The HSE published the second review into the implementation of the Structured Chronic Disease Management (CDM) Programme in General Practice on Wednesday 22nd March 2023.
The report focuses on the first two years of implementation from January 2020 to January 2022. It largely describes a population aged 65 years and over due to the age-based phased introduction of the programme and it aims to reach full implementation in 2023.
Key Information:
This reports refers to patients treated by GPs for the first two years of the programme and comprises 186,210 patients in total. It focusses particularly on patients (43,600) who have had at least three reviews in the first two years of the programme to describe trends in outcomes.
The report's major findings include:
Multi-morbidity
It is extremely encouraging to note that the vast majority of multi-morbidity patients did not attend hospital for the routine management of their chronic conditions and their conditions were reported as being fully managed routinely in Primary Care.
Lifestyle Health Behaviour Improvements
The report shows improvements in all the modifiable risk factors concerned between the first and third visit, including patients who had higher risk profiles at the first visit.
Bio Metric Risk Factor Improvements (Medical)
There is an improving trend in in biometric measurements such as blood pressure, LDL cholesterol and HbA1c, over time in this cohort.
Blood test results
The Chronic Disease Treatment Programme requires a series of blood tests to be carried out at specified intervals, some in common across all conditions and some specific to the condition concerned. Overall the results for LDL (low-density lipoprotein) cholesterol show important improvements against target for all sub categories, between their first and third visit to their doctor, indicating a raised awareness among doctors and patients and tighter control either by diet or medication in combination.
Patients with Diabetes also showed important improvements against their targets for Hba1C levels.
Diabetic Foot Examinations
Diabetic foot disease is a major cause of hospital admission and surgery for diabetic patients, hence early identification and management is essential. The Chronic Disease Treatment Programme requires the GP or the Practice Nurse to carry out a number of tests on diabetes patients' feet to identify foot complications.
Healthcare
The CDM programme requires that General Practitioners develop, discuss and record a care plan with each of their patients and that this plan is updated at each visit. The care plan includes anticipatory care, recommended actions for when the patient deteriorates and facilitates the development of patient-centred goals for treatment and behaviour change to be agreed and documented between patient and their GP.
Hospital attendances
GPs participating in the Treatment Programme are asked to indicate whether their patients are also attending hospital for the care of each of the chronic conditions included in the Treatment Programme. A major objective of the Chronic Disease Management Programme and the Enhanced Community Care programme is to enable patients to be managed in primary care as much as possible.
The full report is available on the HSE website here.