The Mobile Health Readiness of People Receiving In-Center Hemodialysis and Home Dialysis

Reach, Acceptability, and Patient Preferences of a Mobile Health-Based Survey to Assess COVID-19 Vaccine Hesitancy Among Patients Receiving Dialysis

Rationale & Objective

The majority of patients with kidney failure receiving dialysis own mobile devices, but the use of mobile health (mHealth) technologies to conduct surveys in this population is limited. We assessed the reach and acceptability of a short message service (SMS) text message-based survey that assessed coronavirus disease 2019 (COVID-19) vaccine hesitancy among patients receiving dialysis.

Study Design & Exposure

A cross-sectional SMS-based survey conducted in January 2021.

Setting & Participants

Patients receiving in-center hemodialysis, peritoneal dialysis, or home hemodialysis in a nonprofit dialysis organization in New York City.

Outcomes

(1) Reach of the SMS survey, (2) Acceptability using the 4-item Acceptability of Intervention Measure, and (3) Patient preferences for modes of survey administration.

Analytical Approach

We used Fisher exact tests and multivariable logistic regression to assess sociodemographic and clinical predictors of SMS survey response. Qualitative methods were used to analyze open-ended responses capturing patient preferences.

Results

Among 1,008 patients, 310 responded to the SMS survey (response rate 31%). In multivariable adjusted analyses, participants who were age 80 years and above (aOR, 0.49; 95% CI, 0.25-0.96) were less likely to respond to the SMS survey compared with those aged 18 to 44 years. Non-Hispanic Black (aOR, 0.58; 95% CI, 0.39-0.86), Hispanic (aOR, 0.31; 95% CI, 0.19-0.51), and Asian or Pacific Islander (aOR, 0.46; 95% CI, 0.28-0.74) individuals were less likely to respond compared with non-Hispanic White participants. Participants residing in census tracts with higher Social Vulnerability Index, indicating greater neighborhood-level social vulnerability, were less likely to respond to the SMS survey (fifth vs first quintile aOR, 0.61; 95% CI, 0.37-0.99). Over 80% of a sample of survey respondents and nonrespondents completely agreed or agreed with the Acceptability of Intervention Measure. Qualitative analysis identified 4 drivers of patient preferences for survey administration: (1) convenience (subtopics: efficiency, multitasking, comfort, and synchronicity); (2) privacy; (3) interpersonal interaction; and (4) accessibility (subtopics: vision, language, and fatigue).

Limitations

Generalizability, length of survey.

Conclusions

An SMS text message-based survey had moderate reach among patients receiving dialysis and was highly acceptable, but response rates were lower in older (age ≥ 80), non-White individuals and those with greater neighborhood-level social vulnerability. Future research should examine barriers and facilitators to mHealth among patients receiving dialysis to ensure equitable implementation of mHealth-based technologies.

Use of eHealth and remote patient monitoring: a tool to support home dialysis patients, with an emphasis on peritoneal dialysis

Implementing eHealth requires technological advancement, universal broadband and internet access, and devices to conduct telemedicine and remote patient monitoring in end-stage kidney disease patients receiving home dialysis. Although eHealth was beginning to make inroads in this patient population, the COVID-19 pandemic spurred telemedicine usage when many regulations were waived during the Public Health Emergency to limit the spread of infection by endorsing social distancing. At the same time, two-way communication automatic peritoneal dialysis cyclers were introduced to advance remote patient monitoring. Despite the numerous advantages and potential benefits afforded by both procedures, challenges and untapped resources remain to be addressed. Continuing research to assess the use of eHealth and technological innovation can make eHealth a powerful tool in home dialysis. We review the past, present and future of eHealth and remote patient monitoring in supporting home dialysis.

