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PLOS Medicine Journal: Integrating Florence into Clinical Workflow at Scale

Telemonitoring at scale for hypertension in primary care: An implementation study 

Uncontrolled hypertension is the largest manageable cause of stroke and myocardial infarction.  Despite the effectiveness of anti-hypertensive medication, many patients still have uncontrolled blood pressure (BP).

Having previously demonstrated that Florence encourages medication use and is effective at lowering BP in this cohort, NHS Lothian’s award winning Scale-Up BP Team led by Professor Brian McKinstry expanded their scope to understand if integrating Florence directly into the clinical workflow would increase adoption even further, what impact this would have on clinician workload, and if study participant changes in BP would match those of randomised controlled trials (RCTs).

NHS Lothian subsequently developed an integrated system providing regular summaries of patient home-monitored BP readings via Florence to routine GP data management systems accessed by their general practitioner.  Patient home-readings were delivered alongside routine laboratory results for clinical review.

The number of participating practices grew steadily following the launch, and by July 2019 75 practices had participated and recruitment reached 3,200 patients with established hypertension.  Expected challenges to the adoption of new technology were mitigated well by the project team by engaging frontline clinicians in development of Florence’s use, activating local champions, and strong continuous support from a facilitator team.  The success of practices who recruited large numbers of patients acted as a stimulus for other practices to follow; patients liked Florence and there was a low rate of discontinuation.  Previous studies have been in the context of RCTs with practices contributing relatively small numbers of patients that are relatively easy to manage however within this study some practices were recruiting hundreds of patients. The evaluation subgroup of 8 practices (905 patients) demonstrated clinical value in that BP fell in the intervention group:

  • A mean systolic BP reduction of 6.55 mm Hg
  • A mean diastolic BP reduction of 4.23 mm Hg
  • Along with Florence’s uptake, change in BP and participants’ views, a key objective of the study was to understand the impact on changes in clinician appointment use.  Compared with the previous year, the study demonstrated that there was no increase in practice workload, specifically:

    • participating patients made 19% fewer face-to-face appointments, compared with 11% fewer in patients with hypertension who were not supported by Florence.
    • total consultation time for participants fell by 15.4 minutes, compared with 5.5 minutes in patients not supported by Florence.

    The paper states;
     “There have been no direct trials to our knowledge exploring the impact of telemonitoring on cardiovascular outcomes, but based on previous studies of anti-hypertensive agents, BP reductions of the magnitude achieved in this study, probably through intensification of anti-hypertensive therapy, if sustained, would be expected to lead to a greater than 15% reduction in risk of stroke and a greater than 10% reduction in risk of coronary heart disease.”

    The paper concludes that based on these detailed findings, that Scale-up BP is ready for routine use across NHS Scotland and possibly also other parts of the UK. To read more about this, the paper can be accessed here or watch this short video.

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