Use of telemedicine for haemodialysis: perceptions of patients and health-care providers, and clinical effects

Patient Perspectives on Using Telemedicine During In-Center Hemodialysis: A Qualitative Study

Rationale & Objective

In the wake of the coronavirus disease 2019 (COVID-19) pandemic, the United States federal government expanded originating telemedicine sites to include outpatient dialysis units. For the first time, nephrology practitioners across the United States could replace face-to-face visits with telemedicine for patients receiving in-center hemodialysis. This study describes patients' perspectives on the use of telemedicine during in-center hemodialysis.

Study Design

A qualitative study.

Setting & Participants

Thirty-two patients from underserved populations (older, less educated, unemployed, persons of color) receiving in-center hemodialysis who used telemedicine with their nephrologist during the COVID-19 pandemic.

Analytical Approach

Telephone semistructured interviews were conducted in English or Spanish. Transcripts were thematically analyzed.

Results

We identified 6 themes with subthemes: adapting to telemedicine (gaining familiarity and confidence, overcoming and resolving technical difficulties, and relying on staff for communication); ensuring availability of the physician (enabling an immediate response to urgent medical needs, providing peace of mind, addressing patient needs adequately, and enhanced attention and contact from physicians); safeguarding against infection (limiting COVID-19 exposures and decreasing use); straining communication and physical interactions (loss of personalized touch, limited physical examination, and unable to reapproach physicians about forgotten issues); maintaining privacy (enhancing privacy and projecting voice enables others to hear); and supporting confidence in telemedicine (requiring established rapport with physicians, clinical stabilty of health, and ability to have in-person visits when necessary).

Limitations

Interviews were conducted later in the pandemic when some nephrology care providers were using telemedicine infrequently.

Conclusions

Patients receiving in-center hemodialysis adapted to telemedicine visits by their nephrologists in the context of the COVID-19 pandemic and observed its benefits. However, further considerations regarding communication, privacy, and physical assessments are necessary. Integrating telemedicine into future in-center hemodialysis care using a hybrid approach could potentially build trust, optimize communication, and augment care.

The Use of Telemedicine by US Nephrologists for In-Center Hemodialysis Care During the Pandemic: An Analysis of National Medicare Claims

Rationale & Objective

Because of coronavirus disease 2019 (COVID-19), the US government issued emergency waivers in March 2020 that removed regulatory barriers around the use of telemedicine. For the first time, nephrologists were reimbursed for telemedicine care delivered during in-center hemodialysis. We examined the use of telemedicine for in-center hemodialysis during the first 16 months of the pandemic.

Study Design

We ascertained telemedicine modifiers on nephrologist claims. We used multivariable regression to examine time trends and patient, dialysis facility, and geographic correlates of telemedicine use. We also examined whether the estimated effects of predictors of telemedicine use changed over time.

Setting & Participants

US Medicare beneficiaries receiving in-center hemodialysis between March 1, 2020, and June 30, 2021.

Exposures

Patient, geographic, and dialysis facility characteristics.

Outcomes

The use of telehealth for in-center hemodialysis care.

Analytic Approach

Retrospective cohort analysis.

Results

Among 267,434 Medicare beneficiaries identified, the reported use of telemedicine peaked at 9% of patient-months in April 2020 and declined to 2% of patient-months by June 2021. Telemedicine use varied geographically and was more common in areas that were remote and socioeconomically disadvantaged. Patients were more likely to receive care by telemedicine in areas with higher incidence of COVID-19, although the predictive value of COVID-19 diminished later in the pandemic. Patients were more likely to receive care using telemedicine if they were at facilities with more staff, and the use of telemedicine varied by facility ownership type.

Limitations

Limited reporting of telemedicine on claims could lead to underestimation of its use. Reported telemedicine use was higher in an analysis designed to address this limitation by focusing on patients whose physicians used telemedicine at least once during the pandemic.

Conclusions

Some US nephrologists continued to use telemedicine for in-center hemodialysis throughout the pandemic, even as the association between COVID-19 incidence and telemedicine use diminished over time. These findings highlight unique challenges and opportunities to the future use of telemedicine in dialysis care.

