Pilot Study of Pharmacist-Led Patient-Centric Remote Chronic Kidney Disease (CKD) Management System...

Year Submitted: 2025
Published Date: 05 December 2025

Tags: Technology, Tele-Monitoring, Telehealth, Digital Health, Digitalisation, Digital Platforms, Tele-Consultation, Data Management, Data Visualization

About this Content

Aims

1. To leverage on tele-monitoring strategies to empower and activate CKD patients to manage their blood pressure (BP) and CKD-related symptoms.

2. To improve medication adherence and reduce medication discrepancies.

3. To provide timely interventions and tailored pharmacotherapy management to CKD patients in between regular renal clinic visits.

4. To improve patients satisfaction of health care service provided.

Background

Poorly controlled hypertension is strongly associated with CKD progression in a dose-dependent manner. As CKD progresses, BP control becomes more challenging and often requires the combination of multiple classes of anti-hypertensives to optimize BP control. Patients see multiple physicians for the management of multiple comorbidities, thus placing them at risk of receiving contradictory medical advice and increased polypharmacy leading to medication non-compliance. Medication discrepancies are prevalent due to multiple reasons such as fragmented communication among multiple prescribers. This places CKD patients at a higher risk of polypharmacy and medication non-adherence. Regular home-based BP monitoring with timely feedback provided to healthcare team will allow prompt optimisation of BP to retard CKD progression.

Methods

CKD stages 3B and 4 patients with hypertension, were enrolled from Tan Tock Seng Hospital nephrology clinics, between 1 September 2022 to 30 June 2023. Patients completed 6 months of remote BP monitoring using the HD+ program. Surveys on medications and CKD-related symptoms, Domains of Subjective Extent of Nonadherence (Part 1) and patient satisfaction survey (PSS) were administered. Home BP readings were shared with the healthcare team (HCT), comprising pharmacists and nephrologists, via the HD+ dashboard. Teleconsultations were conducted to titrate anti-hypertensives for optimization of BP control and resolve drug related problems (DRPs). Demographics, clinical and laboratory data were collected till the end of follow-up.

Results

A) Baseline Characteristics of Patients

A total of 30 patients were recruited.
- 28 (93.3%) patients completed 6 months of HD+ vital signs monitoring via the mobile application and dashboard.
- 2 patients withdrew due to personal reasons.

14 Stage 3B and 16 Stage 4 CKD patients were recruited.
52% were female, and 47% were male.
Race distribution: 80.0 % Chinese, 13.0 % Malay, 7.0 % Indian
Mean age was 60.7 (+ 12.4) years old.
Diabetes was the main aetiology of CKD in 43.0 % of the patients, followed by 26.0 % due to glomerulonephritis.

B) Blood Pressure, Proteinuria and Estimated Glomerular Filtration Rate (eGFR)
After 6 months, the proportion of patients with BP 130/80 mmHg improved by 33.1 % (13.3 % to 46.4 %), with a significant improvement in systolic BP (153.5 + 25.2 mmHg vs 126.9 + 8.1 mmHg, P 0.01), but not for diastolic BP (78.6 + 9.7 mmHg vs 76.7 + 9.7 mmHg, P = 0.38). Upon exit, there was a significant difference in eGFR (28.9 + 7.9 ml/min/1.73m2 vs 26.6 + 8.0 ml/min/1.73m2, P = 0.01), but not for proteinuria (2.3 + 2.3 g/day vs 1.8 + 1.5 g/day, P= 0.06).

*Target set with reference to TTSH HALT-CKD data.
Non-diabetic/diabetic patients with albuminuria/proteinuria: 130/80mmHg

C) Medication Adherence:
- Percentage of patients with DOSE medication adherence scores upon exit: 21/28= 75%
- Improvement in mean DOSE medication adherence score, compared to baseline: 3.9 to 3.0.
- 36.3% of the patients who were not fully adherent [DOSE Med adherence score 3] had at least 1-point improvement in score from study entry score.

D) Drug Related Problems:
- A total of 49 DRPs were identified and resolved for 28 patients over 6 months.
- 48.9% of the DRPs were due to increase or reduction of doses or frequencies.

E) Adherence to BP Monitoring
Mean percentage of adherence to BP monitoring over 6 months of HD+: 79.9%

Conclusion

Remote BP monitoring using the HD+ Program, with timely interventions from the HCT was safe, feasible and effective to improve BP control in advanced CKD patients. This care model can be expanded to improve outcomes of the CKD population.

Lessons Learnt

a) Patients with white coat hypertension may be discharged early from the program once BP was observed to be stable after 1-3 months of BP monitoring. This allows for more efficient use of manpower and resources.

b) HD+ missed reading alerts on HD+ vital signs monitoring dashboard were useful.
- Provided opportunity to remind patients to adhere to regular BP monitoring.
- Prompted the HCT team to provide timely check ins and allowed delivery of prompt medical advice to patients to seek immediate medical attention to avoid medical emergencies.

Additional Information

The Remote CKD Management System is a proof of concept (POC) project. The project was funded by the TTSH Centre for Allied Health & Pharmacy Excellence (CAPE) Fund. It is a collaboration between the Division of Pharmacy and the Department of Renal Medicine, TTSH.

https://www.synapxe.sg/healthtech/telehealth/chronic-kidney-disease-remote-monitoring

Management of Hypertension in CKD: Beyond the Guidelines. Adv Chronic Kidney Dis. 2015; 22(2): 116-122.

Hypertension, hypertension control, and chronic kidney disease in a Malay population in Singapore. Asia-Pacific J Public Heal. 2011; 23(6): 936-945.

Keywords

Remote Blood Pressure Monitoring, Chronic Kidney Disease

Innovators' Details

Connect with this contributor!

Chuang Shen Hui - shen.hui.chuang@nhghealth.com.sg

Project Attachment

938_TTSH, Synapxe_CAPE FY20_Pilot Study of Pharmacist-Led Patient-Centric Remote Chronic Kidney Disease Management.pdf