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Ann Acad Med Singapore. 2002 Jul;31(4):431-9.

A preliminary evaluation of a disease management programme for patients with diabetes mellitus and hypertension in a primary healthcare setting.

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National Healthcare Group Polyclinics, Level 6, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433.



The Comprehensive Chronic Care Programme (CCCP) is an intensified programme designed to provide comprehensive care for the management of diabetes mellitus, hypertension and hyperlipidaemia at a primary healthcare setting. A formative study was done to evaluate the effectiveness of the CCCP compared to the normal polyclinic management of diabetes mellitus.


Control of diabetes (HbA1c) and hypertension (blood pressure) in 63 diabetic patients of a pilot CCCP was compared with 100 diabetic patients not on the programme (non-CCCP) after a 6-month follow-up. Paired t-tests were conducted for differences in mean HbA1c values between baseline and after 6 months. The H-rank test was applied to check for significant differences in change categories of hypertension control between CCCP and non-CCCP cases.


In the CCCP group, there was a two-point decrease in HbA1c after 6 months and 65.1% of the patients showed improvement. The proportion of patients achieving optimal diabetic control increased from 9.5% to 36.5%. Conversely, there was deterioration in the non-CCCP group with decrease in the proportion of patients achieving optimal diabetic control from 31% to 21%. Of the hypertensive patients in the CCCP group, 54.5% showed an improvement in blood pressure (BP) control while 44% of the non-CCCP group showed improvement at 6 months.


CCCP, a comprehensive chronic disease management programme, is effective for good diabetic control of patients with diabetes mellitus.

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