Lessons learnt and future directions in managing dialysis access during the COVID 19 pandemic: Patient and provider experience in the United States

BACKGROUND

The COVID 19 pandemic adversely impacted delivery of preventive, routine, urgent, and essential care worldwide. Dialysis access care was particularly affected due to the lack of specific guidelines regarding procedures for its creation and maintenance. Early guidance by Centers for Medicare and Medicaid was inadvertently interpreted as guidance to stop dialysis access procedures. Prompt action by professional societies was needed to furnish detailed guidance to establish essential nature of these procedures.

METHODS

The American Society of Diagnostic and Interventional Nephrology (ASDIN) issued a joint statement with Vascular Access Society of the Americas (VASA) - "Maintaining Lifelines for ESKD Patients" to clearly establish the role of vascular access as a lifeline for ESKD (End Stage Kidney Disease) patients and the importance and urgency of its timely management. ASDIN also conducted a survey in mid-2020, that was administered to the ASDIN database as well as shared with the general public via the organization's social media platforms. The respondents reported their experiences in the care of dialysis access, practice patterns and the utility of the ASDIN-VASA statement during the COVID 19 pandemic.

RESULTS

Of the 2030 individual surveys sent, 581 were opened and 53 (9.1%) responses were received from different parts of the country and from different practice settings. ASDIN COVID 19 triage document was frequently utilized and 83% of respondents found the document valuable. The survey also revealed multiple obstacles, including logistical and financial issues that led to significant disruption of services.

CONCLUSIONS

The care of dialysis access was significantly affected in the United States during the COVID 19 pandemic due to multiple reasons. ASDIN actions provided valuable specific guidance regarding and explored barriers to dialysis access care. We describe those results and discuss strategies to prevent COVID 19 transmission with innovative strategies of providing access care. Individualized decision making is of essence when considering dialysis access procedures.

Evaluation of the experience with the use of telemedicine in a home dialysis program-a qualitative and quantitative study

INTRODUCTION

Assisted home hemodialysis is a therapeutic modality for patients diagnosed with end-stage renal disease who require dialysis replacement therapy and have concomitant health limitations that prevent them from attending a satellite dialysis unit or performing their own treatment.

OBJECTIVE

The main objective of this study was to evaluate whether telemedicine provided through telemonitoring can improve the ongoing relationship between the doctor, the nurse and the patient.

METHOD

This prospective longitudinal, qualitative and quantitative study analyzes the impact of telemedicine through an evaluation of the experiences of patients and nurses. During the study, we performed remote weekly monitoring for 6 months.

RESULTS

A total of 17 patients and 12 nurses were included. We observed that the patients and nurses had positive experiences with telemonitoring and highlighted feelings of being cared for and improved confidence, although they indicated that telemonitoring does not replace face-to-face visits.

CONCLUSION

Telemonitoring is a useful tool to increase satisfaction with and confidence in home hemodialysis.

Video-Based Telemedicine for Kidney Disease Care: A Scoping Review

BACKGROUND AND OBJECTIVES

Video-based telemedicine provides an alternative health care delivery model for patients with CKD. The objective was to provide an overview of the available evidence on the implementation and outcomes of adopting video-based telemedicine in nephrology.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and CINAHL were searched in December 2019 and again in January 2021 for studies using video-based telemedicine for adults across the spectrum of kidney disease. Study types included peer-reviewed clinical trials, observational studies, and descriptive studies available in full text. Search results were independently screened by two authors, who then independently reviewed and extracted data from the eligible studies. Results were synthesized in tabular format, summarizing study characteristics by area within nephrology; the video-based interventions used; and clinical, health care utilization, and patient-reported outcomes.

RESULTS

After reviewing 1870 unique citations, 24 studies were included (four randomized controlled trials, six cohort studies, five pre-post intervention studies, seven case series, and two qualitative studies). Video-based technology was used to facilitate care across all stages of CKD. Although earlier studies used a range of institution-specific technologies that linked main hospital sites to more remote health care locations, more recent studies used technology platforms that allowed patients to receive care in a location of their choice. Video-based care was well received, with the studies reporting high patient satisfaction and acceptable clinical outcomes.

CONCLUSIONS

Video-based telemedicine is being used for kidney care and has evolved to be less reliant on specialized telemedicine equipment. As its use continues to grow, further primary studies and systematic reviews of outcomes associated with the latest innovations to video-based care in nephrology can address knowledge gaps, such as approaches to sustainable integration and minimization of barriers to access.

