Combined checks for chronic conditions

   

  • Many chronic conditions are closely related and lead to the same serious complications — heart attack, stroke, renal disease

  • Monitoring and management is very similar and most people have more than one chronic condition
  • Combined checks Table 4.1 are for all people with one or more of
    • Coronary artery disease (CAD)
    • Hypertension (high BP)
    • Abnormal blood lipids (fats)
    • Chronic kidney disease (CKD)
    • Diabetes 
    • Heart failure 
    • Schizophrenia, bipolar affective disorder, antipsychotic use 
    • Chronic obstructive pulmonary disease (COPD), bronchiectasis
  • Tools for completing chronic conditions checks may be available on your clinic information system

When to do checks

New Diagnosis

  • Complete assessment and GP management plan/team care arrangements at diagnosis
  • CAD, CKD, diabetes, heart failure, CLD — monthly reviews for the first 3 months to achieve good control and support self-management
  • Heart attack, cardiac surgery, acute heart failure — weekly reviews for cardiac rehabilitation, self-management support, and then medical follow up at 4 weeks (can be a case discussion)

Timing of ongoing recall cycles

  • Do annually
  • Frequency of recall (1, 3 or 6 monthly) is based on person’s diabetes status, level of absolute cardiovascular risk and chronic kidney disease risk — see Table 4.1
    • If check only applies to one condition, the condition is written on table, eg diabetes
    • If check is needed less often than recall schedule, the frequency is written on table, eg 6 monthly

Table 4.1 Combined checks for chronic conditions 

Checks with a tick (✓) are for everyone

Pathology recall cycle

Table 4.2 Monthly pathology — person with CKD 5  

* If diabetic check HbA1c every 3 months

Table 4.3 3 monthly pathology — person with diabetes, high CVR AND 1 or more conditions OR moderate to high CKD risk level 

*Repeat HbA1c in 3 months if more than 7% or if declining renal function. Repeat in 6 months if HbA1c less than 7% and no decline in renal function

Table 4.4 6 monthly pathology — person with high BP or hyperlipidaemia, no diabetes, low to moderate CVR AND 1 or more other conditions AND normal to low CKD risk level

  • TFT 
    then level 2 (triangle dot points)
    • Do once when Type 1 diabetes diagnosed or CKD reaches mod-high
    • Do every 6 months for person taking lithium
  • 25-hyproxyvitamin D - (em dash) do on first assessment for person with CKD and eGFR less than 60