Recipe Name:

Identify at risk patients who have a chronic condition and are eligible for both a Heart Health Check and a GP Chronic Disease Management Plan.


Various chronic conditions are often linked with increased risk of heart disease1. It is therefore important to conduct absolute CVD risk assessments (Heart Health Checks) for patients with chronic diseases. This recipe will identify patients who are eligible for both a Heart Health Check and a GP chronic disease management plan.

1. National Vascular Disease Prevention Alliance. Guidelines for the management of absolute cardiovascular disease risk. 2012.


Patients aged 45 and over with no diagnosis of CVD and any of the following conditions:

  1. Diabetes
  2. Respiratory conditions
  3. Chronic renal failure
  4. Musculoskeletal diseases
  5. Cancer

Target patients must also not have claimed a Heart Health Check, GP chronic disease management plan, or any other health assessment in the previous 12 months.

CAT Starting Point:

  1. CAT Open - CAT4 view (all reports) loaded
  2. Population Extract Loaded and Extract Pane “Hidden”
    1. Filter Pane open and under the ‘General’ tab ‘Active Patients’ (3x <2 years) selected (this step can be
       omitted if you want to search for all patients).

CAT4 Starting Point

Filter Steps

On the General tab enter age criteria (start age 45) and active status:

On the Conditions tab select the 'No' for existing CVD:

On the MBS Attendance tab, exclude all patients with health assessments, GPMPs or heart health checks claimed in the past 12 months. Make sure you exclude all items for a GPMP to this filter. Currently the relevant items are: 721, 229, 92024, 92068, 92055, 92099. You will only see items that have been claimed in your practice, so if you don't see the item 177 it might be because it has never been claimed at your practice.

Now all filter criteria have been set, please click on 'Recalculate' to apply the filter:

Report Steps

To see the full report, first minimise the filter panel by clicking on the   in the top left corner.

Part 1 - Find patients with chronic conditions (excluding cancer)

Now that we have applied the above filter, we need to find those patients with any of the specified chronic conditions. To find those patients use the Disease report and click on the bars as shown below to select any of those conditions.

Click in the 'Export' icon in the top right to see the patients with the selected conditions. All of them will have no GPMP/Heart Health Check or Health Assessment claimed in the last 12 months as well as the other filter criteria.

Part 2 - Find patients with cancer

If you haven't done so already, please clear the selected conditions from the 'Disease' filter. Then click on the 'Cancer Conditions' report tab and then click on 'Select All' to add those patients to our search:

Click on the 'Export' button in  the top right to see a list of all patients with cancer.

From this report you can export the patient list to Excel or send voice or text messages directly from CAT4. To export a list, click on the disk icon and choose your preferred file format:

To create SMS or Voice messages, please see here for more information: Recall CAT - Using SMS and Voicemessages in CAT4