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Recipe Name: | Find high risk patients eligible for ‘My Health For Life’ |
Rationale: | My health for life will help people at high risk of developing chronic conditions such as heart disease, stroke and type 2 diabetes make healthy lifestyle changes. The steps in this recipe show how to identify patients meeting all or most of the eligibility criteria. Further information and resources are available here: https://www.myhealthforlife.com.au/ |
Target: | To identify all patients with no current diagnosis of diabetes, Heart Failure, CVD or chronic kidney disease who are eligible to be referred to the ‘My Health For Life’ program. |
CAT Starting Point: |
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As the eligibility criteria for this recipe are quite comprehensive this recipe will show how to find those patients meeting all or most of the criteria. We provide other recipes showing how to find patients based on a single eligibility criteria on our My Health For Life recipe page here: My Health For Life Recipes
CAT Start screen
RECIPE Steps Filters:
- In the Start Age box type 45 18 to only show patients older than 45.If you want to search for indigenous patients older than 18 you will have to also apply the ‘Indigenous’ filter on the ‘Ethnicity’ tab. See here for full details: Ethnicity Filter)
- In the "General" filter tab click on 'Active (3x in 2yrs)' - OPTIONAL as this will only show those patients with at least 3 visits in the last 2 years
- Click on "Conditions" tab under Diabetes select “No”
- Select "No" for Heart Failure
- Select “No” for all conditions listed under the CVD group
- Select “No” for “Chronic Renal Failure”
- Click on the 'Date Range (Results) filter to only show results that have been recorded in a specified date range, in this case in the last 24 months. This will move all patients with results older than 24 months to the 'not recorded' part of the reports and avoids listing patients with old results.
We have now created a filter to find patients older than 4518, with no diagnosis of diabetes, Heart Failure, CVD or chronic renal disease. All of these patients may be eligible for the My Health For Life program. To see a list of all patients, click “Recalculate”
This will most likely produce a large list of patients, in this case more than 3000 patients. Further filters can be applied to reduce the number of patients found, for example only active patients (3 visits in 2 years) or only patients who have been to the clinic in the last 6 months can be selected by adding to the filter criteria.
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- without clearing your filters, click on the Conditions/Other tab and then on "Yes" under familial hypercholesterolaemia
Taking lipid modifying medication
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- on the Medication tab, click on 'Medications/Heart' and then tick the 'Yes' under Lipid M/fying
Adding Measures/Pathology
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- click on the "Measures/BP" tab and then on the '>140/90' part of the graph to select it
Increased Waist Circumference
- Click on the ''Measures/Waist/CVD Risk'' tab and select the parts of the graph ''Greatly Increased'' that is M > 102cm,F > 88
High Cholesterol
- Click on the "Pathology/Lipids/Cholesterol" tab and select the parts of the graph higher than 5.5:
Combining high BP, increased Waist Circumference and high Cholesterol
You will notice that both report tabs have a
next to the report title. This indicates that you have selected one or more parts of a graph.
To combine the selections, click on the "Report" icon. For more information on cross-tabulation see our user guide here: Cross Tabulation Report
This will create a cross-tabulated report showing only those patients older than 18 with no diabetes, CVD or CKD, taking lipid modifying medications and with a high BP AND increased waist circumference AND a high Cholesterol in the last two years. In my example there are only 19 patients - these would be at high risk and benefit from being referred to the My Health for Life program as soon as possible.
You can modify the above steps by applying less or more filters - depending on which patients you want to find.
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