Patient Training and Patient Safety in Home Hemodialysis

The success of a home hemodialysis program depends largely on a patient safety framework and the risk tolerance of a home dialysis program. Dialysis treatments require operators to perform dozens of steps repeatedly and reliably in a complex procedure. For home hemodialysis, those operators are patients themselves or their care partners, so attention to safety and risk mitigation is front of mind. While newer, smaller, and more user-friendly dialysis machines designed explicitly for home use are slowly entering the marketplace, teaching patients to perform their own treatments in an unsupervised setting hundreds of times remains a foundational programmatic obligation regardless of machine. Just how safe is home hemodialysis? How does patient training affect this safety? There is a surprising lack of literature surrounding these questions. No consensus exists among home hemodialysis programs regarding optimized training schedules or methods, with each program adopting its own approach on the basis of local experience. Furthermore, there are little available data on the safety of home hemodialysis as compared with conventional in-center hemodialysis. This review will outline considerations for training patients on home hemodialysis, discuss the safety of home hemodialysis with an emphasis on the risk of serious and life-threatening adverse effects, and address the methods by which adverse events are monitored and prevented.

Can Telehealth Improve Access to Dietary Management in Patients Receiving Dialysis? Insights from Consumers

Timely, effective, and individualised dietary interventions are essential for patients undergoing dialysis. However, delivery of dietary advice is challenging due to limited access to renal dietitians, as well as logistic and scheduling difficulties for patients receiving dialysis. The objectives of this study were to explore consumer perspectives regarding dietary advice utilising telehealth technology. Twenty-two participants (seventeen patients receiving dialysis, five caregivers) were purposively recruited from a local dialysis centre and participated in one of three focus groups. Each focus group was recorded, transcribed, and analysed using inductive thematic analysis. One overarching theme: "a desire to learn" was apparent. The four themes that facilitated this process are herein described: Meaningful communication-a need for improved and individualised communication about diet using positively framed messages with consistency among clinicians. Conducive information-a preference for tailored, current, and clear dietary information (plain language was preferred, with practical advice on making dietary changes). Appropriate timing-health advice at the right time (consumers felt overwhelmed, not supported enough with timely advice, and experienced difficulty attending appointments in addition to dialysis treatments). Contemporary modalities-delivering information using different technologies (consumers preferred a combination of delivery methods for dietetic advice including text/SMS/App messages as an adjunct to face-to-face care). The results showed that consumers believe that telehealth options are an acceptable adjunct to receive dietary advice in a timely manner, and feedback from patients and caregivers has informed the design of a clinical trial to incorporate the use of telehealth to improve the management of serum phosphate.

Expectation of clinical decision support systems: a survey study among nephrologist end-users

BACKGROUND

Chronic kidney disease (CKD), a major public health problem with differing disease etiologies, leads to complications, comorbidities, polypharmacy, and mortality. Monitoring disease progression and personalized treatment efforts are crucial for long-term patient outcomes. Physicians need to integrate different data levels, e.g., clinical parameters, biomarkers, and drug information, with medical knowledge. Clinical decision support systems (CDSS) can tackle these issues and improve patient management. Knowledge about the awareness and implementation of CDSS in Germany within the field of nephrology is scarce.

PURPOSE

Nephrologists' attitude towards any CDSS and potential CDSS features of interest, like adverse event prediction algorithms, is important for a successful implementation. This survey investigates nephrologists' experiences with and expectations towards a useful CDSS for daily medical routine in the outpatient setting.

METHODS

The 38-item questionnaire survey was conducted either by telephone or as a do-it-yourself online interview amongst nephrologists across all of Germany. Answers were collected and analysed using the Electronic Data Capture System REDCap, as well as Stata SE 15.1, and Excel. The survey consisted of four modules: experiences with CDSS (M1), expectations towards a helpful CDSS (M2), evaluation of adverse event prediction algorithms (M3), and ethical aspects of CDSS (M4). Descriptive statistical analyses of all questions were conducted.

RESULTS

The study population comprised 54 physicians, with a response rate of about 80-100% per question. Most participants were aged between 51-60 years (45.1%), 64% were male, and most participants had been working in nephrology out-patient clinics for a median of 10.5 years. Overall, CDSS use was poor (81.2%), often due to lack of knowledge about existing CDSS. Most participants (79%) believed CDSS to be helpful in the management of CKD patients with a high willingness to try out a CDSS. Of all adverse event prediction algorithms, prediction of CKD progression (97.8%) and in-silico simulations of disease progression when changing, e. g., lifestyle or medication (97.7%) were rated most important. The spectrum of answers on ethical aspects of CDSS was diverse.

CONCLUSION

This survey provides insights into experience with and expectations of out-patient nephrologists on CDSS. Despite the current lack of knowledge on CDSS, the willingness to integrate CDSS into daily patient care, and the need for adverse event prediction algorithms was high.

