  • Negative outcomes from the use of the intervention/side effects.

SettingA community-based primary healthcare setting such as general practice primary healthcare clinics, Aboriginal healthcare centres; community healthcare clinics and after-hours GP clinics within a hospital or any combination of these settings. This includes primary health care (PHC) services provided in a person’s home.
Outpatient clinics such as cardiac rehabilitation and diabetes clinics (may be on or adjacent to a hospital site) if they cater for people residing in the community and provide valuable services for the management of chronic conditions.
Solely inpatient hospital-based services.
Non-health-based settings, that is, gyms, private insurance companies and so on.
  • GP, general practitioner; IMPACT, Innovative Models Promoting Access-to-Care Transformation.