The Ardens Risk Stratification searches have been designed to help practices focus on chronic disease reviews on higher risk patients and to pro-actively prioritise patients. There is no formal guidance around how to do this and we have based our searches on recommendations that are supported by NHS England.


To locate the searches navigate to the Population Reporting module > Ardens Searches > 1.12 LTC Reviews - Risk Strat >  Chronic Disease Risk Stratification - UCLP criteria folder.



This folder is broken down by conditions, and the searches within each folder are broken down by risk factors and then further by those that have not had a review this financial year, or those that have any outstanding QOF indicator: 



Where appropriate, folders also contain invitation searches broken down by risk factors.



These invitation searches run on the same principle as the main  Ardens LTC Recall System, based on month of birth, broken down by preferred contact method and coding searches to code additional QOF conditions invites.


The search suite has been designed for practices to plan which priority patients they want to call in over a period time. It may suit best to focus on inviting High risk patients for each condition in the first instance, followed by Intermediate and Low risk when required. However, practices can choose how they prefer to invite patients in. 


Please see below break down of the criteria of the priorities for each condition, noting this is not based on formal guidance:


Asthma 

These searches are based on patients on the Asthma register.

  • High risk - displays high risk patients with an ACT Asthma Control Test score below 15.
  • Intermediate risk - displays medium risk patients with an ACT score between 15 - 20.
  • Low risk - displays low risk patients with an ACT score above 20.
  • Unknown risk - displays patients missing an ACT score.


Atrial Fibrillation

These searches are based on patients on the AF register.

  • Priority 1 - displays patients that are currently not on oral anticoagulants.
  • Priority 2 - displays patients that are on an anticoagulant and antiplatelets that require a review for AP.
  • Priority 3 - displays patients that are on Warfarin with or with no TTR.


CVD Prevention

This search folder is broken down by primary and secondary prevention.


For primary prevention (no pre-existing CVD):

  • Priority 1 - patients with a QRISK score more than 20% who have CKD or Diabetes, no CVD and not on a statin.
  • Priority 2 - patients with a QRISK score 15-19% and not on statin.
  • Priority 3 - patients with a QRISK score 10-14%  and not on statin.
  • Priority 4 - patients on statin for primary prevention but not on high intensity. 


For secondary prevention (pre-existing CVD):

  • Priority 1 - patients not on statin therapy.
  • Priority 2 - patients on suboptimal statin dose.
  • Priority 3 - patients with Non-HDL more than 2.5 despite max tolerated statin therapy. 


COPD

These searches are based on patients on the COPD register.

  • High risk - displays high risk patients with a CAT COPD Assessment Test score above 20.
  • Intermediate risk - displays medium risk patients with a CAT score between 10-20.
  • Low risk - displays low risk patients with a CAT score below 10.
  • Unknown risk - displays patients missing a CAT score, or it the latest CAT score was recorded more than a year ago.


Diabetes

These searches are based on Type 2 Diabetic patients. 

  • High risk - displays high risk patients with a latest HbA1c over 90 and those patients with a latest HbA1c over 75 and they are on the Heart Failure register, severely frail, on injectables, included in the BAME population and have a social complexity (such as housebound, homeless or alcohol or drug dependent). As well as patients with a latest HbA1c over 75 and is either recorded with foot ulcer in the last 3 years, latest eGFR under 45, Stroke/TIA in last 12 months or a Metabolic syndrome. 
  • Intermediate risk - displays medium risk patients with a latest HbA1c between 58-75 and falls within a COVID risk group.
  • Low risk - displays low risk patients that do not meet any of requirements above.

 

Hypertension

These searches are based on patients on the Hypertension register. 

  • Priority 1 - high risk patients with a latest BP of 180/20 and over.
  • Priority 2 - medium risk patients whose latest BP is over 160/100 or over 140/90, or who have had no BP recorded in the last 18 months. 
  • Priority 3 - patients over 80 with a latest BP under 150/90, or under 80 with a latest BP under 140/90. 
  • Priority 4 - patients low risk under 80 with a latest BP under 140/90 or patients low risk over 80 with latest BP under 150/90.


The Sub Reports folder is a baseline for the searches above and do not need to be run.


To run the searches above, right click on the folder (or search) and select Run. We recommend for large practices to run the folders they require separately, to eliminate the searches queuing for a long time or failing.



If you require any further assistance on the process above, please contact Ardens support on: [email protected].