UPDATED CHRONIC DISEASE MANAGEMENT

Click on the topics below -  for examples of evidence based (brief) guidelines for Primary Care 

• CVD risk management and lipids 
• Hypertension with August 2019 NICE guidance
• Ischaemic Heart Disease 2019
• Heart failure 2021
• AF 2021 with May 2021 NICE guidance
• TIA and Stroke with May 2019 NICE guidance
• PVD
• Type 2 diabetes 2021
• IGR and Gestational Diabetes 2020
• Chronic Kidney Disease 2021 NICE guidance
• Abnormal Liver Function Tests 2020
• Asthma 2020
• COPD 2019 NICE guidance
• Osteoporosis 2020
• Rheumatoid Arthritis annual review 
• How long should an CDM review appointment be with the Practice Nurse?
• What bloods need to be done at the annual review?
• Please make an appointment - prescription attachment
• DVLA medical rules
• Fitness to fly

Although we seek to provide accurate and up to date information (note dates of update), there can be no guarantee that the information is accurate or that it will continue to be accurate in the future. We do not accept responsibility for any errors. This is particularly so with regard to drug indications, suggested doses, side-effects and interactions, which should always be guided by an appropriate national formulary.

Home BP monitoring diary
Spreadsheet for admin team to calculate average of home BPs
Staggered home blood glucose monitoring diary
Peak Flow Diary from Patient.co.uk

In order to deliver quality chronic disease management services within primary care we have to have:

• A patient centred approach.
• Consistency from the multidisciplinary team in terms of targets, schedules of care, clinical management etc.
• Validated and maintained disease registers.
• Robust call and recall systems.
• Accessible, pragmatic, evidence based, primary care orientated guidelines.

Unfortunately one of the great challenges we face in general practice is keeping pace with the rapidly changing evidence base for chronic disease management. To cope with this and to standardise care Brig Royd Surgery has created (and updated annually) these chronic disease management guidelines. As there are conflicting national guidelines in some areas of chronic disease management we have opted for pragmatic, achievable targets that fall between differing national guidelines.

NEXT UPDATE  November 2021