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Kim E, Sung HC, Kaplow K, Bendersky V, Sidoti C, Muzaale AD, Akhtar J, Levan M, Esayed S, Khan A, Mejia C, Al Ammary F. Donor Perceptions and Preferences of Telemedicine and In-Person Visits for Living Kidney Donor Evaluation. Kidney Int Rep 2024; 9:2453-2461. [PMID: 39156145 PMCID: PMC11328557 DOI: 10.1016/j.ekir.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/24/2024] [Accepted: 05/06/2024] [Indexed: 08/20/2024] Open
Abstract
Introduction Living kidney donor evaluation is a lengthy and complex process requiring in-person visits. Access to transplant centers, travel costs, lost wages, and dependent care arrangements are barriers to willing donors initiating evaluation. Telemedicine can help streamline and epedite the evaluation process. We aimed to deeply understand donor experiences and preferences using hybrid telemedicine video/in-person visits to ease access to donor evaluation or counseling. Methods We conducted in-depth, semistructured interviews with donors or donor candidates who completed their evaluation through telemedicine/in-person, or in-person only visits at a tertiary transplant center between November 27, 2019 and March 1, 2021. Enrollment continued until data saturation was reached (interviews with 20 participants) when no new information emerged from additional interviews. Transcripts were analyzed using inductive thematic analysis. Results Eight themes were identified as follows: (i) reducing financial and logistical burdens (minimizing travel time and travel-related expenses), (ii) enhancing flexibility with scheduling (less time off work and child or family caregiver arrangements), (iii) importance of a walkthrough and establishing shared understanding, (iv) supporting information with technology and visual aids, (v) key role of the coordinator, (vi) preferred visit by provider role (meeting donor surgeon in-person to create rapport and engaging primary care provider in donor evaluation/follow-up), (vii) comparing modality differences in human connection, and (viii) opportunity for family and support network engagement (allowing loved ones to be involved in telemedicine visits irrespective of geographic locations and pandemic restrictions). Conclusion Telemedicine/in-person hybrid model can make donor evaluation more accessible and convenient. Our findings help inform about determinants that influence the adoption of telemedicine to initiate donor evaluation to motivate willing donors. In addition, our results call for policy and legislation that support telemedicine services for living donor kidney transplantation across states.
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Affiliation(s)
- Ellie Kim
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hannah C. Sung
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Katya Kaplow
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Victoria Bendersky
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carolyn Sidoti
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Abimereki D. Muzaale
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jasmine Akhtar
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Macey Levan
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Suad Esayed
- Department of Medicine, University of California Irvine, California, USA
| | - Amir Khan
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christina Mejia
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Fawaz Al Ammary
- Department of Medicine, University of California Irvine, California, USA
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2
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Shrestha S, Haq K, Malhotra D, Patel DM. Care of Adults with Advanced Chronic Kidney Disease. J Clin Med 2024; 13:4378. [PMID: 39124645 PMCID: PMC11313041 DOI: 10.3390/jcm13154378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 07/23/2024] [Accepted: 07/23/2024] [Indexed: 08/12/2024] Open
Abstract
Chronic kidney disease (CKD) impacts over 10% of the global population. Adults with CKD face significant morbidity and mortality. As kidney disease progresses, the risk of adverse outcomes increases. Here, we present an overview of strategies to care for adults with advanced CKD (stage 4-5 CKD, not receiving kidney replacement therapy). We aim to guide clinicians through several aspects of CKD care, ranging from recommended laboratory assessments to interdisciplinary support for patients as they plan for kidney replacement therapy (dialysis, transplantation, or conservative management). We incorporate considerations of health equity and person-centered care, empowering clinicians to deliver high-quality care to people with CKD.
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Affiliation(s)
| | | | | | - Dipal M. Patel
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA (D.M.)
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3
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Haltom TM, Lew SQ, Winkelmayer WC, Chertow GM, Jaure A, Erickson KF. Patient Perspectives on Using Telemedicine During In-Center Hemodialysis: A Qualitative Study. Kidney Med 2024; 6:100848. [PMID: 38938646 PMCID: PMC11209005 DOI: 10.1016/j.xkme.2024.100848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024] Open
Abstract
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.
