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We are living longer and healthier lives due to health promotion, better medical care and improved disease prevention. However, this means that as many of us age, we may live longer with a chronic condition, such as diabetes, kidney disease, or coronary heart disease. As these chronic conditions are now recognised and diagnosed earlier, the focus on who helps manage them has shifted gradually from hospital-based clinicians (secondary care) to GPs (primary care).

A major factor in good management of chronic conditions is being able to monitor them over a long period through long-term monitoring. Despite the considerable economic costs, for many conditions there is little or poor evidence available on how, what, and when to monitor.

More frequent monitoring is not necessarily better - besides the financial costs, there are considerable downsides to over-frequent measurement. These include personal costs such as the time spent, the need for invasive tests, an increase in anxiety, and sometimes unnecessary hospital visits. Perhaps more important is the potential for changes in how disease is managed based on incorrect test results showing deterioration when it is not really present, and vice versa.

Our research 

Through research, we aim to improve how chronic conditions are managed in primary care. We will study how to optimise the utility and frequency of tests used for monitoring on two specific areas - chronic kidney disease (CKD) and chronic heart failure (CHF).

This programme of research will provide new evidence to inform the adequate management of chronic kidney disease and chronic heart failure in primary care. An important aspect of our research will be to understand what impact our findings will have on patients and health professionals. We will work with the National Institute for Health and Care Excellence (NICE) and GP commissioners across Oxfordshire to disseminate these findings.


The National Institute for Health Research funds the Applied Research Programme on Monitoring Long Term Conditions in Primary Care at the University of Oxford