Patients' Experiences and Perspectives of Telehealth Coaching with a Dietitian to Improve Diet Quality in Chronic Kidney Disease: A Qualitative Interview Study

Telemedicine in Advanced Kidney Disease and Kidney Transplant: A Qualitative Meta-Analysis of Studies of Patient Perspectives

Rationale & Objective

While the use of telemedicine has increased dramatically across disciplines, patient perspectives on telemedicine related to chronic kidney disease are not well understood. We systematically reviewed qualitative studies on patients with chronic kidney disease as well as those with kidney transplant to better understand these patients' perspectives related to telemedicine.

Study Design

Qualitative meta-analysis.

Setting & Participants

Pre-dialysis chronic kidney disease and kidney transplant patients that used telemedicine.

Selection Criteria for Studies

English language studies published in the year 2000 and beyond that investigated patient perspectives in a qualitative manner. Works that were not qualitative or did not focus on provider-patient interactive modes of telemedicine were excluded.

Data Extraction

375 articles were pulled from PubMed, Embase, and Academic Science Premier. After filtering, 8 final articles were selected. These articles were critically appraised for quality and were used in the final analysis.

Analytical Approach

We used a grounded theory approach to develop a codebook to systematically review each of the selected articles through a qualitative meta-analysis of the included literature.

Results

Telemedicine was seen by patients to have notable strengths as well as weaknesses. These characteristics can be organized into 4 primary themes (autonomy, logistics, privacy/confidentiality, and trust). Within each primary theme, we identified subthemes. Universally, all articles included the subtheme "fewer trips to the health care facility" as a beneficial factor of telemedicine within the primary theme "logistics." A majority (6 of 8) of the articles included positive patient perspectives on the primary theme "autonomy" in terms of telemedicine promoting the subtheme of "engagement." Patients' views on telemedicine were mixed regarding the primary themes of "privacy/confidentiality" and "trust" related to telemedicine.

Limitations

Lack of provider perspectives, non-English studies, and studies published before the year 2000. Articles published after the start of data extraction were also not included.

Conclusions

Telemedicine should continue to be offered to patients with chronic kidney disease and kidney transplant patients to facilitate access. Additional research should focus on ways to decrease negative factors experienced by some patients such as difficulty using the technology.

Incorporating digital platforms into nutritional care in chronic kidney disease

Digital health is increasingly recognized for its value to enhance patient care and clinical care processes. People with chronic kidney disease often find dietary self-management challenging. There is promising evidence that digital health interventions can support people with chronic kidney disease to self-manage their diet, by providing more frequent access to nutritional information and dietitians and by facilitating regular monitoring and feedback. There is some emerging evidence of the impact of digital interventions in chronic kidney disease; however, more research is needed to provide meaningful interpretation of how digital interventions can enhance current practice. Importantly, a number of factors need to be considered when designing, developing, implementing, and evaluating the impact of digital interventions. Consideration of the nutrition service and patients' needs, motivation and digital literacy, type of digital intervention, and the ability to embed the digital intervention into current care processes are critical. This paper overviews the current literature on digital health and self-management, factors to consider when embedding digital interventions and platforms into nutrition care and practical considerations for designing and implementing digital health interventions to enhance the nutritional care of people with chronic kidney disease.

Preferences of people with chronic kidney disease regarding digital health interventions that promote healthy lifestyle: qualitative systematic review with meta-ethnography

OBJECTIVES

Diet and physical activity are crucial for people with chronic kidney disease (CKD) to maintain good health. Digital health interventions can increase access to lifestyle services. However, consumers' perspectives are unclear, which may reduce the capacity to develop interventions that align with specific needs and preferences. Therefore, this review aims to synthesise the preferences of people with CKD regarding digital health interventions that promote healthy lifestyle.

DESIGN

Qualitative systematic review with meta-ethnography.

DATA SOURCES

Databases Scopus, CENTRAL, MEDLINE, CINAHL and SPORTDiscus were searched between 2000 and 2023.

ELIGIBILITY CRITERIA

Primary research papers that used qualitative exploration methods to explore the preferences of adults with CKD (≥18 years) regarding digital health interventions that promoted diet, physical activity or a combination of these health behaviours.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened title, abstract and full text. Discrepancies were resolved by a third reviewer. Consumers' quotes were extracted verbatim and synthesised into higher-order themes and subthemes.