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Affiliation(s)
- Trenton M. Haltom
- Center for Innovations in Quality, Effectiveness and Safety, Baylor College of Medicine, Houston, TX
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX
| | - Susie Q. Lew
- Division of Renal Diseases and Hypertension, George Washington University, Washington, DC
| | | | - Glenn M. Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
| | - Allison Jaure
- School of Public Health, University of Sydney, Sydney, Australia
| | - Kevin F. Erickson
- Center for Innovations in Quality, Effectiveness and Safety, Baylor College of Medicine, Houston, TX
- Section of Nephrology, Baylor College of Medicine, Houston, TX
- Baker Institute for Public Policy, Rice University, Houston, TX
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4
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Stevens PE, Ahmed SB, Carrero JJ, Foster B, Francis A, Hall RK, Herrington WG, Hill G, Inker LA, Kazancıoğlu R, Lamb E, Lin P, Madero M, McIntyre N, Morrow K, Roberts G, Sabanayagam D, Schaeffner E, Shlipak M, Shroff R, Tangri N, Thanachayanont T, Ulasi I, Wong G, Yang CW, Zhang L, Levin A. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int 2024; 105:S117-S314. [PMID: 38490803 DOI: 10.1016/j.kint.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 10/31/2023] [Indexed: 03/17/2024]
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5
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Accorsi TAD, dos Santos GGR, Nemoto RP, Moreira FT, De Amicis K, Köhler KF, Cordioli E, Pedrotti CHS. Telemedicine and patients with heart failure: evidence and unresolved issues. EINSTEIN-SAO PAULO 2024; 22:eRW0393. [PMID: 38451690 PMCID: PMC10948100 DOI: 10.31744/einstein_journal/2024rw0393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 10/26/2023] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Heart failure is the leading cause of cardiac-related hospitalizations. Limited access to reevaluations and outpatient appointments restricts the application of modern therapies. Telemedicine has become an essential resource in the healthcare system because of its countless benefits, such as higher and more frequent appointments and faster titration of medications. This narrative review aimed to demonstrate the evidence and unresolved issues related to the use of telemedicine in patients with heart failure. No studies have examined heart failure prevention; however, several studies have addressed the prevention of decompensation with positive results. Telemedicine can be used to evaluate all patients with heart failure, and many telemedicine platforms are available. Several strategies, including both noninvasive (phone calls, weight measurement, and virtual visits) and invasive (implantable pulmonary artery catheters) strategies can be implemented. Given these benefits, telemedicine is highly desirable, particularly for vulnerable groups. Although some questions remain unanswered, the development of new technologies can complement remote visits and improve patient care.
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Affiliation(s)
| | | | - Renato Paladino Nemoto
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Flavio Tocci Moreira
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Karine De Amicis
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Karen Francine Köhler
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Eduardo Cordioli
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
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6
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Santosh R, Mohammed YN, Rahaman Z, Khurana S. The Role of Telemedicine in Enhancing Chronic Kidney Disease (CKD) Management and Dialysis Care. Cureus 2024; 16:e55816. [PMID: 38590481 PMCID: PMC10999887 DOI: 10.7759/cureus.55816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2024] [Indexed: 04/10/2024] Open
Abstract
Telemedicine has emerged as a transformative solution in the realm of healthcare, particularly in addressing the complexities and challenges associated with chronic kidney disease (CKD) and dialysis care. This editorial explores the potential of telemedicine in revolutionizing the management and treatment of kidney diseases, highlighting its role in mitigating the burdens faced by healthcare systems worldwide. With the advent of high-quality audio and visual platforms, telemedicine has facilitated remote healthcare delivery, enabling healthcare professionals to provide exceptional care from a distance. This is particularly relevant in the context of CKD and end-stage kidney disease (ESKD) patients, where the need for continuous care and monitoring is critical. This editorial underscored the escalating incidence of ESKD, driven by prevalent risk factors, such as diabetes, hypertension, and obesity, and the disparities in access to treatments among different populations. The integration of telemedicine in CKD and dialysis care presents a pathway toward a more accessible, efficient, and cost-effective healthcare delivery. It offers numerous benefits, including the convenience of remote monitoring, enhanced patient compliance, reduced healthcare costs, and improved patient satisfaction and quality of life. Telemedicine facilitates a multidisciplinary approach to care, allowing for timely intervention and follow-ups, which are crucial for patients undergoing dialysis. Moreover, the COVID-19 pandemic has accelerated the adoption of telemedicine, showcasing its effectiveness in maintaining continuity of care amid restrictions on patient contact. Despite its promising potential, its implementation of telemedicine faces several challenges, including regulatory hurdles, concerns about the security of medical information, and the adequacy of virtual platforms to capture crucial health indicators. In addition, the financial implications of telemedicine and its long-term sustainability remain areas requiring further investigation. In conclusion, telemedicine holds significant promise in enhancing the care and management of CKD and dialysis patients. It offers a vital solution to overcome the geographical barrier, improve access to care, and alleviate the strain on healthcare systems. However, further research is needed to fully understand its benefits compared to traditional care models and to address the challenges associated with implementation. The expansion of telemedicine in kidney care signifies a step toward a more inclusive, efficient, and patient-centered healthcare future.
