Feasibility and preliminary effectiveness of a population health management approach to improve cardiovascular risk management in primary care: a mixed-method implementation study

Cardiovascular disease (CVD) is a leading cause of death and results in a significant burden on the healthcare system. Population-level prevention strategies in primary care, especially combined with technology such as remote patient management (RPM), are promising for managing risk factors effectively. To overcome implementation barriers in cardiovascular risk management using RPM, population health management has been proposed as a systematic approach for proactively assigning appropriate interventions tailored to specific subgroups of patients.

This study evaluated the feasibility, acceptability and preliminary effectiveness of Connect@Heart, a proactive population health management RPM program which includes a blood pressure monitor, scale, or activity tracker. These devices were connected to a data exchange platform, enabling real-time cardiovascular risk management.

We conducted a mixed methods feasibility study to assess the improvement of blood pressure control through a six-month pre-post intervention in four general practices in the Leiden region in the Netherlands. Patients with a moderate to high risk of CVD or established CVD were proactively identified by an algorithm embedded in the electronic health record. Assessments were performed between baseline and six-month follow-up using paired-sample t-tests and linear mixed effects models. Feasibility criteria included >80% enrollment and completion rates. Acceptability was measured using the System Usability Scale (score > 68), Client Satisfaction Questionnaire-8 (score > 20), and interviews with healthcare professionals. Preliminary effectiveness was determined by changes in blood pressure and weight.

94% (189/200) of eligible patients were enrolled, of which 81% (153/189) completed the assessments after 6 months. In total, 121 technical queries sent to the technical portal of which 71% could be solved immediately. Patients rated the program as acceptable (SUS = 65.86 and CSQ-8 = 24.58). Interviews with healthcare professionals confirmed this. At 6-month follow-up, patients showed significant reductions in systolic blood pressure (baseline mean 140 mmHg, SD 18 mmHg; follow-up mean 131 mmHg, SD 14 mmHg; p < 0.001) and diastolic blood pressure (baseline mean 86 mmHg, SD 10 mmHg; follow-up mean 81 mmHg, SD 9 mmHg; p < 0.001). A 49% relative risk reduction in uncontrolled systolic blood pressure (>135 mmHg) was found at 6-months.

The Connect@Heart program is an acceptable and feasible approach for healthcare professionals and patients, tailored for individuals at risk of cardiovascular disease or with established CVD, and may substantially reduce blood pressure levels.

The Connect@Heart program