Opportunities in the cloud or pie in the sky? Current status and future perspectives of telemedicine in nephrology

The use of telehealth to support, enhance or substitute traditional methods of delivering healthcare is becoming increasingly common in many specialties, such as stroke care, radiology and oncology. There is reason to believe that this approach remains underutilized within nephrology, which is somewhat surprising given the fact that nephrologists have always driven technological change in developing dialysis technology. Despite the obvious benefits that telehealth may provide, robust evidence remains lacking and many of the studies are anecdotal, limited to small numbers or without conclusive proof of benefit. More worryingly, quite a few studies report unexpected obstacles, pitfalls or patient dissatisfaction. However, with increasing global threats such as climate change and infectious disease, a change in approach to delivery of healthcare is needed. The current pandemic with coronavirus disease 2019 (COVID-19) has prompted the renal community to embrace telehealth to an unprecedented extent and at speed. In that sense the pandemic has already served as a disruptor, changed clinical practice and shown immense transformative potential. Here, we provide an update on current evidence and use of telehealth within various areas of nephrology globally, including the fields of dialysis, inpatient care, virtual consultation and patient empowerment. We also provide a brief primer on the use of artificial intelligence in this context and speculate about future implications. We also highlight legal aspects and pitfalls and discuss the 'digital divide' as a key concept that healthcare providers need to be mindful of when providing telemedicine-based approaches. Finally, we briefly discuss the immediate use of telenephrology at the onset of the COVID-19 pandemic. We hope to provide clinical nephrologists with an overview of what is currently available, as well as a glimpse into what may be expected in the future.

Feasibility and Acceptability of Telemedicine-Facilitated Palliative Care Consultations in Rural Dialysis Units

Background: Patients receiving dialysis have unmet palliative care needs. Limited access to palliative care is a key barrier to its integration into routine dialysis care. Objective: To determine the feasibility and acceptability of telepalliative care in rural dialysis units. Methods: This was a single-arm pilot clinical trial. The target population was patients with kidney failure receiving outpatient dialysis in a rural U.S. state. Feasibility was measured by one-month completion rate. Acceptability was measured using an adapted telemedicine questionnaire. Results: We recruited 39 patients with mean age 71.2 years to undergo a telepalliative care consultation while receiving dialysis. Four specialty palliative care clinicians (three physicians and one nurse practitioner) conducted the visits. The recruitment rate was 40% (39/96), scheduling rate was 100% (39/39), and one-month completion rate was 77% (30/39). Thirty-six patient participants (14 women and 22 men) completed the baseline survey. Audiovisual aspects of the visit were rated highly. More than 80% reported the visit being at least as good as an in-person visit and 41% felt the teleconsult was better. Eighty-one percent of patients felt the appointment was relevant to them, 58% felt they learned new things about their condition, and 27% reported the appointment changed the way they think about dialysis. Discussion: Telepalliative care is acceptable to patients receiving dialysis and is a feasible approach to integrating palliative care in rural dialysis units. The study was registered with Clinicaltrials.gov (NCT03744117).

Interventions to Improve Clinical Outcomes in Indigenous or Remote Patients With Chronic Kidney Disease: A Scoping Review

Background:

Chronic kidney disease (CKD) associates with a significant health care burden with a disproportionate impact on indigenous persons or people living in remote areas. Although screening programs have expanded in these communities, there remains a paucity of evidence-based interventions to enhance clinical renal outcomes in these populations.

Objective:

The objective of this study was to identify evidence-based interventions to enhance renal outcomes in these populations.

Design:

A scoping review was conducted for studies in the Cochrane, MEDLINE, and Embase databases and from major nephrology meetings.

Setting:

Chronic kidney disease, including those on dialysis.

Patients:

Remote or indigenous populations

Measurements:

Studies that performed an intervention that was followed by measurement of renal outcomes or patient-centered outcomes (ie, quality of life) were included.

Methods:

All studies were described by study type, intervention, and clinical outcome, and trends were identified by both authors. Meta-analysis was not conducted due to study heterogeneity.

Results:

Thirty-two studies met inclusion criteria, only 2 (6.3%) of which were randomized controlled trials. Intervention types included multidisciplinary (34.4%), satellite (32.3%), telehealth (25.0%), or other (9.4%). All multidisciplinary interventions were performed in the CKD (non-dialysis) setting and reported improved patient travel time, waiting time, quality of life, kidney function, proteinuria, and blood pressure. Telehealth interventions improved program cost, patient attendance, hospitalization, and quality of life. Satellite interventions were performed in the hemodialysis setting, with 1 study evaluating acute hemodialysis. Satellite interventions improved patient travel time, dialysis clearance, quality of life, and survival, but increased program costs.