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Affiliation(s)
| | - Yaqub Nadeem Mohammed
- Internal Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, USA
| | - Zubair Rahaman
- Internal Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Sakshi Khurana
- Radiology, New York Presbyterian/Columbia University Irving Medical Center, New York, USA
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7
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Moore L, Balmer F, Woywodt A. The environmental impact of changing to virtual renal transplant aftercare: 2-year experience with a single outpatient clinic. Future Healthc J 2024; 11:100004. [PMID: 38646053 PMCID: PMC11025045 DOI: 10.1016/j.fhj.2024.100004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Affiliation(s)
- Louise Moore
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, U.K
| | - Frances Balmer
- Sustainability Fellow, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, U.K
| | - Alexander Woywodt
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, U.K
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8
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Mohottige D. Paving a Path to Equity in Cardiorenal Care. Semin Nephrol 2024; 44:151519. [PMID: 38960842 DOI: 10.1016/j.semnephrol.2024.151519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
Cardiorenal syndrome encompasses a dynamic interplay between cardiovascular and kidney disease, and its prevention requires careful examination of multiple predisposing underlying conditions. The unequal distribution of diabetes, heart failure, hypertension, and kidney disease requires special attention because of the influence of these conditions on cardiorenal disease. Despite growing evidence regarding the benefits of disease-modifying agents (e.g., sodium-glucose cotransporter 2 inhibitors) for cardiovascular, kidney, and metabolic (CKM) disease, significant disparities remain in access to and utilization of these essential therapeutics. Multilevel barriers impeding their use require multisector interventions that address patient, provider, and health system-tailored strategies. Burgeoning literature also describes the critical role of unequal social determinants of health, or the sociopolitical contexts in which people live and work, in cardiorenal risk factors, including heart failure, diabetes, and chronic kidney disease. This review outlines (i) inequality in the burden and treatment of hypertension, type 2 diabetes, and heart failure; (ii) disparities in the use of key disease-modifying therapies for CKM diseases; and (iii) multilevel barriers and solutions to achieve greater pharmacoequity in the use of disease-modifying therapies. In addition, this review provides summative evidence regarding the role of unequal social determinants of health in cardiorenal health disparities, further outlining potential considerations for future research and intervention. As proposed in the 2023 American Heart Association presidential advisory on CKM health, a paradigm shift will be needed to achieve cardiorenal health equity. Through a deeper understanding of CKM health and a commitment to equity in the prevention, detection, and treatment of CKM disease, we can achieve this critical goal.
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Affiliation(s)
- Dinushika Mohottige
- Institute for Health Equity Research, Department of Population Health, Icahn School of Medicine at Mount Sinai, New York, NY; Barbara T. Murphy Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
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9
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Jones JL. Patient Perspective on Telehealth. KIDNEY360 2024; 5:264-265. [PMID: 38421858 PMCID: PMC10917111 DOI: 10.34067/kid.0000000000000370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
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10
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Bevilacqua M, Melnyk Y, Chiu H, Williams J, Watson P, Lee B, Dhariwal P, McGuire M, Wei J, Chohan R, Logie A, Fryer M, Stoll D, Levin A. Patient and Clinician Experiences With the Combination of Virtual and In-Person Chronic Kidney Disease Care Since the COVID-19 Pandemic. Can J Kidney Health Dis 2023; 10:20543581231217833. [PMID: 38107157 PMCID: PMC10722955 DOI: 10.1177/20543581231217833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 10/27/2023] [Indexed: 12/19/2023] Open
Abstract
Background Following onset of the COVID-19 pandemic, chronic kidney disease (CKD) clinics in BC shifted from established methods of mostly in-person care delivery to virtual care (VC) and thereafter a hybrid of the two. Objectives To determine strengths, weaknesses, quality-of-care delivery, and key considerations associated with VC usage to inform optimal way(s) of integrating virtual and traditional methods of care delivery in multidisciplinary kidney clinics. Design Qualitative evaluation. Setting British Columbia, Canada. Participants Patients and health care providers associated with multidisciplinary kidney care clinics. Methods Development and delivery of semi-structured interviews of patients and health care providers. Results 11 patients and/or caregivers and 12 health care providers participated in the interviews. Participants reported mixed experiences with VC usage. All participants foresaw a future where both VC and in-person care was offered. A reported benefit of VC was convenience for patients. Challenges identified with VC included difficulty establishing new therapeutic relationships, and variable of abilities of both patients and health care providers to engage and communicate in a virtual format. Participants noted a preference for in-person care for more complex situations. Four themes were identified as considerations when selecting between in-person and VC: person's nonmedical context, support available, clinical parameters and tasks to be completed, and clinic operations. Participants indicated that visit modality selection is an individualized and ongoing process involving the patient and their preferences which may change over time. Health care provider participants noted that new workflow challenges were created when using both VC and in-person care in the same clinic session. Limitations Limited sample size in the setting of one-on-one interviews and use of convenience sampling which may result in missing perspectives, including those already facing challenges accessing care who could potentially be most disadvantaged by implementation of VC. Conclusions A list of key considerations, aligned with quality care delivery was identified for health care providers and programs to consider as they continue to utilize VC and refine how best to use different visit modalities in different patient and clinical situations. Further work will be needed to validate these findings and evaluate clinical outcomes with the combination of virtual and traditional modes of care delivery. Trial registration Not registered.
