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