Limitations:

The study was restricted to interventional trials assessing clinical outcomes and to studies in developed countries, which likely excluded some research contributing to this field.

Conclusions:

There is significant heterogeneity among studies of interventions for patients with CKD who are indigenous or live remotely. Interventions were more likely to be successful when the remote or indigenous community was included in program development, with a culturally safe approach. More large, high-quality studies are needed to identify effective interventions to enhance clinical renal outcomes in indigenous or remote populations.

Trial Registration:

This trial is registered under PROSPERO, Registration Number 128453.

Electronic Health Self-Management Interventions for Patients With Chronic Kidney Disease: Systematic Review of Quantitative and Qualitative Evidence

BACKGROUND

Chronic kidney disease (CKD) poses a major challenge to public health. In CKD patients, adequate disease self-management has been shown to improve both proximal and distal outcomes. Currently, electronic health (eHealth) interventions are increasingly used to optimize patients' self-management skills.

OBJECTIVE

This study aimed to systematically review the existing evidence regarding the implementation and effectiveness of eHealth self-management interventions for patients with CKD.

METHODS

Following a search in 8 databases (up to November 2017), quantitative and qualitative data on process and effect outcomes were extracted from relevant studies. Quality was appraised using the Crowe Critical Appraisal Tool; narrative synthesis was performed to analyze the data extracted.

RESULTS

Of the 3307 articles retrieved, 24 (comprising 23 studies) were included in this review; of these, almost half were appraised to be of low to moderate quality. There was considerable heterogeneity in the types of interventions used and the outcomes measured. A total of 10 effect and 9 process outcome indicators were identified. The most frequently reported effect outcome indicators were specific laboratory tests and blood pressure (BP), whereas satisfaction was the most frequently reported process outcome indicator. Positive effects were found for proximal outcomes (eg, BP control and medication adherence), and mixed effects were found for more distal outcomes (eg, quality of life). High feasibility, usability, and acceptability of and satisfaction with eHealth self-management interventions were reported. The determinant ability of health care professionals to monitor and, if necessary, anticipate on patient measurements online was mostly cited to influence patients' adherence to interventions.

CONCLUSIONS

eHealth self-management interventions have the potential to improve disease management and health outcomes. To broaden the evidence base and facilitate intervention upscaling, more detailed descriptions and thorough analysis of the intervention components used are required. In addition, our review reveals that outcomes closely related to the scope and duration of the intervention implemented are most likely to be impacted. For instance, if a 4-week Web-based training to optimize disease management skills is implemented, the outcome perceived control would more likely be affected than kidney function. Although this seems obvious, most studies evaluate only distal outcomes and thereby fail to capture intervention effects that might contribute to long-term health improvement. We advise future researchers to carefully consider their choice of outcomes based on their sensitivity for change. In this way, we ensure that relevant effects are captured and legitimate conclusions are drawn.

Expansion of Telemedicine Services: Telepharmacy, Telestroke, Teledialysis, Tele-Emergency Medicine

As more specialized care gets centralized in centers of excellence, patients admitted to rural hospitals may be at a disadvantage at the time of accessing expertise or receiving advanced care. In this setting, telemedicine models provide a justification to equalize care across different levels. The diversity in telemedicine services is vast and is expanding. Even with all the subsets of telemedicine, including telepharmacy, telestroke, teledialysis, and tele-emergency medicine, the reasons for providing services and associated limitations are similar. However, there is a lack of empirical research including best practices and resultant outcomes for these subsets of telemedicine models.

Clinical Videoconferencing as eHealth: A Critical-Realist Review and Qualitative Meta-Synthesis

Background

Earlier work has described videoconferencing technologies, peripheral equipment, organizational models, human relations, purposes, goals and roles as versatile, multifaceted, and those used differently in different clinical practices. Knowledge about benefits and challenges connected to specific characteristics of services are lacking. A 2005 systematic review of published definitions of electronic health (eHealth) identified 51 unique definitions. In addition, the “10 E’s of eHealth” was developed. In 2015, the question “What Is eHealth: Time for an Update?” was posed.

