Study population
Primary care group PoZoB (vicinity of Eindhoven, south-east part of the Netherlands) was founded in 2002 and started with implementing the chronic care programs Diabetes Mellitus type 2 (DM2) and Asthma/COPD (AC) in 2005 and 2008, respectively. At the start of the CVRM implementation project in 2009, the care group comprised 143 GP practices (190 GPs) with 402623 registered patients living in the south-eastern part of the province of Brabant, and the western part of the province of Limburg in The Netherlands.
Identification of suitable patients for CVRM care
The implementation process was initiated in basically three steps; first: identification of patients, second: inclusion/exclusion in the program, and third: treatment and follow-up. Before starting the implementation process, the PoZoB primary care group contacted every individual GP to identify suitability for participation in the CVRM care program, defined as participation in running care programs for diabetes and asthma/COPD, and having sufficient available working hours allowed for the trained practice nurse (PN) and the GP to pay full attention to new patients eligible for integrated CVRM care. If these conditions were met, the identification process started. Identification was based on 2 steps. The first step was extraction of information from the electronic health record (EHR) to identify which patients had an increased risk for cardiovascular disease or a history of cardiovascular disease. Extraction was carried out by a certified organization for multidisciplinary data management and scientific research (“Meetpunt Kwaliteit”, since 2015 INZO = Instituut voor ZorgOptimalisatie) based on medical diagnosis, on prescribed medication in patients older than 18 years and on labels that practices already used for identifying patients. Medical diagnosis was linked to the International Classification of Primary Care (ICPC) code and prescribed medication was linked to the Anatomical Therapeutical Chemical (ATC) classification. For the ICPC and ATC codes used for identification see supplementary file 1.
The second step was inclusion or exclusion in the CVRM care program for which the EHR was scrutinized if diagnoses or risk factors were set correct, based on discharge letters from the specialist. Practices were given one year to complete the EHR investigation for correct ICPC codes and labeling, invite patients and start with CVRM care. A mandatory group course was offered to the GP and PN to standardize registration of patients. During this year, all practices were visited two or three times by specialized care group nurses to monitor progress and to discuss unclear diagnoses. If necessary, staff nurses were reachable by phone to discuss in- or exclusion in the CVRM care program.
Criteria for inclusion in the CVRM care program were:
Patients with CVD or kidney disease: (i) documented 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 and (ii) primarily treated in primary care and (iii) aged 18 years or above.
Patients at high risk of CVD: (i) a 10 year cardiovascular mortality risk > 5%, based on the SCORE table from the 2006 National Guideline for Cardiovascular risk management (4) or (ii) use of antihypertensive or lipid lowering drugs in men aged ≥ 55 years and women aged ≥ 60 years or (iii) Systolic blood pressure > 180 mm Hg and/or total cholesterol > 8 mmol/l ever measured, independent of the 10 year mortality risk and (iv) primarily treated in primary care and (v) aged 18 years or above.
Exclusion criteria for both groups were: (i) primarily treated by a specialist in hospital or outpatient clinic or (ii) Diabetes mellitus (as they received cardiovascular risk management in a diabetes care program).
Chain Information System
In 2010 a Multidisciplinary Information System for integrated care (Chain Information System, CIS: Care2U) was introduced. CIS data registered by the PN ended up automatically in the EHR. All patients were labeled in the CIS and in the EHR as follows:
- V1: Patients at high risk for CVD, treatment and follow up by the GP/PN
- V2: Patients at high risk for CVD, treatment and follow up by a specialist in hospital or out-patient clinic
- V3: Patients at high risk for CVD, refusing care by a GP/PN
- Z1: Patients with CVD, treatment and follow up by the GP/PN
- Z2: Patients with CVD, treatment and follow up by a specialist in hospital or out-patient clinic
- Z3: Patients with CVD, refusing care by a specialist
Ultimately, only patients who had their treatment and follow up in primary care (V1 and Z1) were included in the CVRM care program.
Measurements
Once the patient was eligible for CVRM care he/she received an invitation letter from the general practice to make an appointment with the PN, who plays a central role in the care program. If the patient did not respond within 2 weeks, the practice assistant called the patient. During the first consultation the patient was asked whether he/she was willing to participate in the CVRM care program. Time for the intake was estimated 45 minutes and was often split in 2 visits to the practice. The intake comprised an interview, check of in- and exclusion criteria, a physical examination and referral for blood testing to determine the cardiovascular risk profile. The main items from the interview the PN conducted with the patient are summarized in Table 1.
The physical examination, based on the PoZoB protocol that was based on the CVRM guidelines of the Dutch Society of General Practice, assessed blood pressure, height and weight and body mass index (BMI kg/m2), heart rate and waist circumference. Blood and urine samples were taken for fasting glucose, lipids (total cholesterol, HDL, LDL and triglycerides) and kidney function (serum creatinine, estimated glomerular filtration ratio (eGFR) and proteinuria). Blood tests performed less than 3 months ago could also be used. Blood sampling was performed at a local hospital laboratory or at a local diagnostic health center. Based on test results, for patients without a history of a cardiovascular disease and without preventive cardiovascular medication, a 10 year cardiovascular risk was estimated using the SCORE table from the 2006 National Guideline for Cardiovascular risk management (4). For patients younger than 55 (Male) or 60 (Female) years of age the SCORE had to be calculated based on blood pressure or cholesterol levels before starting medication. If the SCORE was < 5%, the patient was not eligible for the CVRM care program.
Treatment and follow-up
After determining the cardiovascular risk profile, the PN made an individual care plan with the patient and supported self-management by informing about CVD or risk factors and motivating the patient to take the lead in coping with it in the best possible way. The PN discussed the individual care plan with the GP, who had final medical responsibility. The PN was responsible for preparing and discussing the individual care plan with the patient, comprising non-pharmacological and pharmacological treatment.
Although treatment goals were set in shared decision with the patient, in most cases targets values were used according to the National Guideline CVRM 2006. Treatment guidelines and treatment targets based on the Dutch Guideline CVRM 2006 are listed in supplementary 2.
If necessary, the PN referred the patient to a smoking cessation program, a physiotherapist or a dietician. If lifestyle advise resulted in insufficient effect on the risk factors level, blood pressure or lipid lowering medication could be initiated after consultation with the GP. When a cardiovascular event occurred or a patient failed to meet target values for blood pressure or lipids after maximum drug therapy, the GP referred to or consulted a specialist according to the criteria outlined in Table 2.
Regular follow up was agreed with the patient, depending on presence of comorbidity, complexity, achievement of treatment goals and advice according to the CVRM guideline. Patients were seen at least once a year by the GP to discuss laboratory results and seen 1-3 times a year by the PN to discuss lifestyle improvement and setting of new treatment goals if needed or wanted.
Data registration
Patient data (anamnestic, biometric, laboratory) were collected in the CIS. The CIS automatically called patients for annual blood tests by linking the call to the date of birth. Due to registration problems in the EHR and to linking problems between 8 different EHR systems and the CIS, data collection was delayed and limited at the beginning. In the first quarter of 2013 these problems were finally solved. From April 2013, CIS data were monitored monthly and every practice was able to view their data (process and outcome) any time.