The Northern Sydney General Practice Network's Chronic Disease Management (CDM) Program focuses on coronary heart disease and diabetes.

Coronary Heart Disease

Cardiovascular diseases are diseases of the heart and blood vessels including ischaemic (coronary) heart disease, stroke, heart failure, and peripheral vascular disease. Of these, ischaemic heart disease and stroke are  major causes of mortality and morbidity in New South Wales. High blood pressure (hypertension) is a precursor for coronary heart disease, stroke, congestive heart failure, and renal insufficiency. The risk of coronary heart disease (CHD) increases as the level of blood pressure increases. Similarly, high blood cholesterol is also a precursor for coronary heart disease and for some types of stroke.

Overall, 89% of adults had their blood pressure measured by a medical practitioner or nurse in the last 2 years. A significantly lower proportion of males (85.4%) than females (92.4%) had their blood pressure measured by a medical practitioner or nurse in the last 2 years.

The estimated number of people with circulatory system disease in Northern Sydney area is 33,732. The estimated number of people with high cholesterol in the Northern Sydney area is 14,110.

The Northern Sydney General Practice Network Practice Support can help your practice identify and better manage your practice population with CHD with:

• Canning data extraction tool – installation and support with your clinical systems
• Clinical Guidelines for Hypertension, Ischemic Heart Disease, Chronic Heart Failure and Stroke
• Desktop Guide resource relating to Chronic Disease Management MBS Item numbers
• Allied Health referral information
• Support with practice recall and reminder systems
• Practice visits, telephone and email advice.

Diabetes

Diabetes is a chronic disease characterised by high blood glucose levels, resulting from the body either not producing insulin or not using insulin properly. Insulin is a hormone enabling glucose to enter cells and be converted to energy.

Diabetes affects a person’s health in 2 ways:

1. by direct metabolic complications, which can be immediately life threatening if not treated promptly;
   
2. by long term complications involving the eyes, kidneys, nerves, and major blood vessels including those in the heart.

There are three main forms of diabetes:

1. Type 1, insulin dependent diabetes mellitus, occurs when the pancreas no longer produces insulin;
   
2. Type 2, non insulin dependent diabetes mellitus, occurs when the pancreas is not producing enough insulin and the insulin it produces is not working effectively; and
   
3. Gestational diabetes, occurs in pregnancy and should disappear after the birth.

Type 2 diabetes accounts for up to 90% of all cases of diabetes, and 71% of hospitalisations for diabetes. In 2006, diabetes was the principal cause of 2.0% of deaths and a related cause of almost 5.0% of deaths in New South Wales. Between 1989-90 and 2006-07, hospitalisations for which diabetes was recorded as a principal diagnosis increased by more than 160% in New South Wales.

The estimated number of people with Type 2 Diabetes in Northern Sydney area is 4,939.

NSGPN Practice Support Team can assist your practice identify and better manage your practice population of diabetic patients with the:

• Canning data extraction tool – installation and support with your clinical systems
• Clinical Guidelines for Management to Diabetes in General  
• Desktop Guide resource relating to Chronic Disease Management MBS Item numbers
• Type 2 Allied Health Group Services Referral Form
• Local providers 
• Support with practice recall and reminder systems

Other important CDM information

MBS dental services for CDM patients

MBS allied health services for patients on GP Management Plans (GPMP) or Team Care Arrangements (TCAs)  

Case Conferencing between GPs and allied health professionals or upon discharge

CDM Medicare Item Numbers Q&As

The benefits of Home Medicine Reviews

How Practice Nurses can work with GPs in managing patients with chronic diseases

For useful templates, click here

Links

• RACGP Clinical Guidelines
• RACGP Templates
• Diabetes Australia
• Heart Foundation
• Diabetes & Kids
• Australian Diabetes Educators Association
• Juvenile Diabetes Research Foundation
• Health Insite

For further Information contact:

Simon Iskandar

Primary Care Support Officer

(02) 9411 3533

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