Koelewijn-van Loon commented on our study, a pragmatic randomised trial of the clinical effectiveness of nurses as substitutes for GPs in cardiovascular risk management. In our study, we found a greater decrease in the mean value of risk factors in the practice nurse group than in the GP group, but after confounders and baseline risk factors were controlled for, a statistically significant decrease was found only for total cholesterol [1].

The majority of patients included concerned secondary prevention. Indeed, "these patients were probably already aware of the need for a good lifestyle". Still, we found that many patients did not meet the treatment targets and were not adherent to a healthy lifestyle. Non-adherence to treatment is a major factor in the lack of success of cardiovascular prevention hence caregivers should communicate with patients about their drug use and adherence to life style interventions. In this regard, improvement of cardiovascular prevention is still needed. The outcomes achieved by practice nurses were better than those of general practitioners, still nurses only inquired about drug use in only 40% of patients [2].

Koelewijn-van Loon did question if the effect is caused by nurses acting as substitutes for GPs or by the fact that "nurses were specifically trained", "nurses performed well because this new task recognized their position" or/and "nurses were familiar with lifestyle counselling in contrast to GPs". Indeed, these factors could give an explanation for the results achieved by practice nurses, still cardiovascular risk management was a new task for practice nurses in our study. In addition, they were not specifically trained. Therefore, it is expected that in the future practice nurses will achieve even better health outcomes, as their education improves and more experience is gained. The possibility must be taken into account that practice nurses in our study were more successful compared to other practice nurses because of the awareness that their performance was being assessed. However, this also could be stated for participating general practitioners. Our qualitative study among nurses also showed that nurses in our study were uncertain about the content of lifestyle advice [3]. Still, we found that practice nurses play an important role in the successive removal of barriers to the implementation of cardiovascular prevention within the health care centre and therefore will improve cardiovascular prevention in primary care. It could be concluded that substitution of cardiovascular risk management from GPs to practice nurses concerns more the performance of complementary tasks instead of substitution of tasks.

Another comment concerned the study population being unbalanced. From an univariate analysis of variance - with control for healthcare centre - no baseline differences were found, except for body mass index (SBP:1.9(-1.4-5.3)p=0.258, DBP:0.003(-1.70-0.17)p=0.997, TChol:-0.07(-0.03 -0.12)p=0.460, LDL:-0.03(-0.22-0.16)p=0.783, HDL:0.06(-.001-0.123)p=0.055, BMI-1.05(-1.76--0.34)p=0.004). Body mass index was underestimated in the general practitioner group because of the lack of correction for self-reported body length.

Our conclusion that practice nurses achieve the same or even better results in cardiovascular risk management compared with GPs is therefore justified. However, more education for nurses is needed; this training should include knowledge of cardiovascular diseases (symptoms) to allow early recognition of recurrences or new expressions of cardiovascular disease, cardiovascular pharmacology and content of lifestyle intervention related to cardiovascular diseases. Moreover, it is important to enhance practical skills in lifestyle interventions.

REFERENCES 1. Voogdt-Pruis HR, Beusmans GH, Gorgels AP, Kester AD, Van Ree JW. Effectiveness of nurse-delivered cardiovascular risk management in primary care: a randomised trial. Br J Gen Pract.2010 Jan;60(570):40-6.

2. Voogdt-Pruis HR, Van Ree JW, Gorgels AP, Beusmans GH. Adherence to a guideline on cardiovascular prevention: A comparison between general practitioners and practice nurses. Int J Nurs Stud. 2010 Dec 20. doi:10.1016/j.ijnurstu.2010.11.008.

3.Voogdt-Pruis HR, Beusmans GHMI, Gorgels APM, Van Ree JW. Experiences of doctors and nurses implementing nurse-delivered cardiovascular prevention in primary care: a qualitative study. Journal of Advanced Nursing. 2011; doi: 10.1111/j.1365-2648.2011.05627.

Conflict of Interest:

None declared