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Diabetes Victoria Life! pProgram – Risk Criteria c3

Recipe Name

Identify eligible patients for theDiabetes Victoria Life! pProgram meeting that meet the risk criteria c3

Rationale

The following inclusion criteria willpresent in a patient determine eligibility for Diabetes Victoriathe Life! pProgram:

  • Age 18 years and above
  • One or more of the following pre-existing conditions
  • CVD
  • CKD
  • GDM
  • PCOS
  • Prediabetes
  • Familial Hypercholesterolemia
  • Serum Total Cholesterol > 7.5mmol/L
  • Systolic BP of ≥ 180 mmHg or Diastolic BP ≥110mmHg.

    The exclusion criteria includes patients with:
  • Diabetes
  • Active Cancer
  • Cardiovascular Disease (CVD) diagnosis in the last 3 months

Target

Patients at high risk who can be recommended for/are eligible for Diabetes Victoriathe Life! pProgram

CAT Starting Point
  1. CAT Open – CAT4 view (all reports) loaded.
  2. Population extract loaded and extract pane "hidden".
  3. Optional Only: Filter Pane Open and under the 'General' tab, "Active Patients (3x < 2 years)" selected. *The decision to select either "Active" or "Any" patient is left to the practice to make

Main Steps to set common inclusion and exclusion criteria:

  1. In the Filters Pane, under 'General' tab, enter age '18' in the Start Age box under 'Age'

  1. Select Conditions tab then click Chronic tab. Check the box beside the No under Diabetes. This will exclude patients with an existing diagnosis of diabetes.

  1. Click Cancer tab. Check all the No boxes. This will exclude patients with an existing diagnosis of cancer.

  1. Click Recalculate button.


Next steps:

  • To identify patients with CVD:
      1. Follow main steps 1-3
      2. Click Chronic tab and click the check box next to Cardiovascular Disease (CVD).



      1. Select Date Range tab and enter in the to field enter the date that correspondence to 3 months ago. In my example below, extract date is 17/04/2023 but the to date is 17/01/2023. (From date is at users' discretion)



      1. Click on Recalculate button and then 'View Population' button to view list of patients meeting these criteria.



      1. List can be saved/printed or be sent a SMS/Voicemail Recall via the Patient Reidentification window.


  • To identify patients with CKD:
      1. Follow main steps 1-4
      2. In Reports Pane, select Disease Report and select Chronic Kidney Disease (CKD)



      1. Click 'Report' button to view list of patients meeting these criteria.



      1. List can be saved/printed or be sent a SMS/Voicemail Recall via the Patient Reidentification window.


  • To identify patients with GDM or Familial Hypercholesterolemia:
      1. Follow main steps 1-3
      2. For GDM, select Chronic tab and then select Gestational



      1. For Familial Hypercholesterolemia, select 'Other' tab and check the box beside 'Yes' under Familial Hypercholesterolemia.



      1. Click on Recalculate button and then 'View Population' button to view list of patients meeting these criteria.
      2. List can be saved/printed or be sent a SMS/Voicemail Recall via the Patient Reidentification window.


  • To identify patients with Serum Total Cholesterol > 7.5 mmol/L
      1. Follow main steps 1-4
      2. In the Reports pane, select 'Pathology' report, 'Lipids' tab and then 'Cholesterol' tab



      1. Select >7.5 and click on 'Report' button to view list of patients meeting these criteria.
      2. List can be saved/printed or be sent a SMS/Voicemail Recall via the Patient Reidentification window.


  • To identify patients with Systolic BP of ≥ 180 mmHg or Diastolic BP ≥110mmHg:
      1. Follow main steps 1-4
      2. In the Reports pane, select 'Measures' report and then 'BP' tab



      1. Select >140/90 and click on 'Report' button to view list of patients meeting these criteria.
      2. List can be saved/printed or be sent a SMS/Voicemail Recall via the Patient Reidentification window.


Patients with PCOS and Prediabetes aren't identifiable through CAT at this stage
Create a prompt to display in Topbar
Remember you need to be in the CAT4 Daily View to be able to create prompts. Other pre-requisites are:

  • Topbar is installed
  • CAT4 is linked to Topbar via Edit/Preferences/Topbar - check here for details: Linking CAT4 to Topbar

To start click on the 'Daily View' icon on the top of your CAT4 screen:

Once you have applied the filter(s) and displayed the patients of interest as described above, you can create a prompt that will be shown to all clinicians using Topbar if a patient meeting the prompt criteria is opened in their clinical system.