Digital literacy as a new determinant of health: A scoping review

INTRODUCTION

Harnessing new digital technologies can improve access to health care but can also widen the health divide for those with poor digital literacy. This scoping review aims to assess the current situation of low digital health literacy in terms of its definition, reach, impact on health and interventions for its mitigation.

METHODS

A comprehensive literature search strategy was composed by a qualified medical librarian. Literature databases [Medline (Ovid), Embase (Ovid), Scopus, and Google Scholar] were queried using appropriate natural language and controlled vocabulary terms along with hand-searching and citation chaining. We focused on recent and highly cited references published in English. Reviews were excluded. This scoping review was conducted following the methodological framework of Arksey and O'Malley.

RESULTS

A total of 268 articles were identified (263 from the initial search and 5 more added from the references of the original papers), 53 of which were finally selected for full text analysis. Digital health literacy is the most frequently used descriptor to refer to the ability to find and use health information with the goal of addressing or solving a health problem using technology. The most utilized tool to assess digital health literacy is the eHealth literacy scale (eHEALS), a self-reported measurement tool that evaluates six core dimensions and is available in various languages. Individuals with higher digital health literacy scores have better self-management and participation in their own medical decisions, mental and psychological state and quality of life. Effective interventions addressing poor digital health literacy included education/training and social support.

CONCLUSIONS

Although there is interest in the study and impact of poor digital health literacy, there is still a long way to go to improve measurement tools and find effective interventions to reduce the digital health divide.

Transition of Kidney Care at 18: Challenges and Practical Solutions for India

Health-care transition (HCT) from pediatric-centered to adult-oriented health-care setting is more than a simple transfer of care. It is a carefully planned movement specially tailored for the needs of adolescents and young adults (AYAs). Similar to other chronic diseases, the need for HCT for AYAs with kidney disease has been well established by the International Society of Nephrology (ISN) and the International Pediatric Nephrology Association (IPNA) consensus statements since 2011. However, successful HCT in India and other low- and middle-income countries (LMICs) has been limited. Undertaking the HCT program in India requires involvement of many stakeholders, that is, AYAs, parents/caregivers, health-care providers, and the health-care system. In this article, we discuss the need for HCT, the challenges faced during the transition, and the recommended models for HCT in kidney care. We focus on the unique challenges faced in India and conclude with practical suggestions to implement HCT in our setting.

The potential of mHealth for older adults on dialysis and their care partners: What's been done and where do we go from here?

Self-care, or the dynamic, daily process of becoming actively involved in one's own care, is paramount to prevent and manage complications of end-stage kidney disease. However, many older dialysis patients face distinctive challenges to adequate engagement in self-care. One promising strategy for facilitating self-care among older dialysis patients and their care partners is the utilization of mobile health (mhealth). mHealth encompasses mobile and wireless communication devices used to improve healthcare delivery, patient and care partner outcomes, and patient care. In other disease populations, mHealth has been linked to maintenance of or improvements in self-management, medication compliance, patient education, and patient-provider communication, all of which can slow disease progression. Although mHealth is considered feasible, acceptable, and clinically useful, this technology has predominately targeted younger patients. Thus, there is a need to develop mHealth for older dialysis patients and their care partners. In this article, we describe current mHealth usage in older dialysis patients, including promising findings, challenges, and research gaps. Given the lack of research on mHealth among care partners of older dialysis patients, we highlight lessons learned from other disease populations to inform the future design and implementation of mHealth for these key stakeholders. We also propose that leveraging care partners represents an opportunity to meaningfully tailor mHealth applications and, by extension, improve care partner physical and mental health and decrease caregiver burden. We conclude with a summary of future directions to help older dialysis patients and their care partners receive recognition as target end-users amid the constant evolution of mHealth.

Pilot Study of a Wearable Hydration Monitor in Haemodialysis Patients: Haemodialysis Outcomes & Patient Empowerment Study 02

Introduction

We aimed to assess the validity and reproducibility of a wearable hydration device in a cohort of maintenance dialysis patients.

