Implementation of a surveillance and monitoring system for chronic disease: A scoping review

Yejin Kim; Hyung-Seop Sim; Bomgyeol Kim; Vasuki Rajaguru; Tae Hyun Kim; Yejin Kim; Hyung-Seop Sim; Bomgyeol Kim; Vasuki Rajaguru; Tae Hyun Kim

doi:10.3934/publichealth.2026036

AIMS Public Health

2026, Volume 13, Issue 3: 671-688. doi: 10.3934/publichealth.2026036

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Review Special Issues

Implementation of a surveillance and monitoring system for chronic disease: A scoping review

Running title: Chronic disease surveillance and monitoring system

1.
Graduate School of Cancer Science and Policy, National Cancer Center, Goyang 10408, Republic of Korea
2.
Department of Public Health, Graduate School, Yonsei University, Seoul 03722, Republic of Korea
3.
Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, Seoul 03722, Republic of Korea
4.
Department of Healthcare Management, Graduate School of Public Health, Yonsei University, Seoul 03722, Republic of Korea
5.
Department of Biohealth Industry, Graduate School of Transdisciplinary Health Sciences, Yonsei University, Seoul 03722, Republic of Korea

Received: 31 December 2025 Revised: 04 April 2026 Accepted: 23 April 2026 Published: 24 June 2026

Background
Numerous national-based indicators aid in designing population-centered chronic disease surveillance. However, there is little consensus on the key indicators and goals to develop a chronic disease surveillance analysis system.
Objective
This study aimed to develop evidence-based indicators to measure and improve the health outcomes of chronic disease surveillance systems in Korea.
Methods
A scoping review was focused on peer-reviewed literature from 2012 to 2022 using PubMed, Medline, Embase, PsychINFO, CINHAL, Wiley Online, Scopus, and Cochrane Library. Three reviewers evaluated and selected the articles in accordance with comprehensive inclusion and exclusion criteria. Data were synthesized using median descriptive analyses, prioritization, and agreement. There was a consensus meeting to discuss the recommendations, and the findings were thematically and descriptively analyzed.
Results
Forty-eight articles were finalized and most of them were published in 2019 (18.8%). The studies on chronic disease-based surveillance systems and related data sources were primarily conducted in Canada (58.3%). The findings were prioritized by prevalence rate, risk factors, data linkage, complex disease, and updated indicators in a current system. The key themes of focus were mortality, survival management, diagnosis, treatment, and healthcare systems.
Conclusion
Our preliminary measurement methods need validation through follow-up projects. Chronic disease surveillance will improve public health resource allocation and monitoring in real time. Public health and healthcare systems could be enhanced through timely assessments of population health at the local and regional levels. In Korea, experts will validate the chronic disease-based surveillance system's development.
- chronic diseases,
- public health surveillance systems,
- surveillance evaluation,
- surveillance indicators,
- surveillance system monitoring
Citation: Yejin Kim, Hyung-Seop Sim, Bomgyeol Kim, Vasuki Rajaguru, Tae Hyun Kim. Implementation of a surveillance and monitoring system for chronic disease: A scoping review[J]. AIMS Public Health, 2026, 13(3): 671-688. doi: 10.3934/publichealth.2026036

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Abstract

Background

Numerous national-based indicators aid in designing population-centered chronic disease surveillance. However, there is little consensus on the key indicators and goals to develop a chronic disease surveillance analysis system.

Objective

This study aimed to develop evidence-based indicators to measure and improve the health outcomes of chronic disease surveillance systems in Korea.

Methods

A scoping review was focused on peer-reviewed literature from 2012 to 2022 using PubMed, Medline, Embase, PsychINFO, CINHAL, Wiley Online, Scopus, and Cochrane Library. Three reviewers evaluated and selected the articles in accordance with comprehensive inclusion and exclusion criteria. Data were synthesized using median descriptive analyses, prioritization, and agreement. There was a consensus meeting to discuss the recommendations, and the findings were thematically and descriptively analyzed.

Results

Forty-eight articles were finalized and most of them were published in 2019 (18.8%). The studies on chronic disease-based surveillance systems and related data sources were primarily conducted in Canada (58.3%). The findings were prioritized by prevalence rate, risk factors, data linkage, complex disease, and updated indicators in a current system. The key themes of focus were mortality, survival management, diagnosis, treatment, and healthcare systems.

Conclusion

Our preliminary measurement methods need validation through follow-up projects. Chronic disease surveillance will improve public health resource allocation and monitoring in real time. Public health and healthcare systems could be enhanced through timely assessments of population health at the local and regional levels. In Korea, experts will validate the chronic disease-based surveillance system's development.

Abbreviations

CDSS

chronic disease surveillance system

COPD

chronic obstructive pulmonary disease

EHR

electronic health record

EMR

electronic medical record

identification number

NCDs

noncommunicable diseases

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

USA

United States of America

United Kingdom

Conflict of interest

The authors declare no conflict of interest.

Data availability statement

The data presented in this study are available upon request from the corresponding author.

Authors' contributions

Y.K. contributed to data curation, methodology validation, and revised the original draft of the manuscript. H.S.S. handled the data curation and methodology validation. B.K. was responsible for formal analysis and methodology validation. V.R. conducted formal analysis, data curation, and wrote and revised the original draft of the manuscript. T.H.K. performed the conceptualization of the study and provided the resources and supervision. V.R. and T.H.K. reviewed and edited the manuscript. All authors read and approved of the final manuscript.

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