Project of OptiMedis Belgium with AMGEN: Integrated care for patients with elevated cardiovascular risks

OptiMedis Belgium RGBCardiovascular (CV) disease is still the number one mortality cause in Europe and many people are at elevated risk for future CV events, including patients that had already a CV event in the past, patients suffering from familial hypercholesterolemia as well as diabetic patients. In Europe about 45% of all deaths is caused by CV disease which corresponds to 3,9 million deaths a year. In Belgium 29% of the deaths is caused by CV disease resulting in approximately 30.000 deaths a year. The costs associated with CV disease are estimated to be € 210 billion a year for Europe and € 4,67 billon a year for Belgium, these numbers include direct costs for medical care and indirect societal costs.

A major aspect of the identified problem is the absence of a clear CV disease management owner/responsible. In addition, the patient is currently not sufficiently empowered to take ownership of his CV health.  The current project from OptiMedis Belgium and Amgen focusses on a single aspect of CV disease management and lack of a holistic and integrated perspective, which is crucial for a sustainable effect in CV disease management and prevention. This project aims to improve the quality of care for the primary and secondary prevention in patients with elevated CV risk by focusing on an integrated care approach with a more central role for the patients. This quality-improving program consists of the development, implementation and further roll-out of an “integrated cardiovascular risk management system” (ICRMS), consisting of an overarching IT tool and its management. The system will allow identification of patients at elevated CV risk, stratification, set-up and follow-up of a personalized care path and follow-up of quality indicators at population level. The project intends to shift the society from mainly risk insurance toward mainly risk management, what means a shift of the disposable funding from treating CV complications towards funding CV prevention.

Key principles of the integrated care approach

  • Early identification of patients at individual or population level based on CV risk factors
  • Stratification of patients and use of a digital decision support, resulting in individual target setting (eg. for blood pressure, LDL-C, HbA1c, smoking, diet, exercise, medical treatment)
  • Coaching of the patient – integrated support
  • Dashboard for follow-up for patient and for care-providers based on specific target parameters to be achieved
  • Data collection on quality indicators at population level.