A primary care network-led cardiovascular disease (CVD) prevention initiative which joins up self-monitoring with practice-based pharmacists and nurses has been expanded to cover 228,000 patients.

The digital initiative, which was trialled among 1,090 patients across seven practices in Warrington Innovation Network PCN, focused on detecting and managing CVD, and prevented an estimated potential 30 heart attacks and strokes (calculated using QRisk3).

It has now been rolled out across 26 neighbouring GP practices in Warrington and Cheshire, where it is estimated to potentially prevent 80 strokes and heart attacks.

In trial stages, patients were identified using 'health kiosks' in GP surgeries, which enable patients to take their own blood pressure, pulse and BMI, which then feeds directly to their GP records.

The PCN then ran searches each week to identify patients who might need greater intervention. Those patients would then be offered an app, developed by BT Group’s digital incubation arm Etc HealthTech, which allows them to upload clinical data.

The PCN's clinical team then monitored the patient's vitals for two weeks, looking at oxygen saturations and pulse rate for COPD monitoring and blood pressure and pulse rate for hypertension.

'Remote monitoring is incredibly efficient, and we can offer intensive management with micro-interventions. We can see when patients become unwell and react early. We can spot missed readings and remind the patient to upload a new one. And we can ask how medication changes are being tolerated,' Dr Dan Bunstone, clinical director of the Warrington Innovation Network PCN wrote in an explanation of the pilot for our sister title, Pulse PCN.

'Patients are pre-emptively booked into follow-up appointments with a prescribing nurse or a clinical pharmacist so that changes can be made to their medication as necessary. The patient can also have sessions with a healthcare assistant or pharmacy technician, who will work through lifestyle advice,' he added.

And he said that feedback from patients on the service had been 'overwhelmingly positive'. 'They love the proactive care and feel safe and supported in their medical condition.'

The now expanded service will also include patients who want to refer themselves for monitoring.

Director of Etc HealthTech Neal Herman said: ‘We want people, healthy or not, to self-manage their healthcare by recoding their blood pressure, their pulse rate and observing the maintenance or decline over time. That also grants a gateway for clinicians to intervene if there is a decline. It’s about having an ongoing relationship between a clinician and patient and the app enables that. I’m in this field and so I’m looking at my vitals every day, but everyone should be doing so frequently.’

Versions of this article first appeared on our sister title Pulse PCN, here and here. Join the conversation on LinkedIn.