Outcomes of long-term cardiovascular risk management in primary care

This theses describes:
- the implementation of integrated CVRM care by the PoZoB care group
- the steps taken to improve the CVRM care program and
- an observational study comparing PoZoB patients with Julius
GP Network-patients on cardiovascular disease incidence

Chapter 2 describes the working method the PoZoB care group used to implement
nurse-led, integrated CVRM care, comprising i)identification of potentially eligible patients, ii) inclusion/exclusion for participation, iii) inviting patients to determine cardiovascular risk factors, iiii) drawing up a treatment plan and iiiii) organize regular follow-up.

In chapter 3 we describe discontinuation in 3,997 patients between 2010 and 2018. 1190 patients (29.8%) had discontinued the program of whom 355 patients (8,9%) discontinued without a specific reason or on request. These participants were 5 years younger, nearly all without an established CVD (1.7% vs 22.6%), had less often atrial fibrillation, congestive heart failure and chronic kidney disease and finally, were taking twice as often blood pressure lowering and cholesterol lowering medication.

In chapter 4 we show the results of long-term, nurse-led, integrated CVRM care.
Three cardiovascular riskfactors (systolic blood pressure (SBP), low density lipoprotein
(LDL)-cholesterol, non-smoking) improved annually between 2011 and 2018 in
participants with and without an established CVD. Moreover, the number of participants
on target for SBP (≤ 140 mm Hg) and LdL-cholesterol (< 2.6 mmol/l) increased,
as well as the number of participants with a combination of 3 risk factors on target.

In chapter 5 we evaluated sex differences and trends in the management of 3 biological
riskfactors (SBP, LDL-cholesterol and eGFR) and 4 lifestyle risk factors (body
mass index: BMI, non-smoking, responsible alcohol intake and sufficient daily exercise). The mean number of lifestyle riskfactors on target was slightly better in women compared
to men, overall. The mean number of biological risk factors on target was better in men overall. We observed the largest difference between men and women on target for LDL-cholesterol and for eGFR, where men were more often on target than women. Finally, cholesterol lowering medication was clearly more often prescribed to men than to women.

In chapter 6, we described that annual practice visitations did not lead to improvements in completeness of registration and reaching predefined targets the following year, neither in individual patient data nor in aggregated data on practice level. We further evaluated the 25% lowest performing practices in 2017 to see whether the number of visitations influenced completeness of registration and outcomes in 2018. Although the largest improvements were seen in the group visited twice or more, differences between visitation groups were not statistically significant.

In chapter 7 we describe the results of practice visitations in 2016 in 11 practices that
performed below a minimal standard for one outcome indicator: “systolic blood
pressure ≤ 140 mm Hg in patients < 80 years”. With comprehensive problem analysis
and targeted support, 8 out of 11 practices improved above the minimal standard.
The original paper was published in 2017 in “Huisarts en Wetenschap”.

In chapter 8 we compared disease incidence of 5 cardiovascular diseases from 2013 to 2019 between PoZoB-participants receiving integrated CVRM care plus extensive care group support and Julius General Practitioner Network (JGPN)-participants receiving CVRM care from their GP. The disease incidence per 1,000 patient
years (PoZoB vs JGPN) was 17.5 vs 22.2 for men and 13.6 vs 15.8 for women.
Conclusions regarding the reliability of these outcomes should be drawn with great caution due to a non-randomized design.

In chapter 9 the main results are summarized. Next, we make proposals to improve
data collection and proposals to increase the effectivity of the CVRM care program.