RESULTS

Database search yielded 5761 records. One record was identified following communication with a primary author. 15 papers were included. These papers comprised 197 consumers (mean age 51.0±7.2), including 83 people with CKD 1-5; 61 kidney transplant recipients; 53 people on dialysis. Sex was reported in 182 people, including 53% male. Five themes were generated regarding consumers' preferences for digital lifestyle interventions. These included simple instruction and engaging design; individualised interventions; virtual communities of care; education and action plans; and timely reminders and automated behavioural monitoring.

CONCLUSION

Digital health interventions were considered an important mechanism to access lifestyle services. Consumers' preferences are important to ensure future interventions are tailored to specific needs and goals. Future research may consider applying the conceptual framework of consumers' preferences in this review to develop and evaluate the effect of a digital lifestyle intervention on health outcomes.

PROSPERO REGISTRATION NUMBER

CRD42023411511.

Knowledge mapping of telemedicine in urology in the past 20 years: A bibliometric analysis (2004-2024)

Telemedicine refers to the process of utilizing communication technologies to exchange disease information, perform surgery and educate care providers remotely, breaking through the distance limit and promoting the health of individuals and communities. The fifth-generation (5G) technology and the COVID-19 pandemic have greatly boosted studies on the application of telemedicine in urology. In this study, we conduct a comprehensive overview of the knowledge structure and research hotspots of telemedicine in urology through bibliometrics. We searched publications related to telemedicine in urology from 2004 to 2024 on the Web of Science Core Collection (WoSCC) database. VOSviewer, CiteSpace and R package "bibliometrix" were employed in this bibliometric analysis. A total of 1,357 articles from 97 countries and 2,628 institutions were included. The number of annual publications on telemedicine in urology witnessed a steady increase in the last two decades. Duke University was the top research institution. Urology was the most popular journal, and Journal of Medical Internet Research was the most co-cited journal. Clarissa Diamantidis and Chad Ellimoottil published the most papers, and Boyd Viers was co-cited most frequently. Effectiveness evaluation of telemonitoring, cost-benefit analysis of teleconsultation and exploration of telesurgery are three main research hotspots. As the first bibliometric analysis of research on telemedicine in urology, this study reviews research progress and highlights frontiers and trending topics, offering valuable insights for future studies.

Moving towards more sustainable diets: Is there potential for a personalised approach in practice?

Discourse on the relationship between food production, healthy eating and sustainability has become increasingly prominent and controversial in recent years. Research groups often take one perspective when reporting on sustainable diets, and several often neglect considerations for the multiple aspects that make a diet truly sustainable, such as cultural acceptability, differences in nutritional requirements amongst the population and the efficiency of long-term dietary change. Plant-based diets are associated with lower greenhouse gas emissions (GHGEs) and have been linked with better health outcomes, including lower risk of diet-related chronic disease. However, foods associated with higher GHGE, such as lean red meat, fish and dairy, have beneficial nutritional profiles and contribute significantly to micronutrient intakes. Some research has shown that diets associated with lower GHGE can be less nutritionally adequate. Several countries now include sustainability recommendations in dietary guidelines but use vague language such as "increase" or "consume regularly" when referring to plant-based foods. General population-based nutrition advice has poor adherence and does not consider differences in nutritional needs. Although modelling studies show potential to significantly reduce environmental impact with dietary changes, personalising such dietary recommendations has not been studied. Adapting recommendations to the individual through reproducible methods of personalised nutrition has been shown to lead to more favourable and longer-lasting dietary changes compared to population-based nutrition advice. When considering sustainable healthy dietary guidelines, personalised feedback may increase the acceptability, effectiveness and nutritional adequacy of the diet. A personalised approach has the potential for delivering a new structure of more sustainable healthy food-based dietary guidelines. This review evaluates the potential to develop personalised sustainable healthy food-based dietary guidelines and discusses potential implications for policy and practice.

Feasibility and First Experiences from an Online Kidney School for Patients with Chronic Kidney Disease

Objectives: To examine patients' and relatives' experiences with participation in an online kidney school (OKS) and its influence on their choice of treatment modality; furthermore, to report on healthcare professionals' (HCPs) first experiences with OKS. Methods: A mixed-methods design with parallel data collection involving two questionnaires for participants, including patients and relatives and a focus group discussion (FGD) with HCPs. Results: The OKS was feasible, and overall, patients and relatives were satisfied. Participation in the OKS increased the percentage of those who felt ready to make a decision regarding treatment. One over-arching theme (evolvement of the online kidney school over time) and three sub-themes (concerns and perceived barriers, facilitators, and benefits and future possibilities) emerged from the FGD. Conclusions: The OKS proved feasible, was well-accepted, and increased participants' abilities to choose a preferred treatment modality. HCPs displayed initial concerns regarding the quality of the OKS and worried about the practicality of conducting the OKS. They experienced a feeling of something being lost. However, over time, HCPs developed strategies to tackle initial concerns and discovered that patients were more capable of participating than they had anticipated.

