A real-world preventive primary care model for cardiorenal metabolic disease: clinical impact of a personalised care approach in harrow, north west London
Author(s)
Type
Journal Article
Abstract
Abstract:
Cardiorenal metabolic (CRM) disease, is identified by the co-location of multiple disorders including obesity,
diabetes, hypertension, cardiovascular disease and chronic kidney disease (CKD). Early intervention is essential
to slow CKD progression, reduce cardiovascular risk, and improve quality of life. The Harrow CRM Hub project
established a personalised, multidisciplinary pathway to identify high-risk patients, optimise clinical
management, and provide access to lifestyle and psychosocial support. This paper reports on the clinical
outcomes achieved within the first year of implementation.
Methods:
A comprehensive logic model was co-developed to guide the design, delivery, and evaluation of the Harrow CRM
programme. Two EHR-identified cohorts were invited: (1) adults aged 20–80 years with BMI >27.5–30 kg/m²
(ethnicity-dependent) and non-diabetic hyperglycaemia ± hypertension (CRM Stage 2); and (2) adults with
diabetes ± CKD or CVD (CRM Stage 4). Pre visit health questionnaire – using digital tools enabled detailed pre
visit updates and tests. Protected consultations (lasting 30 to 45 minutes) followed a structured EHR template
incorporating guideline-based optimisation of pharmacotherapy, risk calculators, and co-created lifestyle care
plans. Data were extracted for paired analysis of systolic BP, HbA1c, and weight. A qualitative evaluation was
undertaken to explore patient and staff experiences of the CRM pathway.
Results:
Thus far, between November 2024 and September 2025, 2,641 patients were reviewed, with 2,300 included in
paired analysis. Across the full cohort, mean changes were −3.65 mmHg in systolic BP (median −2.0 mmHg),
−1.03 mmol/mol in HbA1c (median 0.0 mmol/mol), and −0.46 kg in weight (median 0.0 kg) (all p<0.001). For
those with an improvement only - an average improvement of −14.12 mmHg (n=1,279) and an average
deterioration of +10.61 mmHg among those whose readings worsened (n=895). HbA1c values showed a mean
cohort wide reduction of −1.03 mmol/mol (median 0.0 mmol/mol), with mean changes of −8.08 mmol/mol
among improvers (n=785) and +5.22 mmol/mol among those with deterioration (n=762). Weight trends showed
a mean overall reduction of −0.46 kg (median 0.0 kg), comprising an average improvement of −3.63 kg among
improvers (n=1,124) and deterioration of +3.93 kg among those with deterioration (n=761).
Among those with paired readings, 33.4% achieved ≥5% BP reduction and 19.7% achieved ≥10%; 19.8% achieved
≥5% HbA1c improvement and 12.7% ≥10%; and 9.6% achieved ≥5% weight loss and 2.7% ≥10%. Overall, 73.9%
improved in ≥1 parameter, while 10.4% improved across BP, HbA1c, and weight simultaneously. This real worldreview identified patients with improvements and deterioration in their health parameters. Qualitative findings
showed patients valued extended consultations and holistic discussions, with vast majority of patients reporting
greater understanding of their health and feeling more confident to manage it. A staff survey (n=14) provided
supportive but preliminary quantitative evidence of having greater confidence in delivering CRM clinics and
increased ability to access multidisciplinary expertise.
Conclusion:
A personalised, multidisciplinary CRM model embedded within primary care was associated with statistically
and clinically significant improvements in blood pressure, glycaemic control, and weight in a large, ethnically
diverse population. Patients and clinicians both reported greater engagement, confidence, and satisfaction. The
approach combining structured identification, extended consultations, co-produced care plans, and workforce
education demonstrates a scalable, sustainable pathway to slow CKD progression, reduce CVD risk, and enhance
patient wellbeing across diverse communities.