Objective

Considering videoconferencing as eHealth, the objective of the paper is twofold: to demonstrate and cluster (different) clinical videoconferencing practices and their situated implications and to suggest interpretive concepts that apply to all clusters and contribute to generative learning of eHealth by discussing the concepts as add-ons to existing descriptions of eHealth in the “10 E’s of eHealth.”

Methods

We performed a literature search via the National Center for Biotechnology Information, encompassing PubMed and PubMedCentral, for quality reviews and primary studies. We used the terms “videoconferencing” and “clinical practices.” The selection process was based upon clearly defined criteria. We used an electronic form to extract data. The analysis was inspired by critical and realist review types, grounded theory, and qualitative meta-synthesis.

Results

The search returned 354 reviews and primary studies. This paper considered the primary studies, and 16 were included. We identified the following 4 broad clusters: videoconferencing as a controlled technological intervention within existing health care organizations for expert advice, controlled mixed interventions with experimental organizational arrangements, videoconferencing as an emerging technosocial service involving dialogue and empowerment of patients, and videoconferencing as a controlled intervention to improve administrative efficiency. The analysis across the clusters resulted in a proposal to add the following 4 D’s to the existing 10 E’s: (inter)-dependent, differentiated across services and along temporal lines, dynamic in terms of including novel elements for meeting incremental needs, and demanding in terms of making new challenges and dual results visible and needing fresh resources to meet those challenges. For a normative discussion about what eHealth should be according to authors’ conclusions, results suggested ethical, in that users interests should be respected, and not harmful in terms of increasing symptom burden.

Conclusions

Services were enacted as dynamic, differentiated concerning content and considerations of quality and adaptive along temporal lines. They were made to work from an ongoing demand for fresh resources, making them interdependent. The 4 D’s—Dynamic, Differentiated, Demanding, and (inter) Dependent—serve as pragmatic add-ons to the “10 E’s of eHealth.” Questions concerning outcome of specified balances between standardization and customization in clinical settings should be addressed in future research along with the emerging dual character of outcome: services being considered both “good” and “bad.”

Effectiveness of a Web-Based eHealth Portal for Delivery of Care to Home Dialysis Patients: A Single-Arm Pilot Study

Background

Improving a patient's experience with their care through an online interface for communication (an eHealth patient portal) has been shown to be beneficial in some studies of chronic disease populations. However, little is known about the effectiveness of an eHealth portal for delivery of care to home dialysis patients.

Objectives

Primary: To determine whether an eHealth portal is effective at improving a patient's experience with their home dialysis care. Secondary: (1) To determine whether an eHealth portal improves health-related quality of life for home dialysis patients, (2) to assess patient satisfaction with an eHealth portal and perceived impact on aspects of their home dialysis therapy and health, (3) to determine the acceptability of the eHealth portal software, and (4) to determine the change in telephone usage for communication after patient adoption of an eHealth portal.

Design

Single-arm pilot trial with recruitment over a 4-month period.

Setting

The multidisciplinary home dialysis clinic in Halifax Nova Scotia Canada.

Patients

Adults (>18 years) receiving either home hemodialysis or peritoneal dialysis.

Measurements

Consumer quality index (CQI), health-related quality of life using the EuroQol Five Dimensions Questionnaire (EQ-5D), acceptability of the eHealth portal software (using the Acceptability E-scale), and satisfaction/perceived impact (using a modified questionnaire).

Methods

A web-based application (McKesson, Canada, RelayHealth®) allowed patients and health care workers to communicate through a secure, password-protected online portal that permitted visualization of the messaging history by patient and provider. Patients and the home dialysis health care team had the ability to send messages related to patient care at any time including proposed changes to medication, instructions after a clinic visit, times of new appointments, upcoming investigations, or questions about care. Patient experience with home dialysis care using the CQI, health-related quality of life using the EQ-5D, acceptability of the eHealth portal software, and satisfaction/perceived impact were assessed at baseline, 6, and 12 months of follow-up (where applicable). Total minutes of telephone communication was assessed prior to and after adoption of the portal.