mHealth education for patients with chronic kidney disease: protocol for a scoping review

INTRODUCTION

More than 10% of the population worldwide is affected by chronic kidney disease (CKD). Despite many promising indications regarding the use of mHealth education for patients with CKD, there is still little evidence regarding the feasibility, effectiveness outcomes and outcome measures. Therefore, we will conduct a scoping review to examine the currently available evidence on mHealth education for patients with CKD and, thus, explore the existing evidence regarding feasibility, effectiveness outcomes and outcome measures, patient and/or provider perception and implementation challenges.

METHODS AND ANALYSIS

A scoping review will be conducted in accordance with Joanna Briggs Institute Manual for Evidence Synthesis chapter on scoping reviews.MEDLINE, Embase, CINAHL and PsycINFO will be searched. The search strategy will consist of blocks, which have been adopted and modified from former Cochrane reviews. Two independent reviewers will screen studies. Characteristics of the included studies, both quantitative and qualitative, will be reported using quantitative descriptive statistics. Quantitative results will be grouped by objectives (feasibility, effectiveness outcomes and outcome measures, patient perception and implementation challenges), types of intervention and characteristics of participants. Qualitative results will be organised into categories using an iterative process, as suggested by Pollock et al. ETHICS AND DISSEMINATION: As this scoping review does not involve primary data collection, ethical permission is unnecessary. Results of the scoping review will be published in an international peer-reviewed scientific journal.

TRIAL REGISTRATION NUMBER

Open Science Framework (https://osf.io/gxkeh/).

The therapeutic relationship between a client and dietitian: A systematic integrative review of empirical literature

Aim

Scientific evidence underpins dietetics practice; however, evidence of how the therapeutic relationship influences outcomes is limited. This integrative review aims to provide a comprehensive overview of the topic of the therapeutic relationship between clients and dietitians in the individual counselling context by summarising empirical literature into qualitative themes.

Methods

An electronic literature search of the Cumulative Index of Nursing and Allied Health Literature, PsychInfo, Scopus and Web of Science databases was conducted in October 2018 and repeated in February 2021. Studies were included if they explicitly referred to the therapeutic relationship (or associated terms), were based on study data and available in full text. Extracted data were checked by a second researcher and the methodological quality was evaluated independently by two researchers using the Mixed Methods Appraisal Tool. An iterative process of qualitatively coding, categorising and comparing data to examine recurring themes was applied.

Results

Seventy‐six studies met the inclusion criteria. Five themes were identified which showed the extent and nature of research in this area. Studies revealed the therapeutic relationship: (i) is valued within clinical dietetic practice, (ii) involves complex and multifactorial interactions, (iii) is perceived as having a positive influence, (iv) requires skills training and (v) is embedded in practice models and tools.

Conclusion

Studies show the therapeutic relationship is a valued and multifactorial component of clinical dietetic practice and is perceived to positively influence the client and dietitian. Observational data are needed to assess the extent to which the strength of the therapeutic relationship might contribute to clients' health outcomes.

U-DECIDE: Utilising technology for Diet & Exercise Change In complex chronic conditions across Diverse Environments: Protocol for a Randomised Controlled Trial (Preprint)

Background

The metabolic syndrome is common across many complex chronic disease groups. Advances in health technology have provided opportunities to support lifestyle interventions.

Objective

The purpose of this study is to test the feasibility of a health technology-assisted lifestyle intervention in a patient-led model of care.

Methods

The study is a single-center, 26-week, randomized controlled trial. The setting is specialist kidney and liver disease clinics at a large Australian tertiary hospital. The participants will be adults with a complex chronic condition who are referred for dietetic assessment and display at least one feature of the metabolic syndrome. All participants will receive an individualized assessment and advice on diet quality from a dietitian, a wearable activity monitor, and standard care. Participants randomized to the intervention group will receive access to a suite of health technologies from which to choose, including common base components (text messages) and optional components (online and mobile app–based nutrition information, an online home exercise program, and group-based videoconferencing). Exposure to the optional aspects of the intervention will be patient-led, with participants choosing their preferred level of engagement. The primary outcome will be the feasibility of delivering the program, determined by safety, recruitment rate, retention, exposure uptake, and telehealth adherence. Secondary outcomes will be clinical effectiveness, patient-led goal attainment, treatment fidelity, exposure demand, and participant perceptions. Primary outcome data will be assessed descriptively and secondary outcomes will be assessed using an analysis of covariance. This study will provide evidence on the feasibility of the intervention in a tertiary setting for patients with complex chronic disease exhibiting features of the metabolic syndrome.

