This primary prevention CV risk screening, performed within the general practice with logistical support of the regional general practice laboratory and service, could be well managed within the GP setting, and resulted in a limited additional workload for the GP and his assistant. The GP was only involved in the selection of the patients and provided the location within his practice. The response rate and attendance of the invitees was high, when compared to the Dutch Prevention Visit for example. The yield in newly identified persons (i.e. not currently treated already for hypertension or hypercholesterolemia) with increased risk was considerable (24% of the analysed participants). Compared to a practice from an area with a lower cardiovascular mortality, the yield in identified high risk patient was higher in the studied practice, as expected. Compared to the five practices with similar screenings, the proportion of individuals that was interested after written invitation and could be invited for the risk assessment, was even slightly higher in the studied practice.
The percentage of individuals that had received an invitation letter and was eventually invited for the screening (68%) is comparable with the results of the Dutch ResCon research agency, which assessed by questionnaires in 45–74 year old persons their willingness to participate in a health check for early detection of cardio metabolic risk: 66% reported to probably or surely be willing to undergo a health check [10
]. Likely reasons for the good attendance are the invitation by their own general practitioner, the screening location within the general practice and the reimbursement by the health insurance provider (depending on the remaining own risk) [10
]. The response rate was considerably higher than during the pilot of the Dutch national Prevention Visit. The admission age was higher in the present study, which is related to a higher response [24
For example, Van de Kerkhof et al. found that respondents at a cardiovascular risk factor screening were significantly older than non-responders (52.7 vs. 49.5 years, p<.001) [24
]. Besides, a considerable number of the analysed participants already used medication and thus was already a regular visitor of the practice. These people probably experience fewer barriers to participate in a medical programme.
Both in the pilot study of the Prevention Visit as well as in the study by Van de Kerkhof et al. a questionnaire was used as first selection step [9
]. The dependence on a questionnaire to be filled in by possible candidates as a first filter for a cardio metabolic screening seems to be less efficient in identifying high risk people than increasing the admission age from 40 to 50 years [27
]. In the present study even in the 50–55 years range, the large majority (92%) of men was in the low risk range. Active invitation is needed to additionally obtain information on missing or incompletely available risk factors for an adequate assessment and identification of high CVD risk patients, as is shown in our and the Prevention Visit pilot studies [9
], but also in the UK primary care setting [28
In the present municipality with a low average SES and increased mortality for cardiovascular disease, the target group had a high response rate with the current approach. Thus, an active screening as performed in the current study seems to be an answer to the demand for a reliable risk assessment in such a low SES group. The expectation that many undertreated persons with increased risk would be identified using the approach via their general practice was confirmed.
A limitation of the currently reported data of only one specific general practice situation may be that the external validity is limited. However, use of the currently described model of CV risk screening within a general practice, in several other general practices in other cities and regions in the northern part of the Netherlands, also in a higher SES class region, revealed no major differences in response rates and yield.
The participating general practitioners, both from the studied practice and from the other municipalities, may be more motivated for improving cardiovascular screening and adjusting practice organisation than average practices, as this was a novel initiative. This may overestimate the effect.
Within the 40% of the further analysed participants with a SCORE risk assessment ≥5% already using pharmaceutical treatment for the risk factors, many were not on the target levels as advised in Dutch and other national CV guidelines. Similar observations have often been made in primary as well as in secondary care [1
]. This group received additional advice as suggested in the guidelines. It illustrates that extension of the current health check model to those in a general practice already receiving pharmaceutical treatment for cardiovascular risk factors may still have added value.
In the described current CV screening model, males were invited >50 years and females >55 years, because SCORE risk assessments are to a large extent determined by age and start to rise to levels qualifying for lifestyle or even pharmaceutical treatment above these age levels [21
]. In other health check risk screening programs, such as the NHS Health Checks programme, but also in the Dutch Prevention Consultation, younger age limits such as 40 or 45 years are used [3
]. Current JBS charts allow assessments for three age ranges: <50, 50–59 and ≥60 years. We are aware that use of the lower age limit better takes into account that younger patients have greater lifetime risk. One may also argue that lowering the admission age has the second advantage of offering a time window for benefits from lifestyle modification with an otherwise still expectant policy. However, we weighed this against a broader acceptance (at least in the Netherlands) of the SCORE risk categories as qualifiers for treatment. Using the currently used age limits, only 8% of the males between 50–55 years did have a SCORE risk assessment ≥5%.
In the current model the logistics and execution of the screening programme and health checks were performed by a regional general practice laboratory and service. Advantages are that the health checks may be performed in or in the neighbourhood of the general practices, and invitees are examined by trained personnel but still under supervision of the general practitioner. Dalton et al. [3
] have already discussed the impact of the substantial extra workload of NHS Health Checks and similar screening programmes for the GPs. Involvement of GP laboratory personnel that organises and performs the screening program within the GP practice may alleviate such extra workload. In 2008 a Dutch NIVEL questionnaire addressed to 330 general practitioners revealed that 94% consider the general practice as the preferred place for detecting high cardiovascular risk patients [30
]. A general practice laboratory was considered the preferred institution for delegation of GP tasks (33.7% agreed/agreed very much, this was the highest percentage of all given options, which were, amongst others: hospital, pharmacy, municipal public health service) [31
]. Although the general practice is well-equipped to perform follow-up for pharmaceutical treatment in the detected persons with increased CV risk, a first or parallel step of lifestyle advices may require further involvement and cooperation with dieticians or physical therapists. Practice nurses within the general practice alternatively may offer integrated advice on lifestyle and pharmaceutical treatment. For long-term follow-up of treatment results health checks after follow-up periods ranging between one and five years may be repeated using the current model.