Results

Of the 41 patients who consented to join the portal, 27 (66%) created an online account. At baseline, patients had a positive experience for the care and communication provided by their nephrologist (CQI: 3.63, 95% confidence interval [CI]: 3.50-3.76) and this did not change significantly over the study period. Similar results were observed for the care provided by other nephrology health care team members. Health-related quality of life using the EQ-5D score was 0.80 (interquartile range [IQR]: 0.71-0.83) at baseline and this also did not significantly change over the study period. Patients were satisfied with the eHealth portal (mean Likert scale score of 6.5 ± 0.6 in overall satisfaction, scale ranging from 1 completely dissatisfied to 10 completely satisfied), but only a minority (N = 12) completed a satisfaction questionnaire. Median monthly phone usage decreased from 12.5 to 10 minutes (P = .02) after adoption of the portal.

Limitations

The study is limited by the small sample size, high rate of patient dropout, and limited response rate.

Conclusions

In this study of home dialysis patients, we identified that an eHealth communication did not lead to significant improvements in patient experience with home dialysis care.

Trial Registration

ClinicalTrials.gov number NCT02128347.

Perspectives from the Kidney Health Initiative on Advancing Technologies to Facilitate Remote Monitoring of Patient Self-Care in RRT

Telehealth and remote monitoring of a patient's health status has become more commonplace in the last decade and has been applied to conditions such as heart failure, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease. Conversely, uptake of these technologies to help engender and support home RRTs has lagged. Although studies have looked at the role of telehealth in RRT, they are small and single-centered, and both outcome and cost-effectiveness data are needed to inform future decision making. Furthermore, alignment of payer and government (federal and state) regulations with telehealth procedures is needed along with a better understanding of the viewpoints of the various stakeholders in this process (patients, caregivers, clinicians, payers, dialysis organizations, and government regulators). Despite these barriers, telehealth has great potential to increase the acceptance of home dialysis, and improve outcomes and patient satisfaction while potentially decreasing costs. The Kidney Health Initiative convened a multidisciplinary workgroup to examine the current state of telehealth use in home RRTs as well as outline potential benefits and drawbacks, impediments to implementation, and key unanswered questions.

Understanding kidney care needs and implementation strategies in low- and middle-income countries: conclusions from a "Kidney Disease: Improving Global Outcomes" (KDIGO) Controversies Conference

Evidence-based cinical practice guidelines improve delivery of uniform care to patients with and at risk of developing kidney disease, thereby reducing disease burden and improving outcomes. These guidelines are not well-integrated into care delivery systems in most low- and middle-income countries (LMICs). The KDIGO Controversies Conference on Implementation Strategies in LMIC reviewed the current state of knowledge in order to define a road map to improve the implementation of guideline-based kidney care in LMICs. An international group of multidisciplinary experts in nephrology, epidemiology, health economics, implementation science, health systems, policy, and research identified key issues related to guideline implementation. The issues examined included the current kidney disease burden in the context of health systems in LMIC, arguments for developing policies to implement guideline-based care, innovations to improve kidney care, and the process of guideline adaptation to suit local needs. This executive summary serves as a resource to guide future work, including a pathway for adapting existing guidelines in different geographical regions.

Effects of Different Models of Dialysis Care on Patient-Important Outcomes: A Systematic Review and Meta-Analysis

Ongoing payment reform in dialysis necessitates better patient outcomes and lower costs. Suggested improvements to processes of care for maintenance dialysis patients are abundant; however, their impact on patient-important outcomes is unclear. This systematic review included comparative randomized controlled trials or observational studies with no restriction on language, published from 2000 to 2014, involving at least 5 adult dialysis patients who received a minimum of 6 months of follow-up. The effect size was pooled and stratified by intervention strategy (multidisciplinary care [MDC], home dialysis, alternate dialysis settings, and electronic health record implementation). Heterogeneity (I²) was used to assess the variability in study effects related to study differences rather than chance. Of the 1988 articles screened, 25 international studies with 74,833 maintenance dialysis patients were included. Interventions with MDC or home dialysis were associated with a lower mortality (hazard ratio [HR] = 0.72, 95% confidence interval [CI] 0.61, 0.84, I² = 41.6%; HR = 0.57, 95% CI 0.41, 0.81, I² = 89.0%; respectively) and hospitalizations (incidence rate ratio [IRR] = 0.68, 95% CI 0.51, 0.91, I² = NA; IRR = 0.88, 95% CI 0.64, 1.20, I² = 79.6%; respectively). Alternate dialysis settings also were associated with a reduction in hospitalizations (IRR = 0.41, 95% CI 0.25, 0.69, I² = 0.0%). This systematic review underscores the importance of multidisciplinary care, and also the value of telemedicine as a means to increase access to providers and enhance outcomes for those dialyzing at home or in alternate settings, including those with limited access to nephrology expertise because of travel distance.