Results

The study was funded in 2019. Enrollment has commenced and is expected to be completed by June 2022. Data collection and follow up are expected to be completed by December 2022. Results from the analyses based on primary outcomes are expected to be submitted for publication by June 2023.

Conclusions

The study will test the implementation of a health technology–assisted lifestyle intervention in a tertiary outpatient setting for a diverse group of patients with complex chronic conditions. It is novel in that it embeds patient choice into intervention exposure and will inform health service decision-makers in regards to the feasibility of scale and spread of technology-assisted access to care for a broader reach of specialist services.

Trial Registration

Australian New Zealand Clinical Trial Registry ACTRN12620001282976; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378337

International Registered Report Identifier (IRRID)

DERR1-10.2196/37556

Technology-supported models of nutrition care: Perspectives of health service providers

Objective

To determine the perspectives to the adoption, scale-up, sustainability, and spread of technology-supported models of nutrition care, in hospital and ambulatory care settings.

Methods

Thirty-one health service providers participated in individual semi-structured interviews from a tertiary health service in Queensland, Australia. The Non-adoption, Abandonment, and challenges to the Scale up, Spread and Sustainability (NASSS) framework, designed to evaluate technology-supported models’ success, informed the qualitative design.

Results

Key findings were that technology-supported models of care could benefit many chronic condition patient groups; dietitians are well suited to adopting this technology: and the value proposition in creating efficiency gains in the health service. However, challenges of transitioning and sustainability were identified. Perceived enablers for technology supported models of care included: previous intentions for technology supported models of care prior to the 2019 novel coronavirus pandemic; opportunity for clinicians to complete higher valued tasks; and integration of technology systems and assisted staff roles. Perceived barriers included: suitability for patients is dependent on experience and ability to use technology, varied confidence by clinicians when conducting clinical assessments; high investment required for set up and ongoing maintenance; and patients desire for adopting face-to-face care over technology. Health service providers perceived that embedding and adapting such models requires maintenance of high-quality service and continued research.

Conclusions

Health service providers recognize adopting, scaling, and sustaining technology-supported models of nutrition care benefits patients, clinicians, and health services in general. Robust clinical trials and health service evaluations of technology-supported models of care, across practice settings are now needed.

Patients' experiences and perspectives of a mobile phone text messaging intervention to improve dietary behaviours in haemodialysis

AIM

Dietary requirements for people on haemodialysis are complex and often poorly adhered to. Mobile phone text messaging offers a simple strategy to enhance current nutritional care. KIDNEYTEXT was a 6-month pilot randomised controlled trial that evaluated the feasibility and impact of mobile phone text messages to alter participants' dietary behaviours. The aim of this study was to elicit the perspectives of people on haemodialysis regarding acceptability of mobile phone text messages targeting dietary behaviours.

METHODS

Semi-structured interviews were conducted with participants in the intervention arm of the KIDNEYTEXT study. Participants were purposively sampled and interviews were conducted in-person or over the phone. Transcripts were thematically analysed using principles of grounded theory.

RESULTS

Interviews were conducted with 25 participants. Four major themes were identified: building awareness (reinforcement of information, simple and comprehensible, guiding choices, accessible information enhancing motivation, gaining skills in management), valuing care (boosting self-esteem, in-person care bolstered by reminders), activating change (adjusting lifestyle, gaining control of electrolytes and fluid, striving to improve overall health), waning attention and motivation (lack of personalisation limiting change, maintaining the status quo, reverting back to old habits).

CONCLUSIONS

Participants perceived that the KIDNEYTEXT intervention enabled participants to build on their knowledge through the dissemination of simple and actionable content. Participants appreciated frequent reminders of how to improve their diet and felt that this increased contact motivated them to alter some dietary behaviours. Future trials should consider strategies to enhance personalisation to further motivate dietary change.

