A FEASIBILITY STUDY OF REMOTE MONITORING OF CAPD PATIENT’S BLOOD PRESSURE AND BLOOD GLUCOSE MEASUREMENTS VIA THE INTERNET. G. Pylypchuk, P. Jacobson, C. McAllister University of Saskatchewan, St. Paul’s Hospital, Saskatoon, Saskatchewan. Regina, Saskatchewan The purpose of this study was to determine the feasibility of remotely monitoring blood pressure (BP) and glucose measurements in a cohort of diabetic patients receiving continuous ambulatory peritoneal dialysis (CAPD).

1. A Feasibility Study of Remote
Monitoring of CAPD Patient’s
Blood Pressure and Blood
Glucose Measurements Via the
Internet
G. Pylypchuck, P. Jacobson, C. McAllister
University of Saskatchewan, St Paul’s Hospital, Department of Nephrology,
ChroniCare

2. Abstract
A FEASIBILITY STUDY OF REMOTE MONITORING OF CAPD PATIENT’S BLOOD PRESSURE AND
BLOOD GLUCOSE MEASUREMENTS VIA THE INTERNET. G. Pylypchuk, P. Jacobson, C. McAllister
University of Saskatchewan, St. Paul’s Hospital, Saskatoon, Saskatchewan. ChroniCare, Regina, Saskatchewan
The purpose of this study was to determine the feasibility of remotely monitoring blood pressure (BP) and
glucose measurements in a cohort of diabetic patients receiving continuous ambulatory peritoneal
dialysis (CAPD). This can be achieved using BP monitors, glucometers and a ChroniCare appliance
(HealthGate) to transmit the data to a secure internet server over a home telephone access. Tight
control of BP and blood sugar has been proven to improve both mortality and renal function in diabetic
patients with end stage renal disease. Physician access to real time BP and glucose measurements
via the internet may allow for better control of these clinical parameters over time. Seventeen diabetic
patients currently monitored by St. Paul’s Hospital dialysis unit were selected to trial this equipment.
After three initial hospital visits for baseline measurement of BP, glucose, hemoglobin A1c and
equipment education, subjects were instructed to continue monitoring their BP and glucose levels at
the same intervals conducted at home. Subjects were instructed to download their data via telephone
line access on a weekly basis. Patients were provided with satisfaction questionnaires to be
completed at the end of the trial. The BP and glucose data could then be monitored in real time via
internet access from any location. Subjects began the study with a mean BP of 147/72 +/- 24/18
mmHg, and a mean Hemoglobin A1c level of 7.6 ± 1.2%. Baseline BP, glucose and Hemoglobin A1c
levels were compared to values at the end of the study. The mean number of values downloaded per
week was 11.9 ± 11.2 with a range between 2 and 48. Of 17 subjects who began the trial, 15 have
been successfully transmitting data on a regular basis. One subject refused to use the equipment after
completing the initial visits and education and two have been experiencing technical difficulties. It was
possible to view the continuous trend of these vital signs in real time. Data was immediately available
using internet access and can be viewed in both tabular and graphical formats. Limits may be set for
each parameter to notify the physicians when dangerous values are recorded. This data may be used
in the future studies to make meaningful changes to the patients’ medication regimens. CAPD
patients only come to the hospital for follow-up every 2-3 months and it is hypothesized that this tool
will allow more rapid changes in treatment effects and patient compliance. Future studies are planned
to determine the long term effectiveness of this tool on BP and glucose control in this patient
population.

3. Introduction
Many patients treated with continuous ambulatory peritoneal dialysis (CAPD) live in
locations remote from their active dialysis center. These patients are seen by
their nephrologist on average once every three months at the dialysis center.
Apart from these visits, routine management of both dialysis and their co morbid
conditions depends upon decisions of the patient and their family physician.
Many patients live long distances from the dialysis center making more frequent
follow up both difficult and expensive.
Two of the most common co morbidities affecting peritoneal dialysis patients are
diabetes and hypertension. Many studies have proven that tight control of blood
glucose and blood pressure improve both mortality and renal function in diabetic
patients with end stage renal disease. Current practice leaves routine monitoring
of these critical parameters up to the patient. Records of self assessment are
kept by each patient and are evaluated at each follow up visit with the family
physician or nephrologist. Subsequent diagnostic decisions are based upon the
patients self reporting of blood sugar and blood pressure measurements take at
home.