Methods

We conducted a prospective, single-arm observational study on 20 haemodialysis patients between January and June 2021 in a single centre. A prototype wearable infrared spectroscopy device, termed the Sixty device, was worn on the forearm during dialysis sessions and nocturnally. Bioimpedance measurements were performed 4 times using the body composition monitor (BCM) over 3 weeks. Measurements from the Sixty device were compared with the BCM overhydration index (litres) pre- and post-dialysis and with standard haemodialysis parameters.

Results

12 out of 20 patients had useable data. Mean age was 52 ± 12.4 years. The overall accuracy for predicting pre-dialysis categories of fluid status using Sixty device was 0.55 [K = 0.00; 95% CI: -0.39-0.42]. The accuracy for the prediction of post-dialysis categories of volume status was low [accuracy = 0.34, K = 0.08; 95% CI: -0.13-0.3]. Sixty outputs at the start and end of dialysis were weakly correlated with pre- and post-dialysis weights (r = 0.27 and r = 0.27, respectively), as well as weight loss during dialysis (r = 0.31), but not ultrafiltration volume (r = 0.12). There was no difference between the change in Sixty readings overnight and the change in Sixty readings during dialysis (mean difference 0.09 ± 1.5 kg), [t(39) = 0.38, p = 0.71].

Conclusion

A prototype wearable infrared spectroscopy device was unable to accurately assess changes in fluid status during or between dialysis sessions. In the future, hardware development and advances in photonics may enable the tracking of interdialytic fluid status.

Digital health technologies to support medication adherence in chronic kidney disease

Non-adherence to medications is a critical challenge in the management of people with chronic kidney disease (CKD). This review explores the complexities of adherence in this population, the unique barriers and enablers of good adherence behaviours, and the role of emerging digital health technologies in bridging the gap between evidence-based treatment plans and the real-world standard of care. We present the current evidence supporting the use of digital health interventions among CKD populations, identifying the key research questions that remain unanswered, and providing practical strategies for clinicians to support medication adherence in a digital age.

Comparison of Acoustic Voice Features Derived From Mobile Devices and Studio Microphone Recordings

OBJECTIVES/HYPOTHESIS

Improvements in mobile device technology offer new opportunities for remote monitoring of voice for home and clinical assessment. However, there is a need to establish equivalence between features derived from signals recorded from mobile devices and gold standard microphone-preamplifiers. In this study acoustic voice features from android smartphone, tablet, and microphone-preamplifier recordings were compared.

METHODS

Data were recorded from 37 volunteers (20 female) with no history of speech disorder and six volunteers with Huntington's disease (HD) during sustained vowel (SV) phonation, reading passage (RP), and five syllable repetition (SR) tasks. The following features were estimated: fundamental frequency median and standard deviation (F0 and SD F0), harmonics-to-noise ratio (HNR), local jitter, relative average perturbation of jitter (RAP), five-point period perturbation quotient (PPQ5), difference of differences of amplitude and periods (DDA and DDP), shimmer, and amplitude perturbation quotients (APQ3, APQ5, and APQ11).

RESULTS

Bland-Altman analysis revealed good agreement between microphone and mobile devices for fundamental frequency, jitter, RAP, PPQ5, and DDP during all tasks and a bias for HNR, shimmer and its variants (APQ3, APQ5, APQ11, and DDA). Significant differences were observed between devices for HNR, shimmer, and its variants for all tasks. High correlation was observed between devices for all features, except SD F0 for RP. Similar results were observed in the HD group for SV and SR task. Biological sex had a significant effect on F0 and HNR during all tests, and for jitter, RAP, PPQ5, DDP, and shimmer for RP and SR. No significant effect of age was observed.

CONCLUSIONS

Mobile devices provided good agreement with state of the art, high-quality microphones during structured speech tasks for features derived from frequency components of the audio recordings. Caution should be taken when estimating HNR, shimmer and its variants from recordings made with mobile devices.

