Many Upsides for Telemedicine in Chronic Kidney Disease

Pam Harrison

December 07, 2021

Patients with chronic kidney disease (CKD) who receive treatment through video-based telemedicine consults have acceptable, if not comparable, clinical outcomes, generally fewer emergency room (ER) visits and hospitalizations, and improved efficiencies compared with those treated in person, a new review indicates.

Moreover, levels of patient satisfaction with telemedicine are uniformly high, the same study shows.

"The nature of CKD care makes it particularly amenable to virtual care given that relevant history, review of laboratory investigations, and counseling can all be conducted via virtual platforms," Ann Young, MD, PhD, University Health Network, Toronto, Ontario, Canada, said in a statement issued by the American Society of Nephrology.

"The main obstacle of virtual care is the lack of a physical exam [so] finding the appropriate balance between virtual visits and in-person visits is key," she added.

The study was published online December 7 in the Clinical Journal of the American Society of Nephrology (CJASN).

Many Benefits of Telehealth but Beware the Digital Divide

However, senior author, Stephanie Ong, BScPhm, MSc, also of the University Health Network, cautioned that the "digital divide" must be considered when assessing the use of telemedicine.

"[These results] are encouraging but as the latest technologies are streamlined into routine healthcare, the 'digital divide' will become more pronounced, negatively impacting those without access to broadband internet connections, video-capable devices, and those with limited technology literacy," she noted in the ASN statement.

"This is an area that deserves further study," she advised.

And in an accompanying editorial, Susie Lew, MD, and Neal Sikka, MD, both from George Washington University in Washington, DC, agree with Ong that the ability to effectively use a device such as a computer or a smartphone is a challenge for some patients who may have low health literacy.

On the other hand, they acknowledge the many benefits of telehealth. "Patients can benefit from access to their care providers, receive multidisciplinary care, include distant relatives in visits, and have the convenience of staying at home," they write. A visiting nurse could also participate in a home care visit and lab draws can be done in the local community.

"For those that are skeptical about telehealth, we feel that a telehealth visit is better than no visit at all for a new or existing patient," Lew and Sikka observe. "[And we believe that telehealth] has clearly become another useful tool for clinicians and patients attempting to increase touchpoints and simplify care delivery."

And in a Patient View published alongside the review and editorial, patient Julie Glennon, of West Palm Beach, Florida, notes that she has suffered from CKD for over three decades and has been on dialysis multiple times.

"There have been many times in my past that a telehealth visit would have been incredibly helpful," she writes, noting that whenever she went into kidney failure, she was very ill. "Gathering the strength to get dressed and drive to my doctor's office was a monumental feat [during those times]," she admits.

Patients who live in rural communities or those with mobility issues can also benefit from a virtual visit, which can help eliminate the stress of having to get to their physician's office, Glennon explains.

However, "there are times when physically going into a doctor's office or imaging facility is necessary," Glennon acknowledges. Nevertheless, she feels that the quality-of-care she received during a virtual visit was equal to the care she would get in a doctor's office. Virtual visits also save time, money, and energy.

"The high patient satisfaction and acceptable clinical outcomes cited in the CJASN study should encourage continued telehealth support and options," Glennon concludes.

Review Included 24 Studies on Telemedicine vs In-Person Care

Young and colleagues reviewed 24 studies across 10 countries that were published between 1997 and 2020. The studies included seven in patients with CKD, eight in patients on dialysis, and eight in kidney transplant recipients.  

Earlier studies primarily reported on the use of institution-specific technologies linking main hospital sites to more remote healthcare locations.

However, more recent studies connected patients — often from their own homes — to their nephrologists using web-based video-conferencing solutions on personal devices with a microphone and webcam.

Across the seven studies that used video-based telemedicine for patients with CKD, there were few differences in reported clinical outcomes, need and timing of dialysis, change in kidney function or blood pressure, or other biochemical markers relative to in-person care.

Moreover, "ER visits and hospitalizations were no more frequent in the telemedicine group compared to in-person care," the investigators note, "and all studies reported improved efficiency with telemedicine, including a reduction in the waiting time to see a specialist, fewer clinic cancellations, [and a] reduction in travel time and distance traveled."

Over 95% of patients also expressed high levels of satisfaction with telemedicine, most noting that the care received was the same level as the care they got being seen in person.

For patients on dialysis who received video-based care, reported clinical outcomes were similar if not better than they were for patients treated in-person. They had fewer ER visits and hospital admissions than those receiving in-person care.

Also, among kidney transplant recipients, clinical endpoints were equal among patients receiving video-based telemedicine compared with those who received in-person care. Hospital admissions were lower in telemedicine patients in one study, although another study reported higher rates of ER visits and hospitalizations after receiving a video-based transplant follow-up.

The authors also note that virtual appointments seemed to improve access to transplant assessment with shorter wait times after referral.

Again, pretransplant care by telemedicine was felt by patients to be at least as good as the care received during a face-to-face consultation.

Study Limitations

The authors caution that they did not formally appraise the quality of the studies included in their overview and publication biases may have affected the reporting of largely positive outcomes for virtual care.

Nevertheless, as has been widely reported by others, the global pandemic caused by COVID-19 dramatically and rapidly shifted healthcare resources from elective and nonurgent care to care for the most acute and critically ill patients so as to limit the spread of the virus.

"Technology-assisted medicine rapidly became a dominant model for chronic disease management to minimize disruptions in access to care during pandemic restrictions," Young and colleagues observe. In Ontario, video visit use increased by 40% between 2019 and 2020 compared to levels seen in 2019, they note. The main disadvantage of delivering care virtually — the inability to do a physical exam — can be partly mitigated by observing patients closely during the virtual appointment and getting patients to help with the clinical examination themselves, such as employing ambulatory blood pressure monitoring.

The study was funded, in part, by the Ontario Ministry of Health and Long-Term Care. Lewis has reported consulting for TrioMed and Baxter. Young, Ong, Sikka, and Glennon have reported no relevant financial relationships.

CJASN. Published online December 7, 2021. Full text, EditorialPatient View

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