4. New technology may make monitoring of both blood pressure and blood glucose
easier and more effective for this patient population. ChroniCare has developed
a telephone based appliance (HealthGate) which incorporates both patient
used blood pressure machines and glucometers. Blood pressure and glucose
are each measured in their routine fashion with a blood pressure cuff and
glucometer. After measurement, the data is transmitted to a secure server via
telephone access using the HealthGate appliance. Both the patient and their
physician once supplied with the appropriate authentication rights can then
access the data over the internet to assist with medical management. The data
can be accessed in real time. All data is conveniently displayed on a web site
www.chronicare.ca in both graphical at numeric formats. The web site is
designed with algorithms to provide mean and standard deviation data of three
different time frames, the most recent 2 weeks, 4 weeks, as well as all
accumulated data. Acceptable limits are set for each parameter measured.
The number of data points that fall outside of the selected range are also
identified. Use of this technology has not been validated in CAPD patients
living in remote locations from their dialysis center.
The purpose of this study was to determine the feasibility of using this technology in
a cohort of diabetic CAPD patients.

5. Methods
Seventeen subjects were recruited from the population of diabetic CAPD patients in
Saskatoon, Saskatchewan. All patients were recruited in the fall of 2004. Two
of the patients subsequently dropped out of the study. Patients were provided
with a blood pressure monitor and a glucometer together with an telephone
compatible hookup (HealthGate appliance) for downloading their
measurements. Each patient was scheduled for an initial training visit at the
Saskatoon peritoneal dialysis clinic. On the initial visit, baseline demographic
data, blood pressure, glucose and hemoglobin A1c measurements were taken.
They were also provided with their HealthGate appliance and instructed in its
use. Regular telephone technical support was provided to each subject on an
as needed basis to assist with equipment difficulty.
Subjects were instructed to download their data on a weekly basis. They were not
instructed how often to measure their vital signs, this was to be done as per
their normal practice at home. Blood pressure, glucose and heart rate data
were monitored on a regular basis by the CAPD clinic staff via the ChroniCare
website. There were however no clinical decisions made based on the
observed data. After a minimum of four weeks of equipment use, a telephone
questionnaire was conducted to assess the quality of the equipment and the
ease of use by the subjects.

6. Results
Data was collected and transmitted to the internet using the HealthGate appliance
(Figure 1). The downloaded vital sings can be viewed via the internet in both
tabular and graphical formats (Figure 2, Table 2). All subjects included in the
data set have been transmitting data for a minimum of four weeks. Subject
demographic information is presented in Table 1. All subjects were diabetic
patients with end stage renal disease on CAPD.
Over four weeks, the mean blood glucose was 10.4 ± 3.4 mmol/L and the mean
blood pressure was 135.8/73.7 ± 21.2/11.7 mmHg. The mean number of
downloads per subject over four weeks was 35.5 ± 26.4 times for glucose and 32
± 37.4 times for blood pressure.
Results from the patient satisfaction questionnaire are presented in table 3. Overall
ease of use was found to be between good and excellent. The quality of all
three parts of the workstation were also rated between good and excellent. The
patients found the data very easy to transmit using their telephone access. The
quality of both the glucometer and the blood pressure cuff were scored between
good and excellent. The overall satisfaction of the workstation features and
performance were rated between good and excellent.

7. Discussion
The results of this study have demonstrated that it is possible to monitor and
track vital signs in CAPD patients remotely. Patients with access to a
telephone can easily transmit data to the internet for immediate monitoring.
Data can be viewed in real time on the internet. The data can be organized
so that trends can be viewed over time. Negative trends and dangerous
readings can be easily identified and acted upon if necessary.
In this population there was a large variance in the number of data points
transmitted by each patient. It would be ideal for diabetic patients on CAPD
to monitor both their blood glucose and blood pressure levels on frequent
intervals as prescribed by their physicians. Patients and their physicians
could use this data to make meaningful changes in their medication
regimens. A future study is planned to determine the effect of using this
technology together with physician based suggestions for medical
intervention to determine the overall effect on long term control of blood
sugar and blood pressure.

