The ZWOlle Transmural Integrated Care for CArdiovaScular Risk Management Study (ZWOT-CASE)

Cardiovascular disease (CVD) contributes importantly to mortality and morbidity. Prevention of CVD by lifestyle change and medication is important and needs full attention.

In the Netherlands an integrated program for cardiovascular risk management (CVRM), based on the Chronic Care Model (CCM), has been introduced in many regions in recent years, but evidence from studies that this approach is beneficial is very limited.

In the ZWOT-CASE study the investigators will assess the effect of integrated care for CVRM in the region of Zwolle on two major cardiovascular risk factors: systolic blood pressure (SBP) and low-density lipoprotein cholesterol (LDL-cholesterol) in patients with or at high risk of CVD.

This study is a pragmatic clinical trial comparing integrated care for CVRM with usual care among patients aged 40-80 years with CVD (n= 370) or with a high CVD risk (n= 370) within 26 general practices. After one year follow-up, primary outcomes (SBP and LDL-cholesterol level) are measured. Secondary outcomes include lifestyle habits (smoking, dietary habits, alcohol use, physical activity), risk factor awareness, 10-year risk of cardiovascular morbidity or mortality, health care consumption, patient satisfaction and quality of life.

Study Overview

• Status: Unknown
• Conditions: Cardiovascular Diseases; Hypertension; Hypercholesterolemia
• Intervention / Treatment: Other: Integrated care for cardiovascular risk management

• Study Type: Observational
• Enrollment (Anticipated): 740

Contacts and Locations

Study Locations

• Netherlands
  • Overijssel
    • Zwolle, Overijssel, Netherlands
      • General Practices

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 40 years to 80 years (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: N/A
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

The ZWOT-CASE study population will consist of a subgroup of 370 patients from the integrated CVRM care group (intervention) and 370 patients in the usual care (control) group. Both groups consist of respectively i) 185 patients with known CVD and ii) 185 patients with a high (>10%) ten year risk of CVD morbidity and mortality based on the Dutch Guideline for CVRM.

Description

Inclusion criteria for patients with CVD:

• Patients with a history of atherosclerotic CVD defined as documented angina pectoris, myocardial infarction, chronic ischemic heart disease, coronary sclerosis, transient ischaemic attack (TIA), cerebral infarction, intermittent claudication or aneurysm of the abdominal aorta
• The CV risk of the patient is managed in primary care, not in the hospital or outpatient clinic by a medical specialist
• Age between 40 and 80 years

Inclusion criteria for high risk patients:

• Use of blood pressure lowering or lipid lowering drugs
• A 10 -years CV risk > 10%, based on the Dutch guideline for CVRM and i) either 1 strongly cardiovascular risk enhancing factor or 2 mildly cardiovascular risk enhancing factors (see table 6) or ii) > 1 CV risk factor (current smoking, SBP>140 mmHg, LDL>2.5 mmol/L, TC/HDL-ratio > 8, chronic renal impairment (age < 65 years: eGFR < 60 ml/min/1,73 m2; age ≥ 65 years: eGFR < 45 ml/min/1,73 m2, and/or (micro)albuminuria).
• A 10-year CV risk of >20% and > 1 CV risk factor (current smoking, SBP>140 mmHg, LDL>2.5 mmol/L, TC/HDL-ratio > 8, chronic renal impairment (age < 65 years: eGFR < 60 ml/min/1,73 m2; age ≥ 65 years: eGFR < 45 ml/min/1,73 m2, and/or (micro)albuminuria).
• The CV risk of the patient is managed in primary care, not in the hospital or outpatient clinic by a medical specialist
• Age between 40 and 80 years

Exclusion criteria for all patients:

• Diabetes mellitus, as these patients are already included in a disease management program for diabetes mellitus
• Limited life expectancy, as assessed by the GP
• Cognitive impairment, as assessed by the GP
• No Dutch language proficiency
• Staying abroad for longer than three months during the duration of the study.
• The CV risk of the patient is managed in the hospital or outpatient clinic by a medical specialist

Study Plan

How is the study designed?

