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Table 1 Elements of the integrated care for CVRM

From: Design of the ZWOT-CASE study: an observational study on the effectiveness of an integrated programme for cardiovascular risk management compared to usual care in general practice

Element Contents
Systematic selection of target population Systematic screening of practice population based on ICPC-codes
Systematic screening of practice population based on ATC-codes
Check of medical records according to in- and exclusion criteria of the programme
Active invitation of patients for the programme Active invitation for an intake consultation by letter
Reminder in case of no response
Collaboration with different disciplines Well trained practice nurses, supervised by GPs
Optional involvement of physiotherapist or dietician
Online consultation of medical specialist
Data registration in multidisciplinary information system for integrated care (KIS, Portavita®) Including data on laboratory measurement, intake consultation and follow-up controls
Benchmark meetings Comparison op patient data of general practice with national data
Laboratory measurement (prior to intake consultation) Lipids (total cholesterol, HDL-cholesterol, TC/HDL-cholesterol ratio, LDL-cholesterol, triglycerides)
Renal function (creatinine, GFR estimated by MDRD)
Glucose
Intake consultation
 Interview Cardiovascular complaints
Family history of CVD
Medication adherence
Lifestyle
Motivation to change behaviour
 Physical examination Length, weight, BMI and waist circumference
Blood pressure
Pulse rate
 Estimation of 10-years cardiovascular risk Based on the risk chart in the Dutch guideline
 cIndividual treatment goals By shared decision making
 General lifestyle advice According to physical activity and diet
 Medication (initiated or adapted if necessary) Blood pressure lowering drugs
Lipid lowering drugs
Anticoagulants
 Referral (if necessary) Smoking cessation programmes
Dietician
Exercise programmes
Physiotherapist
Medical specialist
 Regular follow-up Evaluation of personal goals
Adjustment of treatment