8. As previously stated, glucose and blood pressure control are very important in
diabetic patients on CAPD. This technology allows patients who would
normally have infrequent direct physician contact to be closely monitored at
much more regular intervals. Though not proven by this study, it is likely
that the data transmitted to the internet is much more accurate than the
current system of patient self reporting. Hand written records of glucose
and blood pressure are prone to multiple errors which should be eliminated
by this new technology. Introduction of this technology may introduce new
technological errors into medical data collection, but we feel that these
technological errors will be much less significant than those of hand written
records. This however, has not been clinically proven with this technology.
Further study is again required to determine this effect.
As noted from the patient satisfaction questionnaire, this system of collecting
blood pressure and blood glucose has been very easy to use in this study
cohort. Vital sign measurement was not different than the patients were
previously used to and the added step of downloading the data via
telephone access was easy to use. Patients overall were very pleased with
the quality and ease of use of the equipment. The data presented on the
ChroniCare web site is very easy to monitor and is presented in a
meaningful format to base clinical decisions upon. This technology should
add very useful data to the medical management of diabetic CAPD patients.
With effective use this device should add significantly to gain better control
of both blood pressure and blood glucose in these patients.

9. Table 1. Baseline demographic data.
Age (years) 60.9 ± 11.0
Blood Pressure 147/72 ± 24/18
(mmHg)
Hgb A1c (%) 7.6 ± 1.2
Sex Male (10) Female (5)

10. Table 2. Example of numeric data from www.chronicare.ca
Period n Min. Max. Ave. Stdev.
Glucose 2 weeks 75 3.17 15.00 7.81 3.47
4 weeks 101 3.17 15.00 7.95 3.51
All 419 2.94 18.11 7.92 3.14
Systolic 2 weeks 147 75 152 121.24 12.77
4 weeks 147 75 152 121.24 12.77
All 266 75 153 120.64 12.71
Diastolic 2 weeks 147 56 104 71.61 5.87
4 weeks 147 56 104 71.61 5.87
All 266 56 121 72.13 6.63
Pulse 2 weeks 147 58 111 95.80 7.45
4 weeks 147 58 111 95.80 7.45
All 266 58 112 96.36 7.81
Period High Reading Low Reading
Glucose 2 weeks 0 above 20.00 13 below 4.00
4 weeks 0 above 20.00 14 below 4.00
All 0 above 20.00 39 below 4.00
Systolic 2 weeks 0 above 180 6 below 100
4 weeks 0 above 180 6 below 100
All 0 above 180 12 below 100
Diastolic 2 weeks 1 above 100 0 below 50
4 weeks 1 above 100 0 below 50
All 3 above 100 0 below 50

11. Table 3. Patient Feedback Questionnaire results
• Device Mean Score
– Easy to use 4.8 ± 0.4
– Construction 4.5 ± 0.7
– Easy to read Display 4.5 ± 0.7
– Reliability 4.2 ± 1.0
• Function
– Installation 4.4 ± 0.7
– Sending data 4.4 ± 0.5
– Reading the Display 4.3 ± 0.7
– Glucometer use 4.6 ± 0.5
– BP cuff use 4.7 ± 0.5
– Confirmation of
Successful transmission 4.3 ± 0.6
• Overall
– Device Features 4.7 ± 0.5
– Performance 4.2 ± 0.6

12. Figure 1. The ChroniCare system. Pictured are: glucometer, blood pressure cuff, and
Healthgate appliance for data transmission. (telephone optional)

14. Figure 2. Graphical representation of glucose data over four weeks.

15. Questions?
Colin McAllister PEng, PMP, MBA
Managing Principal – Perspect Managing Consulting
colinm@perspect.ca
www.perspect.ca