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Affiliation(s)
- Micheli Bevilacqua
- BC Renal, Vancouver, Canada
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
| | | | | | | | | | | | - Palvir Dhariwal
- Office of Virtual Health, Provincial Health Services Authority, Vancouver, BC, Canada
| | - Marlee McGuire
- Office of Virtual Health, Provincial Health Services Authority, Vancouver, BC, Canada
| | - Julie Wei
- Office of Virtual Health, Provincial Health Services Authority, Vancouver, BC, Canada
| | - Robin Chohan
- Office of Virtual Health, Provincial Health Services Authority, Vancouver, BC, Canada
| | | | - Michele Fryer
- Office of Virtual Health, Provincial Health Services Authority, Vancouver, BC, Canada
| | - Dominik Stoll
- Office of Virtual Health, Provincial Health Services Authority, Vancouver, BC, Canada
| | - Adeera Levin
- BC Renal, Vancouver, Canada
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
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11
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Vemu PL, Zurlo J, Lew SQ. Telehealth services in an outpatient nephrology clinic during the COVID-19 pandemic: a patient perspective. Int Urol Nephrol 2023; 55:3269-3274. [PMID: 37166551 PMCID: PMC10173904 DOI: 10.1007/s11255-023-03627-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 05/04/2023] [Indexed: 05/12/2023]
Abstract
PURPOSE In response to the COVID-19 pandemic, new policy waivers permitted reimbursement of telehealth services in urban settings. The aim of this study was to assess patient satisfaction with telehealth services during the COVID-19 pandemic in an outpatient urban nephrology practice. METHODS Patients who had virtual encounters were asked to complete an online survey regarding their experiences with telehealth services. RESULTS Twenty-one percent of eligible patients completed the survey. Patients (83.6%) reported overall positive experiences with telehealth and want to see a hybrid healthcare model in the future (80.1%). Additionally, most patients found telehealth appointments convenient to make and telehealth encounters convenient to conduct. Ethnicity, age, gender, and insurance type did not have a statistically significant impact on satisfaction ratings. Technical issues were not encountered by 79.5% of patients and patients were willing to use the video feature. However, if they had technical issues, patient satisfaction ratings were negatively impacted. CONCLUSION Telehealth services are beneficial to patients with regards to convenience, decreased transportation costs and time, increased accessibility to healthcare, and decreased overall opportunity costs. However, challenges still remain with the deployment of telehealth and will be dependent on patients' digital health literacy, access to broadband internet and devices, and legislation and/or regulations. Limitations of the study, including small sample size and surveying patients from a nephrology practice, may prevent it from being generalizable. Additional studies with a larger sample size and multiple specialties may be needed to generalize patients' satisfaction with telehealth services.
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Affiliation(s)
- Prasantha L Vemu
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jessica Zurlo
- Department of Psychiatry, Prisma Health/University of South Carolina School of Medicine Columbia, Columbia, SC, USA
| | - Susie Q Lew
- Department of Medicine, George Washington University, 2150 Pennsylvania Ave., NW, Rm 3-438, Washington, DC, 20037, USA.