Understanding the Drivers of Ghanaian Citizens' Adoption Intentions of Mobile Health Services

Mobile health (m-health) application development and diffusion in developing countries have always been a challenge; therefore, research that seeks to provide an elucidation of the drivers of m-Health adoption is vital. Mobile health information systems and applications can contribute to the delivery of a good healthcare system. This study examined the factors influencing citizens' adoption of mobile health services. The Technology Acceptance Model (TAM) was used as the research underpinning for this study, while the data gathered were analyzed with SmartPLS through the use of the structural equation modeling technique. The results showed that perceived usefulness and ease of use were both significant predictors of the behavioral intention to use and recommend the adoption of mobile health services. Also, perceived risk was negative but significant in predicting the intention to use and recommend adoption. Mobile self-efficacy was found to significantly determine the behavioral intention to use, intention to recommend, perceived usefulness, and perceived ease of use of mobile health services. Besides, word-of-mouth showed a positive impact on both the intention to use and recommend. Contrary to expectations, the intention to use had no significant impact on the recommendation intention. The theoretical and practical implications of these findings are thoroughly examined.

[Long-term physical and psychological consequences of chronic kidney disease]

Aufgrund der verbesserten Behandlungsoptionen können Patient:innen mit chronischen Nierenerkrankungen heute deutlich länger überleben als noch vor 10 Jahren. Das Überleben ist für die Betroffenen jedoch immer mit einem Verlust an Lebensqualität verbunden. In diesem Beitrag wird eine kurze Übersicht über die körperlichen und psychischen Erkrankungsfolgen, Begleiterkrankungen und Therapienebenwirkungen bei chronischen Nierenerkrankungen gegeben. Auf bisher bekannte Auswirkungen der COVID-19-Pandemie wird hingewiesen. Abschließend wird aufgezeigt, wie die Langzeitbehandlung weiterentwickelt werden sollte, um die Lebensqualität der Patient:innen zu erhöhen.

Funktionseinschränkungen der Niere haben aufgrund der Kontamination des Blutes mit harnpflichtigen Substanzen (Urämie) schwere Auswirkungen auf den Gesamtorganismus. Zusätzlich sind die Patient:innen von Nebenwirkungen betroffen, die im Zusammenhang mit der medikamentösen Therapie, Dialyse oder Nierentransplantation auftreten können. Patient:innen und Angehörige sind einer großen psychischen Belastung ausgesetzt. Infektionen mit SARS-CoV‑2 können die Nierenfunktion beeinträchtigen und auch die Prognose einer bereits bestehenden Erkrankung verschlechtern.

Die ganzheitliche Versorgung der Patient:innen mit chronischen Nierenerkrankungen muss neben der medizinischen Versorgung auch die psychologischen und psychosozialen Aspekte berücksichtigen. Nephrologie und Psychonephrologie müssen Hand in Hand weiterentwickelt werden, um die medizinische Versorgung und Lebensqualität der betroffenen Patient:innen zu verbessern.

Smartphone and application use in self-management of chronic kidney disease: a cross-sectional feasibility study

INTRODUCTION

Smartphone and application use can improve communication and monitoring of chronic diseases, including chronic kidney disease, through self-management and increased adherence to treatment.

OBJECTIVE

To assess smartphone use in patients with chronic kidney disease on dialysis and their willingness to use mobile applications as a disease self-management strategy.

DESIGN AND SETTING

This was a cross-sectional study of chronic kidney disease patients on hemodialysis in the São Francisco Valley in the Northeast Region, Brazil.

METHODS

The questionnaire developed by the authors was administered between April and June 2021. Cronbach's alpha coefficient for the construct was 0.69. Associations between the dependent and independent variables were determined using univariate analysis. Multivariate analysis with logistic regression analysis was also performed.

RESULTS

A total of 381 patients were included, of whom 64% had a smartphone, although only 3.1% knew of a kidney disease-related application. However, 59.3% believed that using an application could help them manage their disease. Having a smartphone was associated with treatment adherence, higher educational attainment, and higher per capita income. Educational attainment remained an independent factor in multivariate analysis.

CONCLUSION

More than 64% of patients had a smartphone, although few knew of applications developed for kidney disease. More than half of the population believed that technology use could benefit chronic kidney disease treatment. Smartphone ownership was more common among the younger population, with higher educational attainment and income, and was associated with greater adherence to hemodialysis sessions.