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Intervention group; The intervention under study will be the integrated care for cardiovascular risk management (CVRM), based on the Dutch CVRM guideline. Patients with a history of cardiovascular disease (CVD), a high cardiovascular risk (CVR) (>10%) or use of antihypertensives or lipid lowering drugs are included in the program. Patients will be invited for an intake consultation, including a blood test, an interview, physical examination and estimation of the 10-years cardiovascular risk. If indicated, treatment with medication will be started and general lifestyle advises will be given. Patients can be referred to smoking cessation therapy, dietician and exercise programs or a physiotherapist. Patients will be controlled on a regular base to evaluate and adjust their personal goals.	Other: Integrated care for cardiovascular risk management; Disease management program for the prevention of cardiovascular diseases
Control group; Usual care will be based on the Dutch CVRM guideline, describing how to calculate the CVR and advices to lower this risk by lifestyle intervention and/or medication. However systematic identification of patients eligible for CVRM, actively inviting patients for a visit, regular follow-up and standardized collaboration with other disciplines in the health care chain are not necessarily part of usual care.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Systolic blood pressure	Systolic blood pressure, manual or electronic oscillometric measurement, at least 2 measurements with an interval of 1-2 minutes	After 1 year of follow-up
LDL-cholesterol	Blood sample	After 1 year of follow-up

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
10-years cardiovascular morbidity or mortality risk	10-years cardiovascular morbidity or mortality risk (percentage) (Risk chart Dutch guideline or SMART risk score)	After 1 year of follow-up
Smoking status	Smoking yes or no	After 1 year of follow-up
Body mass index (BMI)	The BMI is defined as the body mass divided by the square of the body height, and is expressed in units of kg/m2, resulting from mass in kilograms and height in metres. BMI will be measured by the general practitioner or practice nurse during the endpoint visit	After 1 year of follow-up
Healthy diet	Healthy diet yes or no according to the Dutch guideline for cardiovascular risk management and national guideline for healthy diet ((daily 150 - 200 grams vegetables and 200 grams fruit; daily 30 - 40 grams dietary fibers; twice a week 100 - 150 gram fish, at least once fatty fish; maximum of 6 grams salt per day; maximum of 2 (men) or 1 (women) alcohol consumptions per day). Food habits will be measured by a questionairre.	After 1 year of follow-up
Physical activity	Squash questionnaire	After 1 year of follow-up
Motivation to quit smoking	Motivation to quit smoking: motivated to quit/not motivated to quit/ considers to quit smoking	After 1 year of follow-up
Awareness of received lifestyle advices	Aware/ not aware of received lifestyle advices, measured by questionairre	After 1 year of follow-up
Awareness of food habits	Patient will be asked whether he/she thinks if he/she has healthy food habits yes or no. Measured by a questionairre	After 1 year of follow-up
Awareness of physical activity	Patient will be asked whether he/she thinks if he/she has a healthy level of physical activity yes or no. Measured by a questionairre	After 1 year of follow-up
Awareness of weight	Patient will be asked whether he/she thinks if he/she has a healthy weight yes or no. Measured by a questionairre	After 1 year of follow-up
Awareness of hyperlipidaemia	Patient will be asked whether he/she thinks if he/she has hyperlipidaemia yes or no. Measured by a questionairre	After 1 year of follow-up
Awareness of cardiovascular disease risk	Estimation by patient of his/her own cardiovascular disease risk by a questionairre	After 1 year of follow-up
Awareness of hypertension	Patient will be asked whether he/she thinks if he/she has hypertension yes or no. Measured by a questionairre	After 1 year of follow-up
Use of adequate antihypertensives	Use of adequate antihypertensives according to Dutch guideline for cardiovascular risk management. Measured by medication registered in electronic medical records in general practice	After 1 year of follow-up
Use of adequate lipid lowering drugs	Use of adequate lipid lowering drugs according to Dutch guideline for cardiovascular risk management. Measured by medication registered in electronic medical records in general practice	After 1 year of follow-up
Use of adequate anticoagulants	Use of adequate anticoagulants according to Dutch guideline for cardiovascular risk management. Measured by medication registered in electronic medical records in general practice	After 1 year of follow-up
Morbidity	Newly developed cardiovascular diseases	After 1 year of follow-up
Newly developed diabetes mellitus	Newly developed diabetes mellitus, based on coded diagnosis in electronic medical record in general practice	After 1 year of follow-up
Newly developed COPD	Newly developed COPD, based on coded diagnosis in electronic medical record in general practice	After 1 year of follow-up
Newly developed heart failure	Newly developed heart failure, based on coded diagnosis in electronic medical record in general practice	After 1 year of follow-up
Newly developed atrial fibrillation	Newly developed atrial fibrillation, based on coded diagnosis in electronic medical record in general practice	After 1 year of follow-up
Mortality	Died due to cardiovascular disease or other cause	After 1 year of follow-up
Primary treating practitioner in the context of cardiovascular risk management	General practitioner or medical specialist.	After 1 year of follow-up
Health care consumption in the past year	Consultations in the contect ox cardiovascular risk management in general practice	After 1 year of follow-up
Self-management in the past year	Patient Activity Measure (PAM)	After 1 year of follow-up
Self-measurements of blood pressure in the past year	Self-measurements of blood pressure in the past year yes or no	After 1 year of follow-up
Patient satisfaction regarding the provided care in the past year	Patient Reported Experience Measure (PREM)	After 1 year of follow-up
Quality of life	EQ-5D	After 1 year of follow-up
Quality of life	SF-12	After 1 year of follow-up
Anxiety and depression	Hospital Anxiety and Depression Scale (HADS), 0-7: no depression or anxiety, 8-10: depression or anxiety is possible,11-21: depression or anxiety is likely	After 1 year of follow-up
Cost-efficiency	iPCQ	After 1 year of follow-up

