Complex Chronic Disease and High System Use: Investigating patient profiles, resource use and health outcomes

Paul Ronksley, Tyler Williamson

Tyler Williamson (

In recruitment



We are seeking to match data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) with administrative health data held by Alberta Health Services (AHS). The overall purpose of this work is to identify and describe patients with complex chronic diseases (CCD) and to characterize those with high healthcare utilization.

In Canada, health care expenditures continue to rise unabated, largely due to an aging population that is living longer with more chronic diseases. While governments and organizations have developed policies to support the care of patients with CCD in the outpatient setting, there are still significant gaps in our understanding of the different clinical profiles of these high-risk patients, how they engage with the health care system, and if some of the spending within this group is potentially preventable.


The objectives of this study are to:

1.       Describe the clinical and socio-demographic characteristics of primary care patients with complex chronic disease.

2.       Explore clinical outcomes and patterns of health care use among patients with complex chronic disease.

3.       Determine patient-level and system-level factors associated with poor outcomes and high use of health care resources among patients with complex chronic disease.

4.       Quantify preventable spending among patients with complex chronic disease identified as high users of health care resources.


This study will link detailed clinical data from electronic medical records with administrative health data to advance our knowledge of patients with CCD and characterize those with high health care utilization.