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12
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Josephson MA, Becker Y, Budde K, Kasiske BL, Kiberd BA, Loupy A, Małyszko J, Mannon RB, Tönshoff B, Cheung M, Jadoul M, Winkelmayer WC, Zeier M. Challenges in the management of the kidney allograft: from decline to failure: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2023; 104:1076-1091. [PMID: 37236423 DOI: 10.1016/j.kint.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023]
Abstract
In March 2022, Kidney Disease: Improving Global Outcomes (KDIGO) held a virtual Controversies Conference to address the important but rarely examined phase during which the kidney transplant is failing or has failed. In addition to discussing the definition of a failing allograft, 4 broad areas were considered in the context of a declining functioning graft: prognosis and kidney failure trajectory; immunosuppression strategies; management of medical and psychological complications, and patient factors; and choice of kidney replacement therapy or supportive care following graft loss. Identifying and paying special attention to individuals with failing allografts was felt to be important in order to prepare patients psychologically, manage immunosuppression, address complications, prepare for dialysis and/or retransplantation, and transition to supportive care. Accurate prognostication tools, although not yet widely available, were embraced as necessary to define allograft survival trajectories and the likelihood of allograft failure. The decision of whether to withdraw or continue immunosuppression after allograft failure was deemed to be based most appropriately on risk-benefit analysis and likelihood of retransplantation within a few months. Psychological preparation and support was identified as a critical factor in patient adjustment to graft failure, as was early communication. Several models of care were noted that enabled a medically supportive transition back to dialysis or retransplantation. Emphasis was placed on the importance of dialysis-access readiness before initiation of dialysis, in order to avoid use of central venous catheters. The centrality of the patient to all management decisions and discussions was deemed to be paramount. Patient "activation," which can be defined as engaged agency, was seen as the most effective way to achieve success. Unresolved controversies, gaps in knowledge, and areas for research were also stressed in the conference deliberations.
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Affiliation(s)
- Michelle A Josephson
- Section of Nephrology, Department of Medicine, and Transplant Institute, University of Chicago, Chicago, Illinois, USA.
| | - Yolanda Becker
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Bertram L Kasiske
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Bryce A Kiberd
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Alexandre Loupy
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, F-75015 Paris, France; Department of Kidney Transplantation, Necker Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Roslyn B Mannon
- Division of Nephrology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Michael Cheung
- Kidney Disease: Improving Global Outcomes (KDIGO), Brussels, Belgium
| | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Martin Zeier
- Division of Nephrology, University of Heidelberg, Heidelberg, Germany.
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13
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Kelly JT, Jegatheesan DK, Dawson J, Barnett A, Khor BH, Chang AR, Carrero JJ, Campbell KL. Are Digital Health Technologies and Models of Nutrition Care the Future of Chronic Kidney Disease Management? J Ren Nutr 2023; 33:S80-S87. [PMID: 36965753 DOI: 10.1053/j.jrn.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 12/11/2022] [Accepted: 02/27/2023] [Indexed: 03/27/2023] Open
Abstract
People living with chronic kidney disease (CKD) require long-term support at varying levels of individualization, intensity, and frequency. Mobile and digital models of nutrition care can facilitate long-term behavior change, address nutrition issues proactively, reduce travel burden, and reach people without access to health care more easily. However, while traditional health delivery continues to be digitally disrupted, there are many barriers to address before mobile and digitally supported models of nutrition care can become business as usual in nephrology and nutrition care practice. This paper overviews the current evidence base concerning the past and present mobile and digital health programs to improve nutrition in CKD and highlights the novel future trends in this field. The way nutrition and dietetic care can be feasible, safe, and potentially effective when delivered using various digital and virtual technologies, including consultations, assessments, establishment of diagnoses, formulation of plans, and monitoring/reviewing clinical progress is discussed. Of the available evidence to date, these modalities appear to improve dietary sodium intake and diet quality, self-efficacy, interdialytic weight gain, and body weight. Many barriers exist to sustaining the continued and widespread adoption of digital and mobile health-supported nutrition care in CKD. These include patient-, clinician-, and health system-specific and are discussed in detail. Mobile and digital-supported models of nutrition care present an exciting opportunity to assist kidney dietitians deliver patient-centred nutrition care in CKD.
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Affiliation(s)
- Jaimon T Kelly
- Centre for Online Health, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.
