Stroke follow-up in primary care: a Norwegian modelling study on the implications of multimorbidity for guideline adherence

Table 4 Patient 3: Recommended annual follow-up activity

	Consultations with the GP	Consultations with specialists	Other recommended health care providers	Laboratory tests	Special procedures
Diabetes	2	1–2	NR	yes
COPD	1–2	NR	Physiotherapist (limited to 40 annual treatments), two supervised work-outs a week	NR	Spirometry. Vaccination
Colorectal cancer	2	NR	NR	yes	2 x CEUS and 1 x LDCT
Depression	6	NR	NR	NR	NR
Painful condition	6	NR	NR		NR
Thyroid disorder	2	NR	NR	yes	NR
Screening	0–1	NR	NR	yes	Gynecological examination. Mammography
Smoking	4	NR	NR	NR	NR
Stroke	1	1	NR	yes	NR
Total	24–26	2–3	yes	yes	7

Minimum activity recommended for a period of 12 months for the patient in example 3, given that all conditions are clinically stable, and no new abnormalities are found in the tests
Abbreviations: COPD Chronic obstructive pulmonary disease, CEUS Contrast-enhanced ultrasonography, LDCT Low-dose computed tomography, NR No recommendations

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