Cardiorenal metabolic (CRM) disease, is identified by the co-location of multiple disorders including obesity,
diabetes, hypertension, cardiovascular disease and chronic kidney disease (CKD). Early intervention is essential
to slow CKD progression, reduce cardiovascular risk, and improve quality of life. The Harrow CRM Hub project
established a personalised, multidisciplinary pathway to identify high-risk patients, optimise clinical
management, and provide access to lifestyle and psychosocial support. This paper reports on the clinical
outcomes achieved within the first year of implementation.
Methods:
A comprehensive logic model was co-developed to guide the design, delivery, and evaluation of the Harrow CRM
programme. Two EHR-identified cohorts were invited: (1) adults aged 20–80 years with BMI >27.5–30 kg/m²
(ethnicity-dependent) and non-diabetic hyperglycaemia ± hypertension (CRM Stage 2); and (2) adults with
diabetes ± CKD or CVD (CRM Stage 4). Pre visit health questionnaire – using digital tools enabled detailed pre
visit updates and tests. Protected consultations (lasting 30 to 45 minutes) followed a structured EHR template
incorporating guideline-based optimisation of pharmacotherapy, risk calculators, and co-created lifestyle care
plans. Data were extracted for paired analysis of systolic BP, HbA1c, and weight. A qualitative evaluation was
undertaken to explore patient and staff experiences of the CRM pathway.
Results:
Thus far, between November 2024 and September 2025, 2,641 patients were reviewed, with 2,300 included in
paired analysis. Across the full cohort, mean changes were −3.65 mmHg in systolic BP (median −2.0 mmHg),
−1.03 mmol/mol in HbA1c (median 0.0 mmol/mol), and −0.46 kg in weight (median 0.0 kg) (all p<0.001). For
those with an improvement only - an average improvement of −14.12 mmHg (n=1,279) and an average
deterioration of +10.61 mmHg among those whose readings worsened (n=895). HbA1c values showed a mean
cohort wide reduction of −1.03 mmol/mol (median 0.0 mmol/mol), with mean changes of −8.08 mmol/mol
among improvers (n=785) and +5.22 mmol/mol among those with deterioration (n=762). Weight trends showed
a mean overall reduction of −0.46 kg (median 0.0 kg), comprising an average improvement of −3.63 kg among
improvers (n=1,124) and deterioration of +3.93 kg among those with deterioration (n=761).
Among those with paired readings, 33.4% achieved ≥5% BP reduction and 19.7% achieved ≥10%; 19.8% achieved
≥5% HbA1c improvement and 12.7% ≥10%; and 9.6% achieved ≥5% weight loss and 2.7% ≥10%. Overall, 73.9%
improved in ≥1 parameter, while 10.4% improved across BP, HbA1c, and weight simultaneously. This real worldreview identified patients with improvements and deterioration in their health parameters. Qualitative findings
showed patients valued extended consultations and holistic discussions, with vast majority of patients reporting
greater understanding of their health and feeling more confident to manage it. A staff survey (n=14) provided
supportive but preliminary quantitative evidence of having greater confidence in delivering CRM clinics and
increased ability to access multidisciplinary expertise.
Conclusion:
A personalised, multidisciplinary CRM model embedded within primary care was associated with statistically
and clinically significant improvements in blood pressure, glycaemic control, and weight in a large, ethnically
diverse population. Patients and clinicians both reported greater engagement, confidence, and satisfaction. The
approach combining structured identification, extended consultations, co-produced care plans, and workforce
education demonstrates a scalable, sustainable pathway to slow CKD progression, reduce CVD risk, and enhance
patient wellbeing across diverse communities.
Date Acceptance
2026-05-06
Citation
BMC Nephrology
ISSN
1471-2369
Publisher
BMC
Journal / Book Title
BMC Nephrology
Copyright Statement
Copyright This paper is embargoed until publication. Once published the Version of Record (VoR) will be available on immediate open access.
License URL
Publication Status
Accepted