title: Effectiveness of a tailored intervention to improve cardiovascular risk management in primary care: study protocol for a randomised controlled trial.
abstract: BACKGROUND
  Cardiovascular disease (CVD) is an important worldwide cause of mortality. In The Netherlands, CVD is the leading cause of death for women and the second cause of death for men. Recommendations for diagnosis and treatment of CVD are not well implemented in primary care. In this study, we aim to examine the effectiveness of a tailored implementation program targeted at practice nurses to improve healthcare for patients with (high risk for) CVD.
  
  
  METHODS
  A two-arm cluster randomized trial is planned. We offer practice nurses a tailored program to improve adherence to six specific recommendations related to blood pressure and cholesterol target values, risk profiling and lifestyle advice. Practice nurses are offered training and feedback on their motivational interviewing technique and an e-learning program on cardiovascular risk management (CVRM). They are also advised to screen for the presence and severity of depressive symptoms in patients. We also advise practice nurses to use selected E-health options (selected websites and Twitter-consult) in patients without symptoms of depression. Patients with mild depressive symptoms are referred to a physical exercise group. We recommend referring patients with major depressive symptoms for assessment and treatment of depressive symptoms if appropriate before starting CVRM. Data from 900 patients at high risk of CVD or with established CVD will be collected in 30 general practices in several geographical areas in The Netherlands. The primary outcome measure is performance of practice nurses in CVRM and reflects application of recommendations for personalized counselling and education of CVRM patients. Patients' health-related lifestyles (physical exercise, diet and smoking status) will be measured with validated questionnaires and medical record audit will be performed to document estimated CVD risk. Additionally, we will survey and interview participating healthcare professionals for exploration of processes of change. The control practices will provide usual care.
  
  
  CONCLUSIONS
  Tailored interventions can improve healthcare. An understanding of the methods to reach the improved healthcare can be improved. This research contributes a share of it. Identification of the determinants of practice and developing implementation interventions were two steps which were completed. The subsequent step was implementation of the tailored intervention program.
  
  
  BACKGROUND
  Name trial register: Nederlands trial register. Web address of trial register: http://www.trialregister.nl. Data of registration: 11 July 2013. Number of registration: NTR4069.
authors.affiliation: Radboud University Nijmegen Medical Center, Scientific Institute for Quality of Healthcare, Postbus 9101, 6500 HB, Nijmegen, The Netherlands. Elke.Huntink@radboudumc.nl.
authors.forename: Elke
authors.initials: E
authors.lastname: Huntink
authors.forename: Naomi
authors.initials: N
authors.lastname: Heijmans
authors.forename: Michel
authors.initials: M
authors.lastname: Wensing
authors.forename: Jan
authors.initials: J
authors.lastname: van Lieshout
mesh_terms: D002318:Cardiovascular Diseases / Q000628:therapy*; D002985:Clinical Protocols; D006801:Humans; D017063:Outcome Assessment, Health Care; D011320:Primary Health Care; D012107:Research Design; D012308:Risk Management