Collaborators and Investigators

• Sponsor: UMC Utrecht
• Collaborators: Isala; Medrie Health Care Group, Zwolle; Hein Hogerzeil Stichting
• Investigators: Study Chair: Arno Hoes, Prof. MD PhD, Julius Center for Health Sciences and Primary Care/ University Medical Center Utrecht; Principal Investigator: Monika Hollander, MD PhD, Julius Center for Health Sciences and Primary Care/ University Medical Center Utrecht; Principal Investigator: Arnoud van 't Hof, Prof. MD PhD, Maastricht University Medical Center, department of cardiology

Publications and helpful links

General Publications

• Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corra U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FDR, Lochen ML, Lollgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van der Worp HB, van Dis I, Verschuren WMM. [2016 European guidelines on cardiovascular disease prevention in clinical practice. The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts. Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation]. G Ital Cardiol (Rome). 2017 Jul-Aug;18(7):547-612. doi: 10.1714/2729.27821. No abstract available. Italian.
• Dyakova M, Shantikumar S, Colquitt JL, Drew CM, Sime M, MacIver J, Wright N, Clarke A, Rees K. Systematic versus opportunistic risk assessment for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev. 2016 Jan 29;2016(1):CD010411. doi: 10.1002/14651858.CD010411.pub2.
• Khunti K, Stone M, Paul S, Baines J, Gisborne L, Farooqi A, Luan X, Squire I. Disease management programme for secondary prevention of coronary heart disease and heart failure in primary care: a cluster randomised controlled trial. Heart. 2007 Nov;93(11):1398-405. doi: 10.1136/hrt.2006.106955. Epub 2007 Feb 19.
• Ebrahim S, Taylor F, Ward K, Beswick A, Burke M, Davey Smith G. Multiple risk factor interventions for primary prevention of coronary heart disease. Cochrane Database Syst Rev. 2011 Jan 19;(1):CD001561. doi: 10.1002/14651858.CD001561.pub3.
• Marchal S, Hollander M, Schoenmakers M, Schouwink M, Timmer JR, Bilo HJG, Schwantje O, van 't Hof AWJ, Hoes AW. 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. BMC Fam Pract. 2019 Nov 1;20(1):149. doi: 10.1186/s12875-019-1039-z.

Study record dates

Study Major Dates

• Study Start (ACTUAL): September 1, 2017
• Primary Completion (ANTICIPATED): March 31, 2018
• Study Completion (ANTICIPATED): March 31, 2018

Study Registration Dates

• First Submitted: January 26, 2018
• First Submitted That Met QC Criteria: February 4, 2018
• First Posted (ACTUAL): February 9, 2018

Study Record Updates

• Last Update Posted (ACTUAL): February 9, 2018
• Last Update Submitted That Met QC Criteria: February 4, 2018
• Last Verified: February 1, 2018

More Information

Terms related to this study

• Keywords: Primary Health Care; Prevention; Integrated care; Disease Management
• Additional Relevant MeSH Terms: Metabolic Diseases; Lipid Metabolism Disorders; Hyperlipidemias; Dyslipidemias; Cardiovascular Diseases; Hypercholesterolemia
• Other Study ID Numbers: 57867

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No