Integrating a Smartphone-Based Self-Management System into Usual Care of Advanced CKD

Abstract

Background and objectives: Patient self-management has been shown to improve health outcomes. We developed a smartphone-based system to boost self-care by patients with CKD and integrated its use into usual CKD care. We determined its acceptability and examined changes in several clinical parameters.

Design, setting, participants, & measurements: We recruited patients with stage 4 or 5 CKD attending outpatient renal clinics who responded to a general information newsletter about this 6-month proof-of-principle study. The smartphone application targeted four behavioral elements: monitoring BP, medication management, symptom assessment, and tracking laboratory results. Prebuilt customizable algorithms provided real-time personalized patient feedback and alerts to providers when predefined treatment thresholds were crossed or critical changes occurred. Those who died or started RRT within the first 2 months were replaced. Only participants followed for 6 months after recruitment were included in assessing changes in clinical measures.

Results: In total, 47 patients (26 men; mean age =59 years old; 33% were ≥65 years old) were enrolled; 60% had never used a smartphone. User adherence was high (>80% performed ≥80% of recommended assessments) and sustained. The mean reductions in home BP readings between baseline and exit were statistically significant (systolic BP, -3.4 mmHg; 95% confidence interval, -5.0 to -1.8 and diastolic BP, -2.1 mmHg; 95% confidence interval, -2.9 to -1.2); 27% with normal clinic BP readings had newly identified masked hypertension. One hundred twenty-seven medication discrepancies were identified; 59% were medication errors that required an intervention to prevent harm. In exit interviews, patients indicated feeling more confident and in control of their condition; clinicians perceived patients to be better informed and more engaged.

Conclusions: Integrating a smartphone-based self-management system into usual care of patients with advanced CKD proved feasible and acceptable, and it appeared to be clinically useful. The results provide a strong rationale for a randomized, controlled trial.

Keywords: Humans; Renal Insufficiency, Chronic; Self Care; ambulatory care; blood pressure; chronic kidney disease; hypertension; self-management; smartphone; telemedicine.

Figure 1.

Flow diagram of patient recruitment and involvement in study. *Three patients had active medical problems and were advised to discontinue self-management activities to allow more intense inpatient and outpatient medical management.

Figure 2.

Adherence rates per month (symptoms, medications, and BP assessments using the mobile application).

Figure 3.

Average unique views per application feature by day over the course of the study.

Figure 4.

Flow diagram illustrating the sequence of events that occurred after patients completed their symptom assessments. *BP, weight, blood sugar, or blood work; **specialist, family physician, or emergency room.