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The purpose of chronic disease management is to provide care that helps people with chronic disease improve their quality of life and live as long as possible. Effective chronic disease management can also reduce overall costs to the public healthcare system. The most common chronic diseases in Alberta include hypertension (high blood pressure), diabetes, chronic obstructive pulmonary disease, asthma, heart failure, coronary artery disease, obesity and depression. The personal consequences of these diseases can range from pain, impaired mobility, reduced ability to work, and social isolation to dependence on drugs, repeated trips to hospital, amputations and early death.

The financial costs to Alberta’s healthcare system run into billions of dollars. Chronic diseases require the services of thousands of healthcare professionals and the infrastructure and systems to support them. People with chronic diseases account for nearly two-thirds of hospital inpatient days, one-third of all visits to physicians and more than one-quarter of visits to emergency rooms.

Objective and Scope

The objective of our audit was to examine whether the Ministry of Health has adequate systems to deliver CDM services effectively. We focused on five key areas:

  • the department’s strategy and systems to determine the healthcare services that should be provided to persons with chronic disease, and who should provide them
  • the department’s processes to link persons with chronic disease with a family physician and care team
  • the CDM services that Alberta Health Services provides
  • care plans provided to patients with chronic disease by physicians and pharmacists
  • information technology used to support CDM, including:
    • electronic medical records used by family physicians
    • personal health records and technology to help patients self-manage their chronic disease


We were consistently impressed with the skills, resourcefulness and dedication of the people we met in all the entities we contacted. We noted many good practices, several of which we refer to in this report because we believe the healthcare system needs to build on such successes rapidly, without reinventing them.

Our overall conclusion is that Alberta provides some excellent care for individuals with chronic diseases. However, that care tends to be fragmented. No entity has overall responsibility for ensuring that all the parts work together well, that all patients receive the same level of care, and that providers are making good use of available resources to understand chronic diseases and manage patient care.