Impact of technology-based interventions on linking potential kidney donors and transplant candidates: a scoping review

Despite the demonstrated survival advantage in end-stage kidney disease (ESKD) patients of a preemptive living donor kidney transplantation (LDKT), there has been a decline in LDKT among African American and Hispanic populations. We performed a scoping review and summarized the evidence about the use of technology-based interventions (TBI) to not only increase knowledge and awareness of LDKT but also link living donors with transplant candidates. We evaluated 31 studies and characterized them into "transplant-candidate facing" TBI, "transplant donor facing" TBI, and "interactive websites" targeting both donors and candidates. For the patient-facing interventions, 60% of studies suggested an increased likelihood of linking possible donors and candidates. The donor-facing interventions showed an increase in donor awareness and 75% of these interventions suggested increasing donor-candidate linkage. This study also demonstrates that TBI (regardless of medium) that are accessible and customized to the specific target population can potentially increase linkage of donors to recipients and serve as effective guides to connect potential donors to transplant candidates.

Integrating Patient Activation Into Dialysis Care

Patient activation, the measure of patients' readiness and willingness to manage their own health care, is low among people receiving in-center hemodialysis, which is exacerbated because such centers are commonly set up for patients to passively receive care. In our pursuit of person-centered care and value-based medicine, enabling patients to take a more active role in their care can lead to healthy behaviors, with subsequent reductions in individual burden and costs to the health care system. To improve patient activation, we need to embrace a patient-first approach and combine it with ways to equip patients to thrive with self-management. This requires changes in the training of the health care team as well as changes in care delivery models, promoting interventions such as health coaching and peer mentoring, while leveraging technology to enable self-access to records, self-monitoring, and communication with providers. We also need health care policies that encourage a focus on patient-identified goals, including more attention to patient-reported outcomes. In this article, we review the current status of patient activation in dialysis patients, outline some of the available interventions, and propose steps to change the dynamics of the current system to move toward a more active role for patients in their care.

SARS-CoV-2 Vaccine Acceptability in Patients on Hemodialysis: A Nationwide Survey

BACKGROUND

Patients on dialysis are at increased risk for COVID-19-related complications. However, a substantial fraction of patients on dialysis belong to groups more likely to be hesitant about vaccination.

METHODS

With the goal of identifying strategies to increase COVID-19 vaccine uptake among patients on hemodialysis, we conducted a nationwide vaccine acceptability survey, partnering with a dialysis network to distribute an anonymized English and Spanish language online survey in 150 randomly selected facilities in the United States. We used logistic regression to evaluate characteristics of vaccine-hesitant persons.

RESULTS

A total of 1515 (14% of eligible) patients responded; 20% of all responders, 29% of patients aged 18-44 years, and 29% of Black responders reported being hesitant to seek the COVID-19 vaccine, even if the vaccine was considered safe for the general population. Odds of vaccine hesitancy were higher among patients aged 18-44 years versus those 45-64 years (odds ratio [OR], 1.5; 95% confidence interval [95% CI], 1.0 to 2.3), Black patients versus non-Hispanic White patients (OR, 1.9; 95% CI, 1.3 to 2.7), Native Americans or Pacific Islanders versus non-Hispanic White patients (OR, 2.0; 95% CI, 1.1 to 3.7), and women versus men (OR, 1.6; 95% CI, 1.2 to 2.0). About half (53%) of patients who were vaccine hesitant expressed concerns about side effects. Responders' main information sources about COVID-19 vaccines were television news and dialysis staff (68% and 38%, respectively).

CONCLUSIONS

A substantial proportion of patients receiving in-center hemodialysis in the United States are hesitant about seeking COVID-19 vaccination. Facilitating uptake requires outreach to younger patients, women, and Black, Native American, or Pacific Islander patients, and addressing concerns about side effects.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/JASN/2021_07_07_JASN2021010104.mp3.

Innovations to Increase Home Hemodialysis Utilization: The Transitional Care Unit

A large proportion of patients undergoing incident dialysis start in-center hemodialysis with suboptimal preparation and predialysis education. Transitional care units deliver a structured program by dedicated staff, with less patient-to-staff ratios than in regular in-center dialysis care, with the goals of supporting the emotional and physical well-being of patients while providing them with education and equipping them with the right tools to start their journey on dialysis. Key components of these programs include an emphasis on patient activation and self-management, educating and supporting patients to make informed modality choices, timely coordination of care, and an integrated approach to formation and use of the dialysis access. While data are still limited on best practices and on outcomes of these programs at a large scale, endorsing the model of transitional care units is a step in the right direction to fill the gap in our current care system.