Intended for healthcare professionals

Practice Uncertainties

Are guidelines for monitoring chronic disease in primary care evidence based?

BMJ 2019; 365 doi: (Published 13 June 2019) Cite this as: BMJ 2019;365:l2319
  1. Martha M C Elwenspoek, research associate12,
  2. Rita Patel, senior research associate12,
  3. Jessica C Watson, GP, doctoral research fellow12,
  4. Penny Whiting, senior lecturer, programme director of MSc in epidemiology12
  1. 1National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), University Hospitals Bristol NHS Foundation Trust, Bristol, UK
  2. 2Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
  1. Correspondence to: M M C Elwenspoek martha.elwenspoek{at}

What you need to know

  • Current UK guidelines for monitoring type 2 diabetes, chronic kidney disease, and hypertension are largely based on expert opinion; robust evidence for optimal monitoring strategies and testing intervals is lacking

  • Unnecessary testing in primary care can lead to false positive and false negative results, increased workload for clinicians, and increased costs for the health service

  • Patients and healthcare professionals should be aware of these uncertainties when making shared decisions about chronic disease monitoring

Pathology tests have a unique place in management of chronic diseases. They are used to guide disease management; assess risk and compliance; and enable early detection of adverse events, complications, and development of secondary diseases. Primary care clinicians rely on guidelines for common chronic diseases such as type 2 diabetes, chronic kidney disease, and hypertension to inform them which tests they should recommend to their patients and how frequently these should be done. With rates of pathology tests rising—at an estimated annual cost of £1.8bn to primary care in the UK1—and the potential for harm from over-testing, it is important to consider the evidence base for these recommendations.

In this article, we review monitoring strategies in current UK guidelines for patients with type 2 diabetes, chronic kidney disease, and hypertension (box 1), highlighting the uncertainties in these guidelines and the need for further research.

Box 1

Search strategy and guideline selection

We searched for published UK guidelines for the management of patients with type 2 diabetes, chronic kidney disease stages 1-3*, or hypertension using the following sources:

  • National Institute for Health and Care Excellence (NICE)

  • Scottish Intercollegiate Guidelines Network (SIGN)

  • Royal Colleges of Pathologists (RCPath), Physicians, and General Practitioners

  • Quality Outcomes Framework (QOF)

The following guidelines are included in this review:

  • SIGN 116 Management of diabetes (2017)2

  • NICE CG127 Hypertension, the clinical management of primary hypertension in adults (2011)3

  • NICE …

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