Regional Integrated Cardiovascular Risk Management Care Pathway in the Netherlands: Benefits and Working Mechanisms

I am convinced that effective CVRM care is provided to patients in my practice.

Within my practice, the willingness to work according to the CVRM guideline* is high.

I feel well equipped to provide care to CVRM patients.

Within my practice, there is positivity about CVRM care.

I am familiar with the Dutch guideline CVRM.

Within my practice, the Dutch guideline CVRM is followed faithfully.

I find the Dutch guideline CVRM clear.

Within my practice, the Dutch guideline CVRM is implemented as intended.

If I notice that a colleague is not following the Dutch guideline CVRM, I discuss it.

Within my team it is clear who does what for CVRM-patients.

I have a clear picture of how CVRM tasks and patient-responsibilities are divided between primary and secondary care.

Coordination of CVRM patients with Deventer hospital is effective.

I know the route for contact/consultation with Deventer hospital well (e.g. VIPlive consultation or visits from the advanced nurse practitioner).

It is clear which CVRM patients should and should not be referred to Deventer hospital.

… bottlenecks in CVRM care are quickly addressed.

… required knowledge and experience is available to provide good care to CVRM patients.

… problems within CVRM care are solved adequately.

… colleagues are always looking for new, innovative ways to improve CVRM care

From cardiac lipid clinic to CVRM clinic: Until 2014, there was a lipid clinic at Deventer Hospital. In 2014, the outpatient clinic was expanded, which included multiple aspects in addition to lipids in the context of preventing or reducing cardiovascular disease events.

New roles: in July internist vascular physician joined Deventer Hospital and, in the fall, the internal training to become an advanced nurse practitioner was started.

Executive Board decides on vascular care/CVRM program: This decision mend the official start of CVRM care pathway.

Integrated working agreements CVRM put on paper: By expanding the outpatient clinic (lipid clinic to CVRM clinic), the working agreements for those involved have been put on paper, including financial implications.

Ezetimib registered: the drug is a cholesterol absorption inhibitor (has a lowering effect) and has especially great influence on LDL levels. This drug must be taken alongside PCSK9 inhibitors (additive to statin).

Prescribing PCSK9: This is medication (injection) that lowers LDL. This drug is only indicated if the patient is statin (medication: cholesterol synthesis inhibitor) intolerant and has a very high risk of cardiovascular disease or has experienced re-event or 1 event and has diabetes or familial hypercholesterolemia.

Starting colleagues: In Sep, two advanced nurse practitioners started training and advanced nurse practitioners from Vascular Surgery started. Secretarial support was also implemented.

Pre-eclampsia care at the CVRM outpatient clinic: Another target group, namely ex-pregnants at high risk of cardiovascular disease, were referred to the CVRM outpatient clinic. This is primary prevention, and the patient is seen once.

Changes of colleagues: in the autumn an advanced nurse practitioner (from Internal Medicine) started and there was a change of chief physician.

New (FMS/NHG) guideline CVRM (revision of 2011): The LDL target levels have been equalized between GPC and Deventer hospital by this guideline. Previously, the Deventer hospital maintained stricter target levels compared to the GPC.

Diagnostics, namely transition from calculated LDL levels to measured LDL levels: Previously, LDL was calculated by using the Friedewald formula. From this point on, most LDL levels could be measured, only some of the LDL levels continue to be calculated.

New colleagues and working method: Advanced nurse practitioners start, a policy officer starts at the CVRM clinic, and GPs can digitally consult the advanced nurse practitioners at Deventer hospital. Yearly practice visits by the advanced nurse practitioner with the GP and/or allied GP professionals are initiated, with room for exchanging knowledge, discussing cases, training and seeing patients together.