The Role of Telenephrology in the Management of CKD

CKD is a common illness across societies, affecting an estimated 13% of the population worldwide (1). The prevalence of CKD is thought to be rising, likely due to a combination of an aging population and increases in comorbid chronic conditions—such as obesity, diabetes, and hypertension—that contribute to its pathogenesis. In the United States, the prevalence of CKD is estimated at nearly 15%, and Medicare spent 114 billion on CKD and ESKD in 2018 (2). Whereas studies indicate that early referral to nephrologists may improve outcomes in CKD, many patients do not see nephrologists until late in the course of their disease. Barriers to early referral include geographic remoteness, with patients living far from available nephrologic care, and difficulties in traveling due to the burden of comorbidities (3–6). Rural patients with CKD have been found to have poorer quality-of-care markers, including timely measurement of urinary albumin excretion and appropriate use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and experience a greater risk for hospitalization and all-cause mortality than urban patients with CKD (5, 6). Telemedicine, a video-based healthcare delivery technology, has the potential to attenuate these disparities and has been used in multiple chronic illnesses, including heart failure, diabetes mellitus, and chronic obstructive pulmonary disease. Although the approach is not appropriate for all encounters, nephrology is, in many ways, particularly suited for telemedicine. The longitudinal follow-up of patients with CKD is heavily dependent on repeat laboratory evaluations and detailed history taking. Although questions regarding changes in weight or edema can be critical, the majority of visits do not center on extensive physical examinations. Similarly, patient appointments for the management of hypertension are typically focused on reviews of BP logs and office measurements of vital signs, whereas encounters for nephrolithiasis involve appraisal of laboratory evaluations and diet history. When conducted in concert with a dedicated nurse or other telemedicine healthcare provider on the patient side, management of these conditions often does not require a face-to-face visit with a physician. There are, however, clear exceptions. Patients with rapidly progressive renal disease (and in particular those who would benefit from evaluation of urine microscopy) should always be seen for an in-person visit. In addition, many providers prefer (and often require) that patients be seen face to face for their initial consult visit. Whereas the potential for the application of telemedicine to the care of renal transplant patients and those patients with ESKD on both peritoneal and hemodialysis is beyond the scope of this review, adaptation of telemedicine to these venues is critical and has been appraised elsewhere (7, 8). Telemedicine may take a variety of forms. Using website-based platforms and applications, primary care physicians may be remotely connected to specialists via videoconferencing for consultation, nephrologists at specialized care facilities may remotely see patients in primary care offices, website-based monitoring devices can be used to collect physiologic data (such as BP and weight), and patients may even be seen for a virtual visit directly from their homes (9). Initiatives such as the Specialty Care Access Network–Extension for Community Healthcare Outcomes allow nephrologists and other specialists to provide educational sessions for primary care providers (PCPs) in rural or distant locations (10). Interest in applying technology to the care of patients with CKD is escalating commercially and clinically, with a recent review finding at least 28 distinct smartphone applications targeting patients with CKD (11). Depending of the specific modality under consideration, multiple factors may affect the logistic feasibility of establishing a telenephrology program for the management of CKD, including equipment cost and availability, local regulations, and practice-specific information technology resources. Regardless of the means by which patients are seen, Health Insurance Portability and Accountability Act of 1996 compliance regulations require implementation of appropriate safeguards for patients’ protected health information. At a minimum, such protections entail encrypted internet access, assurances video transmissions are not stored unless specifically and pre-emptively requested by the provider, authentication- and password-protected access control, and the provider potentially signing a business associate agreement. Within the broader context of telemedicine, telehealth refers to the direct provision of remote healthcare. This can involve synchronous encounters (interactive videoconferencing or phone consults) and asynchronous systems, such as website-based electronic consultations/advice platforms and text messaging. Clinical video telehealth (CVT) is the most common form of telehealth and frequently takes the form of specialist physicians seeing patients located in other offices for real-time, interactive, video teleconferencing. In our experience, this modality is perhaps the most readily adoptable introduction to telehealth. For patients, although they will not be seen face to face by their primary provider, the act of going to a medical office and interacting with staff can be familiar and comforting and help allay concerns that new technology will disrupt the doctor-patient relationship. From a provider’s perspective, initiating telenephrology via an office-based model provides reassurance that patients will still be seen in an orderly and timely manner while surrounded by medical support staff. A videoconference monitor is kept in the physician’s office and a second monitor, variably enhanced with accompaniments—such as a high-resolution mobile digital video camera, stethoscope, and ultrasound probe—is located remotely in the patient examination room. A health technician trained in telenephrology is located with the patient and is available to measure vital signs and assist the physician, as needed, with remote physical examination. In the United States, the Veterans Health Administration (VHA) has been one of the earliest and most widespread adopters of telehealth and CVT. The VHA is the largest integrated healthcare system in the United States, providing care at 1255 healthcare facilities, including 170 Veterans Affairs (VA) Medical Centers and 1074 outpatient sites to >9 million veterans (12). Roughly 36% of VA