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. 2025 Jul 2;26(1):214.
doi: 10.1186/s12875-025-02906-x.

Tailoring remote patient management to optimise cardiovascular risk management in primary care: a mixed-methods implementation study informing large-scale implementation

Margot Rakers  1   2 , Nicoline van Hattem  3   4 , Eric Hiddink  3   4   5 , Petra van Peet  3   4 , Rimke Vos  4   6 , Niels Chavannes  3   4 , Douwe Atsma  4   7   8 , Tobias Bonten  3   4 , Hendrikus van Os  3   4
Affiliations

Tailoring remote patient management to optimise cardiovascular risk management in primary care: a mixed-methods implementation study informing large-scale implementation

Margot Rakers et al. BMC Prim Care. .

Abstract

Aim: Remote patient management (RPM) effectively aids cardiovascular risk management, but its large-scale implementation remains challenging. Panel management may facilitate implementation by using comprehensive data to identify patients at risk of cardiovascular diseases and tailor interventions. This study evaluated the implementation strategies and clinical outcomes of a multi-component RPM intervention 'Connect@Heart'.

Methods: We conducted a mixed-methods study over six months in four primary care practices in the Netherlands, evaluating two patient groups: (i) patients with a BMI < 25 received a blood pressure monitor alone (BP Box), and (ii) patients with a BMI > 25 or cardiovascular disease received a combination of a BP monitor, a scale, and an activity tracker (Lifestyle Box). Baseline and six-month follow-up assessments were performed using linear mixed-effects models, and implementation outcomes were evaluated using the RE-AIM framework.

Results: Our approach achieved high enrolment, with 189 out of 200 initially interested patients (94%) participating. The intervention was associated with a significant reduction in BP levels within both groups (BP Box systolic BP from 139 ± 21 mmHg at baseline to 132 ± 18 mmHg at follow-up, p < 0.001 and Lifestyle Box 142 ± 16 mmHg to 131 ± 14 mmHg at follow-up, p < 0.001), especially for those with uncontrolled hypertension. After six months, 66% of patients performed measurements weekly. All participating practices continued using the intervention post-study.

Conclusion: This study demonstrates that proactively identifying patient panels at risk for CVD and tailoring multi-component RPM interventions to patient panels are promising implementation strategies for reaching favourable clinical outcomes at scale.

Keywords: Blood pressure; Cardiovascular risk; Panel management; Remote patient management; Tailoring devices.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: Data were reported following the Standards for Reporting Qualitative Research (SRQR). The study was conducted according to the guidelines in the Declaration of Helsinki, and all procedures involving research study participants were approved by the Ethics Committee of the Leiden University Medical Center (N21.126). Informed consent was obtained from all the participants and/or legal guardians for the study. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Visualisation of the implementation strategy of Connect@Heart, a multi-component intervention
Fig. 2
Fig. 2
Flowchart of Connect@Heart multi-component intervention
Fig. 3
Fig. 3
Barriers and facilitators per construct of the Theory Framework of Acceptability (TFA)
See this image and copyright information in PMC

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