Telestroke, tele-oncology and teledialysis: a systematic review to analyse the outcomes of active therapies delivered with telemedicine support

Summary

We conducted a systematic review of studies involving telemedicine supervision of active treatment for rural patients in the fields of stroke, medical oncology and nephrology. Searches were performed on the MEDLINE, CINAHL and INFORMIT databases. A total of 521 articles were found, and an additional 42 articles were identified by searching the reference lists. After removing duplicates, screening the abstracts and assessing the full text of the articles, 14 articles remained. Nine concerned telestroke, two concerned tele-oncology and three concerned teledialysis. Most studies did not undertake randomisation, allocation concealment or selective outcome reporting making their risk of bias high. There were no randomised controlled trials and most sample sizes were small. Observational studies in telestroke showed favourable outcomes when comparing face-to-face and videoconferencing-assisted thrombolysis, with no significant differences between survival and intracerebral bleeds. Although tele-oncology has been used routinely for more than 20 years, there have been few formal studies. Home dialysis supervised through videoconferencing had similar patient outcomes compared to hospital dialysis. Telemedicine supervision of active treatment for rural patients appears promising, but more rigorous studies of effectiveness, feasibility and safety are required.

The follow-up of renal transplant recipients by telephone consultation: three years experience from a single UK renal unit

Although telephone consulting is increasingly used by clinicians seeking to balance rising caseloads, heightened patient expectation and the desire to ensure continued improvements in the quality, convenience and accessibility of the care they provide, its use to provide care to renal transplant recipients has not previously been described. Climate change is a major global public health threat. However, the provision of healthcare itself has a significant environmental impact. A transformation to lower carbon clinical care must be achieved without detriment to the quality of the patient care. This article reports the use of telephone consultation clinics to provide follow-up to renal transplant recipients over a three-year period. The benefits of this service to patients, providers and the environment are outlined, the existing literature regarding the provision of virtual care to patients with kidney disease is reviewed, and the possibilities of more widespread adoption are discussed.

Use of telemedicine for haemodialysis in very remote areas: the Canadian First Nations

We used a pre-post design to compare the health and care utilization of patients receiving telehaemodialysis services in two James Bay Cree communities. The Cree are an Amerindian First Nation living in the remote James Bay region. The same group of dialysed patients (n = 19) was followed longitudinally over a two-year period: 12 months pre and 12 months post. Analysis of variables measuring the patients' health conditions showed that the quality of care provided was well within recognized good practice guidelines. Repeated measures ANOVA on the variables measuring care utilization showed a significant decrease in the monthly number of medication changes over time (P < 0.01). Different telehaemodialysis models were used in the two communities (virtual patient rounds and telecase reviews with multidisciplinary teams), but they did not lead to differences in health condition or care utilization. This suggests that there is no single prescriptive model for the delivery of tele-expertise.

Keys to a successful and sustainable telemedicine program

OBJECTIVES

The aim of this study was to determine organizational characteristics evident in successful telemedicine programs. The study proposed four research questions to identify the key organizational characteristics for successful telemedicine programs.

METHODS

Data were collected through an online survey using modified unified theory of acceptance and use of technology (UTAUT) and organizational change readiness (ORC) validated assessments.

RESULTS

Using the UTAUT instrument and the ORC assessment, themes of successful telemedicine programs emerged. Overarching themes of successful programs included being formally structured, forward thinking, seeking to improve the quality of patient care, and being financially stable.

CONCLUSIONS

This research provides a data-driven understanding of organizational issues that serve to maximize a telemedicine program's ability to achieve the overall goals and mission of a healthcare organization.

Telemedicine: What have we learned?

As the health care industry is facing many challenges and is undergoing extensive change, telemedicine is in the position to address these challenges and be an important part of health care's development. Telemedicine has been used for approximately a half century, in which researchers have explored the different technologies utilized, clinical outcomes, cost benefits, perceptions, and adoption challenges of its use. This paper reviews and summarizes these findings and presents possible future research endeavors. Examining what is known about telemedicine can aid in the development of innovative, sustainable and beneficial health technologies that could positively impact health care delivery and outcomes.