| | - Dev K Jegatheesan
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia; Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Jessica Dawson
- Nutrition and Dietetics Department, St George Hospital, Sydney, New South Wales, Australia; NHMRC Clinical Trials Centre, The University of Sydney, Sydney, Australia
| | - Amandine Barnett
- Centre for Online Health, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Ban-Hock Khor
- Faculty of Food Science and Nutrition, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia
| | - Alex R Chang
- Center for Kidney Health Research, Geisinger Health, Danville, PA
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Division of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Katrina L Campbell
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Healthcare Excellence and Innovation, Metro North Hospital and Health Service, Brisbane, Australia
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Meena P, Abdellatif D, Tiwari V, Chatterjee S, Luyckx VA. Health Systems Preparedness for Infectious Disease Outbreaks: Relevance for Nephrology. Semin Nephrol 2023; 43:151465. [PMID: 38199828 DOI: 10.1016/j.semnephrol.2023.151465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
The coronavirus disease (COVID-19) crisis glaringly highlighted the critical need to develop resilient health care systems that are better prepared for epidemics. Millions of people died from COVID-19 itself, but almost three times as many died from health system disruptions. People living with kidney disease are highly vulnerable during outbreaks and pandemics and their needs must be included in preparedness planning. Health systems preparedness requires not only early identification and containment of outbreaks and maintenance of critical services during crises, but also bolstering population resilience and ensuring the safety of both health personnel and patients. Planning for surge capacity in an outbreak must include provision for both acute and chronic dialysis, and ensure access to medications for people with kidney diseases. Quality of care should not be compromised and must be monitored and improved where necessary. Technology, such as telemedicine, can support quality and continuity of care and minimize infection risks. Communication at all levels is crucial to ensure all stakeholders, including communities, have the necessary information to support cooperation and collaboration in effective outbreak responses. Research is important during and after pandemics to improve knowledge and build resilience at all levels, from outbreak detection to the development of therapeutics and optimizing equity in access to interventions. Only with adequate preparation and more resilient health systems can we hope, as a global community, to build on the harsh lessons learned during COVID-19, and improve the response to the next infectious disease outbreak, epidemic, or even pandemic.
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Affiliation(s)
- Priti Meena
- Department of Nephrology, All India Institute of Medical Sciences, Bhubaneswar, India
| | | | - Vaibhav Tiwari
- Institute of Renal Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | | | - Valerie A Luyckx
- Department of Public and Global Health, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland; Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa.
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Anderson NE, Kyte D, McMullan C, Cockwell P, Aiyegbusi OL, Verdi R, Calvert M. Global use of electronic patient-reported outcome systems in nephrology: a mixed methods study. BMJ Open 2023; 13:e070927. [PMID: 37438075 DOI: 10.1136/bmjopen-2022-070927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2023] Open
Abstract
OBJECTIVES The use of electronic patient-reported outcome (ePRO) systems to support the management of patients with chronic kidney disease is increasing. This mixed-methods study aimed to comprehensively identify existing and developing ePRO systems, used in nephrology settings globally, ascertaining key characteristics and factors for successful implementation. STUDY DESIGN ePRO systems and developers were identified through a scoping review of the literature and contact with field experts. Developers were invited to participate in a structured survey, to summarise key system characteristics including: (1) system objectives, (2) population, (3) PRO measures used, (4) level of automation, (5) reporting, (6) integration into workflow and (7) links to electronic health records/national registries. Subsequent semistructured interviews were conducted to explore responses. SETTING AND PARTICIPANTS Eligible systems included those being developed or used in nephrology settings to assess ePROs and summarise results to care providers. System developers included those with a key responsibility for aspects of the design, development or implementation of an eligible system. ANALYTICAL APPROACH Structured survey data were summarised using descriptive statistics. Interview transcripts were analysed using Codebook Thematic Analysis using domains from the Consolidated Framework for Implementation Research. RESULTS Fifteen unique ePRO systems were identified across seven countries; 10 system developers completed the structured survey and 7 participated in semistructured interviews. Despite system heterogeneity, reported features required for effective implementation included early and sustained patient involvement, clinician champions and expanding existing electronic platforms to integrate ePROs. Systems demonstrated several common features, with the majority being implemented within research settings, thereby affecting system implementation readiness for real-world application. CONCLUSIONS There has been considerable research investment in ePRO systems. The findings of this study outline key system features and factors to support the successful implementation of ePROs in routine kidney care.Cite Now.