Perspectives of Registered Dietitian Nutritionists on Adoption of Telehealth for Nutrition Care during the COVID-19 Pandemic

Widespread transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has resulted in a global coronavirus disease 2019 (COVID-19) pandemic that is straining medical resources worldwide. In the United States (US), hospitals and clinics are challenged to accommodate surging patient populations and care needs while preventing further infection spread. Under such conditions, meeting with patients via telehealth technology is a practical way to help maintain meaningful contact while mitigating SARS-CoV-2 transmission. The application of telehealth to nutrition care can, in turn, contribute to better outcomes and lower burdens on healthcare resources. To identify trends in telehealth nutrition care before and during the pandemic, we emailed a 20-question, qualitative, structured survey to approximately 200 registered dietitian nutritionists (RDNs) from hospitals and clinics that have participated in the Malnutrition Quality Improvement Initiative (MQii). RDN respondents reported increased use of telehealth-based care for nutritionally at-risk patients during the pandemic. They suggested that use of such telehealth nutrition programs supported positive patient outcomes, and some of their sites planned to continue the telehealth-based nutrition visits in post-pandemic care. Nutrition care by telehealth technology has the potential to improve care provided by practicing RDNs, such as by reducing no-show rates and increasing retention as well as improving health outcomes for patients. Therefore, we call on healthcare professionals and legislative leaders to implement policy and funding changes that will support improved access to nutrition care via telehealth.

Mobile Health App With Social Media to Support Self-Management for Patients With Chronic Kidney Disease: Prospective Randomized Controlled Study

BACKGROUND

Chronic kidney disease (CKD) is a global health burden. Self-management plays a key role in improving modifiable risk factors.

OBJECTIVE

The aim of this study was to evaluate the effectiveness of wearable devices, a health management platform, and social media at improving the self-management of CKD, with the goal of establishing a new self-management intervention model.

METHODS

In a 90-day prospective experimental study, a total of 60 people with CKD at stages 1-4 were enrolled in the intervention group (n=30) and control group (n=30). All participants were provided with wearable devices that collected exercise-related data. All participants maintained dietary diaries using a smartphone app. All dietary and exercise information was then uploaded to a health management platform. Suggestions about diet and exercise were provided to the intervention group only, and a social media group was created to inspire the participants in the intervention group. Participants' self-efficacy and self-management questionnaire scores, Kidney Disease Quality of Life scores, body composition, and laboratory examinations before and after the intervention were compared between the intervention and control groups.

RESULTS

A total of 49 participants completed the study (25 in the intervention group and 24 in the control group); 74% of the participants were men and the mean age was 51.22 years. There were no differences in measured baseline characteristics between the groups except for educational background. After the intervention, the intervention group showed significantly higher scores for self-efficacy (mean 171.28, SD 22.92 vs mean 142.21, SD 26.36; P<.001) and self-management (mean 54.16, SD 6.71 vs mean 47.58, SD 6.42; P=.001). Kidney Disease Quality of Life scores were also higher in the intervention group (mean 293.16, SD 34.21 vs mean 276.37, SD 32.21; P=.02). The number of steps per day increased in the intervention group (9768.56 in week 1 and 11,389.12 in week 12). The estimated glomerular filtration rate (eGFR) of the intervention group was higher than that of the control group (mean 72.47, SD 24.28 vs mean 59.69, SD 22.25 mL/min/1.73m2; P=.03) and the decline in eGFR was significantly slower in the intervention group (-0.56 vs -4.58 mL/min/1.73m2). There were no differences in body composition between groups postintervention.

CONCLUSIONS

The use of wearable devices, a health management platform, and social media support not only strengthened self-efficacy and self-management but also improved quality of life and a slower eGFR decline in people with CKD at stages 1-4. These results outline a new self-management model to promote healthy lifestyle behaviors for patients with CKD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04617431; https://www.clinicaltrials.gov/ct2/show/NCT04617431.

Plant-based diets to manage the risks and complications of chronic kidney disease

Traditional dietary recommendations for patients with chronic kidney disease (CKD) focus on the quantity of nutrients consumed. Without appropriate dietary counselling, these restrictions can result in a low intake of fruits and vegetables and a lack of diversity in the diet. Plant nutrients and plant-based diets could have beneficial effects in patients with CKD: increased fibre intake shifts the gut microbiota towards reduced production of uraemic toxins; plant fats, particularly olive oil, have anti-atherogenic effects; plant anions might mitigate metabolic acidosis and slow CKD progression; and as plant phosphorus has a lower bioavailability than animal phosphorus, plant-based diets might enable better control of hyperphosphataemia. Current evidence suggests that promoting the adoption of plant-based diets has few risks but potential benefits for the primary prevention of CKD, as well as for delaying progression in patients with CKD G3-5. These diets might also help to manage and prevent some of the symptoms and metabolic complications of CKD. We suggest that restriction of plant foods as a strategy to prevent hyperkalaemia or undernutrition should be individualized to avoid depriving patients with CKD of these potential beneficial effects of plant-based diets. However, research is needed to address knowledge gaps, particularly regarding the relevance and extent of diet-induced hyperkalaemia in patients undergoing dialysis.