Population searches can help drive better health outcomes for patients.

For example:

Targeted Care Delivery

  • Identifies patients with the greatest clinical need, enabling proactive care and reducing the risk of complications.
  • Facilitates early intervention for undiagnosed or poorly managed conditions.

Addressing Health Inequalities

  • Highlights gaps in care for underserved groups (e.g. by ethnicity, socioeconomic status).
  • Ensures equitable access to preventive services and management.

Efficient Resource Allocation

  • Focuses practice resources on high-need populations, enhancing the impact of clinical efforts.
  • Supports QOF targets and population health initiatives.

Data-Driven Insights

  • Identifies trends in lifestyle-related conditions to inform practice priorities and public health partnerships.
  • Helps evaluate the effectiveness of interventions.

Search criteria examples

Type 2 Diabetes

HbA1c 48 mmol/mol but no recent follow-up (No diabetes annual review coding). Missing annual diabetic review (retinal screening, foot care, albumin creatinine ration). Diagnosed but with BP >140/90 mmHg (poorly controlled).

Obesity

Adults with BMI >30 but no weight management plan. Children with BMI above 95th percentile for age, not flagged for intervention. High-risk ethnic groups (e.g., South Asian populations) with undiagnosed metabolic syndrome.

Hypertension

Patients with recorded BP >150/95 mmHg, no antihypertensive prescription. High cardiovascular risk patients (QRISK >10%) but no recent review. Diagnosed patients with no coded lifestyle support/advice.

Deprivation

To identify patients living in deprived areas
Lower Layer Super Output Area (LSOA) or Townsend Score.

SNOMED coding examples

Advice during consultations
 Exercises education, guidance, and counseling
410289001

Leaflet/SMS
 Patient given written advice on benefits of physical activity
429778002

Walking group
 Referral to physical activity program
390893007

Running group
 Physical activity target strenuous exercise
408579009

Swim group
 Group exercise programme
401167006

Signposted to parkrun
 Signposting to community exercise group
1083201000000102

Group lifestyle clinic
 Self-help group support
276049006

Individual lifestyle appointment
 Lifestyle assessment
443781008

Last modified: Wednesday, 5 March 2025, 11:55 AM