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Affiliation(s)
- Nicola Elizabeth Anderson
- Institute of Applied Heath Research, Centre for Patient Reported Outcomes Research, University of Birmingham, Birmingham, UK
- Research, Development and Innovation, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- NIHR Applied Research Collaboration, West Midlands, University of Birmingham, Birmingham, UK
| | - Derek Kyte
- Institute of Applied Heath Research, Centre for Patient Reported Outcomes Research, University of Birmingham, Birmingham, UK
- School of Allied Health and Community, University of Worcester, Worcester, UK
| | - Christel McMullan
- Institute of Applied Heath Research, Centre for Patient Reported Outcomes Research, University of Birmingham, Birmingham, UK
- NIHR SRMRC, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
- NIHR Blood and Transplant Research Unit (BTRU) in Precision Transplant and Cellular Therapeutics, University of Birmingham, Birmingham, UK
| | - Paul Cockwell
- Institute of Applied Heath Research, Centre for Patient Reported Outcomes Research, University of Birmingham, Birmingham, UK
- Department of Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Olalekan Lee Aiyegbusi
- Institute of Applied Heath Research, Centre for Patient Reported Outcomes Research, University of Birmingham, Birmingham, UK
- NIHR Applied Research Collaboration, West Midlands, University of Birmingham, Birmingham, UK
- NIHR Blood and Transplant Research Unit (BTRU) in Precision Transplant and Cellular Therapeutics, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, Birmingham, UK
- Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK
| | - Rav Verdi
- Patient Partner, Institute of Applied Health Research,Centre for Patient-Reported Outcomes Research (CPROR), University of Birmingham, Birmingham, UK
| | - Melanie Calvert
- Institute of Applied Heath Research, Centre for Patient Reported Outcomes Research, University of Birmingham, Birmingham, UK
- NIHR Applied Research Collaboration, West Midlands, University of Birmingham, Birmingham, UK
- NIHR SRMRC, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
- NIHR Blood and Transplant Research Unit (BTRU) in Precision Transplant and Cellular Therapeutics, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, Birmingham, UK
- Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK
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Watson MA, Howle AM, Lenz O, Scalese RJ, King JD, Bolanos JA, Yuan CM. Adapting an Objective Structured Clinical Examination (OSCE) on Conducting Difficult Conversations Between Nephrology Fellows and Patients to a Virtual Platform: A Research Letter. Can J Kidney Health Dis 2023; 10:20543581221150553. [PMID: 36700058 PMCID: PMC9869226 DOI: 10.1177/20543581221150553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/05/2022] [Indexed: 01/19/2023] Open
Abstract
Background We previously described a nephrology-specific "Breaking Bad News" Objective Structured Clinical Examination (OSCE) assessing nephrology fellow communication and counseling skills in 3 scenarios: kidney replacement therapy (KRT) in kidney failure, urgent KRT in acute kidney injury (AKI), and kidney biopsy (KBx). Objective The main objectives of this study is to adapt the OSCE to a virtual platform, simulating nephrology patient telemedicine encounters involving difficult conversations, and to assess fellow and faculty satisfaction with the virtual format. Design Description of a formative telemedicine simulation for nephrology fellows. Setting Fully virtual simulation conducted by 2 academic medical simulation centers. Participants Nephrology faculty and fellows at 3 urban/suburban training programs in the eastern United States. Measurements Description of the virtual OSCE process. Fellow and faculty satisfaction overall and for each scenario. Faculty and fellow estimates of frequency of virtual patient encounters in the past year. Methods The OSCE consisted of 3 scenarios: KRT in kidney failure, urgent KRT in AKI, and KBx. Objective Structured Clinical Examinations were administered in May 2021. Each scenario lasted 20 minutes. The AKI scenario was audio only. Fellows telephoned a simulated patient surrogate for urgent KRT consent. Kidney failure and KBx scenarios were video encounters. Faculty observed while muted/video off. Immediately after the OSCE, fellows and faculty were anonymously surveyed regarding their satisfaction with each scenario, the OSCE overall, and their estimate of outpatient encounters and inpatient KRT counseling done virtually in the preceding year. Results Seventeen fellows completed the OSCE at 2 centers (3 programs). Sixteen (94%) completed the survey. Almost 94% rated the OSCE as a good/very good approximation of telemedicine encounters. Those satisfied/very satisfied with each scenario are as follow: 100% for AKI, 75% for kidney failure, and 75% for KBx. Two commented that they often did urgent KRT counseling by telephone. Fellows estimated a median 20% (interquartile range: 175, 50%) of counseling for acute inpatient KRT and a median 50% (IQR: 33.75, 70%) of outpatient encounters were virtual in the prior year. Two (regarding the kidney failure and KBx scenarios) indicated they would not have counseled similar outpatients virtually. Limitations The 15-minute interactions may be too short to allow the encounter to be completed comfortably. A small number of programs and fellows participated, and programs were located in urban/suburban areas on the east coast of the United States. Conclusions Overall, fellows felt that the OSCE was a good approximation of virtual encounters. The OSCE is an opportunity for fellows to practice telemedicine communication skills.
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Affiliation(s)
- Maura A. Watson
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Anna M. Howle
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | | | | | | | | | - Christina M. Yuan
- Walter Reed National Military Medical Center, Bethesda, MD, USA,Christina M. Yuan, Nephrology SVC, Department of Medicine, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA.