patients reside in rural communities (as compared with 19% of the overall US population) and suffer from high rates of comorbidities that make travel difficult. The nationally integrated Computerized Patient Record System allows for seamless access to remote records and, although physicians need to be credentialed at both patient and provider sites, they can see patients in multiple states without requiring separate state medical licenses by working within the VA system. The VHA is thus uniquely requiring of, and strategically positioned to provide, CVT. In 2016, 12% of veterans received elements of their care via telehealth, spanning >50 specialty areas of care. More than 307, 000 veterans used CVT, with >150, 000 using Home Telehealth (13). One of the pioneering sites for telenephrology has been the James J. Peters VA Medical Center (JJPVAMC) in the Bronx, New York, where Tan et al. (14) studied the effect of telenephrology on the adherence to appointments by patients with CKD along with its effect on clinical outcomes. The JJPVAMC serves as the primary referral center for the Hudson Valley VA Medical Center but is located 65 miles away. In response to a “no show” or cancellation rate of 53% for nephrology referrals, JJPVAMC instituted a CVT program in 2011. Over the subsequent 3 years, 112 patients from Hudson Valley were seen via CVT telenephrology, with a reduction of the no-show or cancellation rate to 28%. When compared with 116 patients seen for face-to-face consults and follow-up at JJPVAMC, there was no difference over 2 years follow-up for a composite end point of death, ESKD, or doubling of serum creatinine (P=0. 96). In addition to increased patient adherence, significant financial savings were realized because travel distance for patients was reduced by 50% with patients not having to commute to the Bronx. Whereas the study by Tan et al. required patients to come to the Hudson Valley VA Medical Center to connect to JJPVAMC via CVT, Ishani et al. (15) conducted a randomized, prospective trial testing whether patient-to-provider, home-based telemedicine improved clinical outcomes in CKD as compared with standard care. A total of 561 patients from the Minneapolis VA Health Care System were identified with an eGFR of 98% of those being seen expressing a preference to continue to be seen in this manner once enrolled. There were few differences between the groups in regards to demographics or comorbidities, although the TC groups exhibited a higher prevalence of diabetes, diabetic nephropathy, and arthritis. Compared with controls, patients receiving care via TC demonstrated increased adherence to appointments and a greater likelihood of visit accompaniment by a family member or caregiver. Over the course of the study, patients seen via TC had a statistically significant reduction in incident RRT (2. 0 versus 3. 5 cases per 100 patient-years) and overall mortality (4. 5 versus 5. 3 cases per 100 patient-years). The number of hospital admissions per patient trended lower in the TC group, 1. 63 versus 2. 25, but did not reach statistical significance. Patients seen via TC lived an average of a 417-km round trip from the referral hospital and thus benefited from significant reductions in travel time and cost by being seen remotely from local facilities. In The Netherlands, Scherpbier-de Haan et al. (18) studied website-based nephrology consultations between PCPs and hospital-based nephrologists. After receiving a consult question containing abstracted clinical and laboratory data, the nephrologists could either reply to the question, request additional data, or recommend that the patient be sent for an in-person evaluation. A total of 122 consults were placed, with PCPs identifying 43 (35%) of them as patients that would have been referred for consultation absent the website-based option. Critically, after evaluating the consultation, nephrologists determined that only seven of the 43 (16%) would actually have required such an evaluation. In addition, of the 79 patients where PCPs would not have otherwise placed a consult, nephrologists determined that in ten of the 79 (13%), such a referral would have been appropriate. These data suggest that even when a face-to-face nephrology consult is indicated, prior screening via telemedicine can more accurately triage patients appropriately. A second, much larger study on approximately 3000 patients in The Netherlands did not find any difference in referral rates for face-to-face nephrology consults when general practitioners were randomized to first use or not use a new electronic consult system, but overall referral rates were much lower than anticipated and the trial may have been underpowered (19). The utility and challenges of telenephrology have also been explored in Jordan, France, and Chile (20–22). Over the past 6 months, the burgeoning field of telehealth has undergone the cataclysmic challenge of adapting, on the fly, to unprecedented disruptions in world healthcare systems engendered by the coronavirus disease 2019 (COVID-19) pandemic. An extraordinary number of providers were forced to adopt telehealth almost overnight, with a mandate to provide high-quality and safe care during a period of extreme uncertainty and upheaval. In light of the temporary closing of many offices, the model of delivering telehealth to the home via remote provider visits has experienced a rapid increase in utilization, and data on outcomes associated with it are under intense study, although few results are yet available. Chen et al. (23) developed a cohort in China of 1164 patients with CKD who had received a kidney biopsy between 2017 and 2019. At the beginning of the COVID-19 pandemic, 82% were being seen for regular follow-up, and 45% were being treated with immunosuppression. Face-to-face clinic visits were interrupted in 836 (72%) patients. As a result, 60%, 67%, and 27% of patients reported difficulties in laboratory examinations, medicine adjustments, and medicine purchases, respectively. In an attempt to maintain follow-up, 255 patients (22%) used telemedicine, including 122 patients (10%) using video telehealth visits, 62 (5%) using instant messaging tools, 48 (4%) using telephone consultation, and 23 (2%) using email. Approximately 80% of telemedicine users were generally satisfied with the experiences. In contrast to much pre-COVID-19 data, the utilization of telemedicine was not statistically associated with the patients’ location (urban versus rural), nor was it affected by sex, age, or education. 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