Mixed Benefits with Telehealth for Kidney Care in the Elderly


Convenient, but plagued by lack of social connection, technical issues and disparities in access

Older patients with chronic kidney disease (CRF) expressed mixed feelings about telehealth visits, as did their care partners and kidney clinicians, according to a survey-based study.

Qualitative study based on semi-structured interviews revealed concerns about clinical efficacy, limitations of virtual physical exams, and potentially growing disparities in access, reported Keren Ladin, PhD, MSc, Tufts University in Medford, Massachusetts, and co-authors of JAMA network open.

Based on their thematic analysis, they came up with four “general themes” drawn from the research:

  • Uneven quality of care.
  • Patient experience and engagement.
  • Loss of connection and mistrust, like challenges discussing bad news.
  • Disparities in access.

“Our results… suggest that telehealth may better complement rather than supplant in-person visits for older and chronically ill patients,” Ladin’s group said of the study, which is part of the DART trial in Classes. DART recruited 400 non-dialysis fluent English patients (over 70 years of age) with CRF, with estimated glomerular filtration rate 2, who received care at nephrology clinics in Boston, Chicago, San Diego and Portland, Maine.

For the present study, the authors used a subsample of participants who were followed for 12 months. These patients participated in semi-structured telephone interviews carried out from August to December 2020. Ladin’s group conducted 60 interviews, half of which were with patients.

More than two-thirds of the patients were female, while almost half were aged 75 to 79 and almost half were Caucasian. In addition, almost three-quarters of caregivers were women, most between the ages of 50 and 79, and almost two-thirds were Caucasian. Of the participating clinicians, more than half were women and> 80% were nephrologists.

Participants were asked to describe their telehealth experiences, including factors that helped or hindered their participation in the visit, the quality of care provided and their satisfaction with it. The average duration of the interviews was 30 minutes.

The authors reported that patients reported concerns that their home diagnostic equipment was not as accurate as professional equipment at their clinician’s site. They also found that patients complained of a loss of social bond between patient and clinician, with the latter struggling to understand the patient’s emotions and offering virtually enough empathy.

Besides, “[m]Most clinicians viewed telehealth as compromising the quality of care due to an inability to perform physical exams and laboratory tests, including inaccurate edema and blood pressure measurements, ”wrote Ladin et al. -authors.

Clinicians also reported poorer telehealth experiences with older patients, patients of lower socioeconomic status, patients with limited health knowledge or hearing loss, and non-English speaking patients.

The authors noted that patients of color were less satisfied with telehealth because they were “more concerned about losing access to in-person visits, skeptical that clinicians could understand their main complaints.”

As for care partners, they reported that telehealth allowed them to participate in the appointment, especially when facilities had restrictions on in-person visits.

But clinicians and patients have noted technical challenges, such as spotty internet connectivity and application issues, as limitations of telehealth.

However, all of the participants “described telehealth as more convenient, less expensive, and more effective for patients than clinic visits,” the authors noted. They also pointed out that “[c]clinicians were generally dissatisfied with telehealth, while most patients expressed a more balanced outlook, appreciating its convenience.

Limitations of the study included recall bias, under-representation of Spanish and non-English speakers, and modest representation from one of the sites.

Ladin’s group concluded that the best way to address these issues would be “to alternate telehealth and in-person visits for elderly chronically ill patients, as outlined in the Home Dialysis Telehealth Policy in the Budget Act. bipartite 2018 ”. In a guest commentary accompanying the study, Devika Nair, MD, MSCI, of the Vanderbilt Center for Health Services Research in Nashville, TN, noted that in deconstructing the telehealth encounter, the authors addressed an under-researched but timely aspect of Person-Centered Renal Failure Care: Developing systems-level solutions to improve patient-clinician communication and remote care delivery.

The research can be seen as a direct response to a June 2021 study JAMA network open editorial by Sharon K. Inouye, MD, MPH, Marcus Institute for Aging Research / Hebrew SeniorLife in Boston, and co-authors calling for the creation of an “evidence base for people-centered strategies to ‘eliminate age-related inequalities in health outcomes,’ explained Nair.

The Inouye group noted that the pandemic “has put additional stress on society and healthcare delivery systems around the world, exposing deep-rooted structural ageism and leading to high rates of morbidity and mortality. among the elderly. Age-related inequalities in access, delivery and outcomes of health care have revealed how unprepared health systems are to meet the needs of a rapidly aging society.

Lack of preparation aside, the global nephrology community has certainly been enthusiastic about using telehealth for remote patient monitoring (RPM). For example, in 2021, the American Society of Nephrology’s Covid-19 home dialysis subcommittee predicted what telehealth would look like for kidney dialysis after the pandemic.

They noted that “[t]Telehealth during the public health emergency changed the practice of health care, with the post-Covid-19 world unlikely to resemble the previous era, “including greater reliance on RPM as” the platforms Current RPM forms of home dialysis allow direct transmission of both biometric information… to providers and to the home HD [hemodialysis] and automated PD [peritoneal dialysis] treatment parameters… RPM avoids the need for paper-based dialysis treatment logs and provides information in key areas of dialysis access, blood pressure, target weight and ultrafiltration management while identifying treatment adherence issues and, in some cases, allowing remote prescription changes.

Researchers in China described “general operational considerations in managing PD” and noted that “[h]Health workers should communicate with patients at a set frequency, varying from daily to monthly, depending on the condition of each patient. For example, if the patient suffers from a serious complication, such as peritonitis or volume overload, communication with the patient should be carried out daily, while the communication frequency will be lower for patients in a stable condition. Patients whose condition worsens should be hospitalized for further management. Therefore, only patients requiring medically essential attention can attend a healthcare facility. RPM ensures that the most serious cases are identified and dealt with efficiently and in a timely manner. As a result, this guarantees an extended stay at home for the majority of patients. ”

And nephrologists in India pointed out that “current models of healthcare delivery for patients with CRF, especially those with advanced stages of the disease, are hospital-centric, with nephrologists being the primary providers of care. care. It has been clear for some time, however, that much of the assessment and care in the early stages of the disease can be effectively delivered in the community by teams of non-physician health workers. But they acknowledged that “the deficiencies and inequalities in kidney care around the world have been widely documented,” as the Global Kidney Health Atlas project reports.

However, not all kidney care specialists are sold entirely on RPM. German researchers found that, among patients with urologic cancer, the “rapid implementation of telehealth” was welcomed during the pandemic, but that there was also a “clear red line regarding changes in relationships. existing patient-physician ”.

“The long-term implementation of adapted services is less favored. We infer that the patient-physician relationship is crucial for cancer patients and must be weighed against social distancing measures to forge future management, ”they wrote in European urology To concentrate.

  1. In older people with chronic kidney disease (CRF), the downsides of telehealth included quality of care issues due to limited physical examination and lab tests and loss of social connection, as well as poor social connection. technical problems and disparities in access to technology and the Internet, according to a survey-based study.

  2. Respondents recognized the convenience of telehealth and greater engagement of care partners, but more resources are needed to support many older people with CRF, especially those with limited English proficiency, hearing loss and limited access to the Internet and technology.

Shalmali Pal, Contributing Writer, BreakingMED â„¢

The study was funded by the Patient-Centered Outcomes Research Institute (PCORI).

Ladin signaled support from the Greenwall Foundation. The co-authors reported relationships with Akebia Therapeutics, Kyowa Kirin, LifeSci Capital, Tricida, and Janssen.

Nair reported the support from the Agency for Research and Quality in Health Care / PCORI.

Cat ID: 127

Topic ID: 81 127 730 127 192925

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