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The Use of Home Electronic Blood Pressure Monitoring (HeBPM) in Renal Transplant Recipients

The Use of Home Electronic Blood Pressure Monitoring (HeBPM) in Renal Transplant Recipients. Daniel R. Migliozzi, PharmD Clinical Pharmacist, Renal Transplantation Rhode Island Hospital . Disclosure. Daniel Migliozzi: nothing to disclose . Pharmacist Objectives.

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The Use of Home Electronic Blood Pressure Monitoring (HeBPM) in Renal Transplant Recipients

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  1. The Use of Home Electronic Blood Pressure Monitoring (HeBPM) in Renal Transplant Recipients Daniel R. Migliozzi, PharmD Clinical Pharmacist, Renal Transplantation Rhode Island Hospital

  2. Disclosure • Daniel Migliozzi: nothing to disclose

  3. Pharmacist Objectives • Discuss the clinical impact of hypertension on transplant related outcomes • Associate the impact of HeBPM on improved blood pressure management • Identify current progress in the HeBPM program at RIH and discuss a notable patient case

  4. Technician Objectives • Identify methods for pharmacy technician involvement in a HeBPM program • Discuss the role of the pharmacy technician for improving patient adherence with HeBPM

  5. Post-transplant Hypertension • 70-90% of renal transplant patients:1-3 • Have arterial hypertension • Require antihypertensive therapy • Few renal transplant recipients achieve optimal BP targets one year after transplant4,5 • Miller LW. Cardiovascular toxicity of immunosuppressive agents. Am J Transplant 2002; 2: 807. • Midvtvedt K, Hartmann A. Hypertension after kidney transplantation: are treatment guidelines emerging? Nephrol Dial Transplant 2002; 17: 1166. • Schwenger V, Zeier M, Ritz E. Hypertension after renal transplantation. Ann Transplant 2001; 6: 25. • Paoletti E et al. Transplantation 2009; 87: 1864-1869 • Mange KC et al. JAMA 2000; 283: 633.

  6. Blood Pressure and Graft Survival • An  in SBP by 5 mm Hg1 • Increases the risk of graft loss • Decreases patient survival • A in SBP even in patients with HTN for years after kidney transplant is associated with improved patient and graft survival2 • Premasathian NC et al. J Hum Hypertension 2004; 18: 871-877 • OpelzG et al. American Journal Transplant. 2005; 5: 2725-2731

  7. Methods for Blood Pressure Monitoring • Office (OBPM) • Home (HBPM) • Self measurement • Hand written logs • Electronic record (HeBPM) • 24 hour ambulatory measurement (ABPM)

  8. Benefits of HeBPM Technology • Minimizes reporting bias • Assessment of BP variability – graphs • Assessment of evening blood pressure • Multiple measurements and real time data • Provides preliminary assessment of adherence • Clinical decision support tool - averages LovibondK et al. Lancet 2011; 378: 1219-1230

  9. HeBPM and MTM • Hypertension management protocols in use by community pharmacies and primary care clinics • Blood pressure data obtained from • Home monitoring (computer uploads) • Automated blood pressure kiosk Zillich AJ et al. J Gen Intern Med 2005; 20: 1091-1096

  10. Benefits of MTM in Renal Transplantation • Transplant patients require multiple medications •  complexity of medication regimen •  risk for non-adherence = uncontrolled BP •  the potential for medication-related problems (MRPS) • Renal transplant patients with MRPs are more likely to have 30 day readmissions • (5% vs. 16%, p = 0.018)1 Taber DJ et al. Pharmacotherapy 2012; 32: 1053–1060

  11. The HeBPM Program at RIH • Total number of patients: 100 • Enrollment • All new transplant recipients • Patients well out from transplant • Close monitoring required • Referred by MD • Program focused on the following elements • Improving blood pressure control • Medication adherence • Reducing medication related problems • Patient involvement in their own care

  12. e-Blood Pressure Patient Portal

  13. e-Blood Pressure Pharmacist Portal

  14. e-Blood Pressure Kiosk

  15. Role of the Pharmacy Technician • Completion of enrollment process • Instruction on kiosk operation • Assist with promoting adherence via follow-up telephone calls • Coordinate data to other providers involved in patients care

  16. Patient Case • HPI: 74-year-old M s/p living donor renal transplant 7-1/2 years ago. Post-transplant course unremarkable but noted to have elevated BP during office visit. Enrolled in HeBPM program on: 10/23/2012. • BP meds: • Lisinopril 20 mg twice daily • Metoprolol 50 mg twice daily

  17. Home Blood Pressure Readings       

  18. Average BP Decline Since Enrollment

  19. RIH HeBPM Summary • Useful tool to supplementOBPM and improve HTN management • Program fosters patient involvement • MTM piece assists w/ resolving MRPs &  adherence • Technology adds convenience for patient & provider • Programs like this provide opportunity and career growth for pharmacy technicians • Area for future research

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