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George K, Subbiah A, Yadav RK, Bagchi S, Mahajan S, Bhowmik D, Agarwal SK. Utility and patient acceptance of telemedicine in nephrology. J Nephrol 2022; 35:2325-2331. [PMID: 36367662 PMCID: PMC9651110 DOI: 10.1007/s40620-022-01471-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 09/23/2022] [Indexed: 11/13/2022]
Abstract
PURPOSE There is an increasing burden of kidney diseases worldwide and access to specialist care is limited. Telemedicine, has been relatively less used in developing countries like India. The current study aims to assess the feasibility and acceptance of telenephrology services at our institute, a public hospital. METHODS A total of 150 patients were selected by stratified random sampling from the list of attendees who had undergone both in-person outpatient consultation and telenephrology consultation. Patient's attitude towards, and knowledge and acceptance of telenephrology services were evaluated. RESULTS The average age of the study cohort was 42.52 ± 15.1 years. More than one-third (39.3%) of our patients belonged to the lower middle socioeconomic class. The median distance traveled to reach our outpatient clinic was 113.5 km (3-2249 km). Patients reported lost workdays in 54.7% cases. The majority (95%) of patients managed to consult through teleservices successfully. Ninety percent of the patients gave a satisfaction score of 4 (out of 5) or above for their tele-consultation experience. The most important perceived benefit of teleconsultation was the reduced risk of infection (40.6%) followed by economic benefits (32%). The major disadvantage (36%) was the absence of physical examination. A combination of physical and telenephrology services was the option preferred by 84% of the patients. CONCLUSION In developing countries like India, with the majority of the population residing outside major cities and with limited medical access, telenephrology has a huge potential to provide quality nephrology care to the remotest parts of the country.
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Affiliation(s)
- Kristin George
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Arunkumar Subbiah
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Raj Kanwar Yadav
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Soumita Bagchi
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Sandeep Mahajan
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Dipankar Bhowmik
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Sanjay Kumar Agarwal
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, 110029, India
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An ISN-DOPPS survey of the global impact of the Coronavirus 2019 pandemic on peritoneal dialysis services. Kidney Int Rep 2022; 7:2196-2206. [PMID: 35941999 PMCID: PMC9349355 DOI: 10.1016/j.ekir.2022.07.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/08/2022] [Accepted: 07/11/2022] [Indexed: 12/18/2022] Open
Abstract
Introduction Home dialysis may minimize SARS-CoV2 exposure risks compared to center-based dialysis. We explored how the pandemic may have introduced challenges related to peritoneal dialysis (PD) supply availability, routine patient care, and how facility practices changed during this time. Methods The PD/Dialysis Outcomes and Practice Patterns Study (PDOPPS/DOPPS) and International Society of Nephrology (ISN) administered a web-based survey from November 2020 to March 2021. Medical director responses were compared across 10 ISN regions. Results One hundered sixy-five PD facilities in 51 countries returned surveys. During the initial COVID-19 wave, the reported frequency of in-person patient visits decreased in 9 of 10 ISN regions. Before the pandemic, most facilities required a mask during PD exchanges which continued over the course of the pandemic. Although most facilities in different regions did not report PD supply disruptions, sites in Africa and South Asia reported major disruptions. Reductions in laparoscopic surgical procedures for PD catheters were reported by facilities in 9 of 10 regions whereas nonsurgical percutaneous procedures increased in facilities in 6 regions. Training of new PD patients declined in facilities in each region. Increased use of remote technology by patients to communicate with clinics was observed in all regions compared to prepandemic levels. Conclusion Marked within-region and across-region variability was noted in PD facility burden, clinical practice, and adaptation to the COVID-19 pandemic. This study highlights opportunities to improve routine PD care, adapt to the ongoing pandemic, and increase preparedness for potential future interruptions in PD care.
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Physician eye contact in telemedicine video consultations: A cross-cultural experiment. Int J Med Inform 2022; 165:104825. [DOI: 10.1016/j.ijmedinf.2022.104825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/14/2022] [Accepted: 06/24/2022] [Indexed: 11/15/2022]
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Lew SQ, Sikka N. Telehealth and Kidney Disease Care: Role after the Public Health Emergency? Clin J Am Soc Nephrol 2021; 16:1784-1786. [PMID: 36630402 PMCID: PMC8729493 DOI: 10.2215/cjn.13651021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Susie Q. Lew
- Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University, Washington, DC
| | - Neal Sikka
- Department of Emergency Medicine, George Washington University, Washington, DC
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21
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Glennon J. Patient Views on Telehealth for Kidney Disease Care. Clin J Am Soc Nephrol 2021; 16:1773-1774. [PMID: 36630400 PMCID: PMC8729478 DOI: 10.2215/cjn.13531021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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