Table 2

Guidelines for grouping patients into three categories according to disease control and/or adherence

Diagnosis groupGood control and/or adherenceSome evidence of concernPoor control and/or adherence or more severe condition
DiabetesMean of HbA1c values ≤53 mmol/molMean of HbA1c values 54–69 mmol/molMean of HbA1c values ≥70 mmol/mol
GastroenterologyVAS 1–2; at least 80% of faecal calprotectin results <100 μg/g and always <300 μg/g; medication unchanged or reduced; no inpatient careVAS 3–5;<80% of faecal calprotectin results within target range or exceeds 300 μg/g even once; no significant medication changes; no inpatient careAny one of the following: VAS 6–7; changes in medication, need for oral corticosteroids and/or commencement of biological medication; episode of inpatient care
Rheumatology, arthritidesOligoarthritis: JADAS10 or cJADAS10 ≤0.5; polyarthritis: JADAS10 or cJADAS10 ≤0.7Oligoarthritis: JADAS10 or cJADAS10 0.6–2.8; polyarthritis: JADAS10 or cJADAS10 0.8–4Oligoarthritis: JADAS10 or cJADAS10 >2.8; polyarthritis: JADAS10 or cJADAS10 >4
Neurology, epilepsyNo seizures in the past year; no adverse effects of medications; no inpatient careNo seizures in 6 months; adverse effects of medication possible; no inpatient careSeizures despite medication
Neurology, disabilitiesNo need for RAH or actualised as planned; no need for aids or use actualised as planned; no need for ORT or actualised as plannedRAH or aids use not actualised as planned; no need for ORT or actualised as plannedNeeds RAH, aids and/or ORT but none actualised as planned
  • Patients with rare conditions (eg, congenital heart defects, solid organ transplants or connective tissue diseases) will be categorised according to symptoms, clinical and laboratory findings and changes in medication.

  • cJADAS, clinical Juvenile Arthiritis Disease Activity Score; HbA1c, glycated haemoglobin; JADAS10, 10-joint Juvenile Arthritis Disease Activity Score; ORT, outpatient rehabilitation therapy (may include occupational, physical and/or speech therapy); RAH, rehabilitation at home; VAS, Visual Analogue Scale.