Table 1 Elements of the integrated care for CVRM

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

 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