Download GP4001 Lecture 7

Dealing with
chronic illness in
general practice –
developing a
generalisable model
What needs to be covered by any
model of chronic disease
management in general practice?
• Nature of the disease
• Usual treatment of the disease and its
complications
• A system of monitoring the disease and its
complications and the treatment thereof
• A curriculum for patient education
• A system for quality assurance of CDM
Nature of the disease
• Basic pathophysiology
• Clinical features
• Usual and unusual
• Early and late
• Definitive diagnosis
• Complications
• Usual and unusual
• How to prevent complications
Usual treatment of the disease
and its complications
• Non drug management
• Lifestyle- diet, activity, occupation, social habits
etc.
• Drug management of disease
• Symptom remedies
• Disease modifying remedies
• Drugs to control or reduce risks of complications
• Surgical treatments (if any)
A system of monitoring the
disease and its complications and
the treatment thereof
• A disease register
• A checklist of parameters to be monitored
• Disease indicators
• Treatment response indicators - +ve and –ve
• Complication indicators
• Protected time – special clinics?
• Action lines in response to various outcomes of
monitoring process
• A call and recall system
A curriculum for patient
education
• Nature of the disease
• Treatment of the disease
• Lifestyle – self care management requirements
• Drugs – name, mode of action, rationale etc.
• Importance of adherence
• Complications
• Indicators of treatment success and failure
• Self monitoring
• How to respond to indicators of failure
• Additional sources of support and help
available
A system for quality assurance of
chronic disease management
• Define/ adopt standards for CDM
• Review of records of relevant patients
• Check all parameters recorded at appropriate
intervals per agreed standards
• Check parameters within desired range per
agreed standards
• Presentation and discussion of findings from
record review
• Decisions on remedial action to be taken
• Review of performance again after an
appropriate interval
The Audit Cycle
Other issues in chronic disease
management
• Sources of evidence and guidance to support
chronic disease management
• Evidence based medicine
• Role of guidelines in chronic disease medicine
• Co-morbidity
• Importance of team-working and primarysecondary care liaison
• Extensions of the chronic disease model e.g.
mental ill health and palliative care
Task for next week
Draw up a practice policy for the management of
the following conditions
Group
Group 1
Group 2
Group 3
Condition
Hypertension
Rheumatoid arthritis
COPD
Group 4
Group 5
Group 6
Psoriasis
Epilepsy
Hypothyroidism
Group 7
Chronic renal disease/ failure
Group 8
Group 9
Group 10
Ischaemic heart disease
Asthma
Gastro-oesophageal disease (GORD)
Tasks to be divided among
group members I
• Nature of disease
• Pathophysiology
• Clinical features – diagnosis
• Complications
• Treatment
• Non-drug treatment
• Drug treatment
• Treatment of principal complications
Tasks to be divided among
group members II
• Monitoring (parameters to be checked and
targets)
• Of disease progression
• Of treatment
• Patient education curriculum
• Indicators of success of treatment
• Indicators of failure of treatment and how to
respond
• Sources of support
Practice policies –
document requirements
• Should cover:• Nature of the disease
• Usual treatment of the disease and its
complications
• A system of monitoring the disease and its
complications and the treatment thereof
• A curriculum for patient education
• Typed out on 2 sides of A4
• Presented to the class in 10 minutes using one
or two overheads