Stepwise Implementation of a Cardiovascular Risk Management Care Program in Primary Care: A Research Article

Abstract Background: Primary care plays a pivotal role in sustainable cardiovascular risk management (CVRM) but little is known about the organizational process of implementing the guidelines. The aim of the study was to describe the approach taken by a primary care group to implement the CVRM guideline.Methods: Stepwise introduction and implementation of a programmatic CVRM care program was organized and facilitated by the care group between April 2010 and April 2012 in 143 affiliated general practices with 190 committed general practitioners (GPs), in the vicinity of Eindhoven, Netherlands. Care group support comprised sufficient staff, support with data extraction based on ICPC and ATC codes and with identification of eligible patients by scrutinizing patient health records and adequate coding of disease conditions. Results: Within 2 years, patient selection based on availability of structured information on ICPC codes and risk factor levels from the electronic health records, led to 38.082 eligible patients in 2013. October 2020, the CVRM program is still running in 157 practices with 49380 patients receiving programmatic CVRM care. Linking problems between 8 different electronic health record systems and the multidisciplinary information system for integrated care ( Care2You) delayed adequate data collection until the beginning of 2013.Conclusion: Introduction and implementation of integrated primary care for cardiovascular risk management is feasible when a number of conditions are met: commitment of affiliated GPs, adequate coding of diagnoses and risk factors, a structured approach and additional funding for sufficient staff support. This approach constitutes the basis for long-term follow up and annual evaluation.