The study was performed in the region Eindhoven, south-eastern part of the Netherlands, in general practices affiliated to the primary care group PoZoB. Between 2010 and 2013, 137 practices followed a stepwise implementation for integrated care and another 8 practices started implementation between 2013 and 2015. Eligibility for participation in integrated CVRM care was based on in- and exclusion criteria given in table 1. Details of the stepwise implementation have been described elsewhere (16).
Table 1 In- and exclusion criteria for enrollment in the programmatic CVRM program
Inclusion criteria for patients with CVD or kidney disease:
Documented previous ischemic or atherosclerotic heart disease (myocardial infarction and angina pectoris), heart failure, atrial fibrillation, aneurysm of the abdominal aorta, peripheral arterial disease, transient ischemic attack, ischemic or hemorrhagic stroke, chronic kidney disease. (ICPC coded?)
The patient is primarily treated in primary care and aged 18 years or above .
Inclusion criteria for patients with high risk of CVD, free from symptomatic CVD or kidney disease
A 10 year cardiovascular mortality risk > 5%, based on the SCORE table from the 2006 CVRM guidelines of the Dutch Society of General Practice (5).
Prescribed of blood pressure lowering or lipid modifying drugs in men aged ≥ 55 years and women aged ≥ 60 years.
Systolic blood pressure > 180 mm Hg and/or total cholesterol > 8 mmol/l ever measured, independent of the 10 year mortality risk.
The patient is primarily treated in primary care and aged 18 years or above.
Exclusion criteria for both groups were:
Primarily treated for cardiovascular disease risk by a specialist in a hospital or at an outpatient clinic.
Diabetes mellitus (patients receive cardiovascular risk management in a diabetes care program).
Patients younger than 18 years.
Interventions between 2010 and 2018
A multidisciplinary registry for integrated care (Care2U), set up from April 1st 2010 onwards, collected data in routine clinical practice. In 2011, Care2U-data of 34,628 participating patients was available, increasing to data of 48,397 patients in 2018.
Data in Care2U automatically ended up in the GPs Electronic Health Record (EHR) and were visible for individual practices in real time. Laboratory test results ended up automatically in Care2U. Smoking status and all SBP measurements taken in one year were registered in Care2U, with the last measured SBP value visible in the data overview of every individual practice. Due to linking problems of Care2U with 8 different EHR systems, data from 2010 were incomplete but registration improved significantly in 2011 and 2012.
After assessment for eligibility patients started with life style improvements and drug therapy. If necessary referral to another health care professional was made, such as a dietician, physiotherapist or a medical specialist. Patients were monitored 1–4 times a year by the PN and once a year by the GP to evaluate cardiovascular risk factors. With the multidisciplinary information system all involved disciplines had acces to the patients’ data, facilitating communication between care givers and exchange of information.
From the start of integrated CVRM care in 2010, a working protocol for the PN was available in which all activities of the PN were recorded, supplemented in 2013 with a protocol for correct blood pressure measurements.
Annual education for GPs and PNs was organized by the care group and based on the most recent guidelines (5, 17). PNs received additional education on motivational interviewing and data processing. During intervision meetings PNs discussed complicated case studies and shared problems on practice organization. In feedback meetings GPs and PNs discussed Care2U benchmark data on registration and outcomes.
The care group started with practice visitations in 2015, carried out by care groups’ staff members to support practices with drawing up an annual practice plan and by formulating one or more areas in which a practice wanted to improve. From 2016 onwards, practice visitations were also used to discuss performance based on data from the quarterly reports.
The care group started with quarterly reports in 2016 that enabled practices to compare individual practice performance with care group performance. The care group established indicators for the prevalence, registration and outcomes of cardiovascular risk factors for participating practices. Standards were set for mean value, minimal norm and best practice, an often used method to compare individual performance with peer group performance (18). Practices asking for support, having problems with organizing adequate CVRM care or performing below a minimal norm based on the care groups’ standards were prioritized for visitation. In 2015 the care group started with visiting 52 practices and in 2016, 2017 and 2018 respectively, 98, 102 and 117 practices were visited at least once.
The LDL-cholesterol toolkit introduced in 2017 comprised two parts: a part for care givers to inform patients on the use and necessity of lipid lowering medication (e.g. statins) and “tips and tricks” in case of impaired patient adherence or side effects. The other part was written information for patients.