Cardiovascular risk reduction with integrated care: results of 8 years follow up

Geert H J M Smits; Sander van Doorn; Michiel L Bots; Monika Hollander

doi:10.1186/s12875-023-02010-y

Cardiovascular risk reduction with integrated care: results of 8 years follow up

BMC Prim Care. 2023 Mar 8;24(1):66. doi: 10.1186/s12875-023-02010-y.

Authors

Geert H J M Smits^{1

2}, Sander van Doorn³, Michiel L Bots³, Monika Hollander³

Affiliations

¹ Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands. g.smits@pozob.nl.
² Primary Care Group PoZoB, Bolwerk 10-14, 5509 MH, Veldhoven, The Netherlands. g.smits@pozob.nl.
³ Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands.

Abstract

Background: Care groups organize integrated cardiovascular risk management programs in primary care for high risk patients. Results of long term cardiovascular risk management are scarce. The aim was to describe changes in low density lipoprotein cholesterol, systolic blood pressure and smoking between 2011 and 2018 in patients participating in an integrated program for cardiovascular risk management organized by a care group in the Netherlands.

Aim: To explore whether long-term participation in an integrated cardiovascular risk management program could lead to the improvement of 3 important risk factors for cardiovascular disease.

Methods: A protocol was developed for delegated practice nurse activities. A multidisciplinary data registry was used for uniform registration. The care group organized annual education for general practitioners and practice nurses on cardiovascular topics and regular meetings for practice nurses only to discuss complex patient cases and implementation issues. From 2015 onwards, the care group started with practice visitations to discuss performance and support practices with organizing integrated care.

Results: In patients eligible for primary prevention as well as for secondary prevention similar trends were observed: lipid modifying and blood pressure lowering medication increased, mean low density lipoprotein cholesterol and mean systolic blood pressure decreased, patients on target for low density lipoprotein cholesterol and systolic blood pressure increased and the proportion of non-smokers with both low density lipoprotein cholesterol and systolic blood pressure on target increased. Improved registration between 2011 and 2013 was partly responsible for the sharp increase of patients on target for low density lipoprotein cholesterol and systolic blood pressure.

Conclusion: In patients participating in an integrated cardiovascular risk management program, we saw annual improvements in 3 important cardiovascular risk factors between 2011 and 2018.

Keywords: Cardiovascular risk management; Integrated care; Practice nurse; Primary health care.

MeSH terms

Blood Pressure
Cardiovascular Diseases* / prevention & control
Cholesterol, LDL
Delivery of Health Care, Integrated*
Follow-Up Studies
Heart Disease Risk Factors*
Humans
Primary Health Care
Risk Factors
Smoking

Substances

Cholesterol, LDL