Are patients prepared to use telemedicine in home peritoneal dialysis programs?

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.

Intelligent "Internet Plus" services in the first case of home hemodialysis in mainland China

BACKGROUND

Many studies have shown that compared with those who use other dialysis modalities, patients using home hemodialysis (HHD) have an increased rate of survival and better quality of life. It was noted in 2006 that there was opportunity for significant expansion of the use of HHD in many countries. China covers a vast area and has a large amount of end-stage renal failure patients. But in mainland China, all dialysis treatments are in-center, and the number of HHD patients is zero. In 2018, our hospital received the permission of the Shanghai government to carry out HHD.

CASE PRESENTATION

We initiated four incident hemodialysis patients on an HHD regimen, one patient has been dialyzed in the home safely for 8 months. The biochemical parameters of the first patient remained stable on the regimen and he achieved standard Kt/V urea targets. Treatment-related adverse events were not reported during the follow-up. We combined HHD with intelligent "Internet Plus" real-time remote monitoring and introduced the Internet, especially visualization software, to replace traditional telephone and home visit methods. It is more intuitive and quicker to assist patients in performing home hemodialysis and improve the safety of treatment.

CONCLUSIONS

HHD can be performed by selected trained patients in mainland China. Combined with the internet, visualization software, and traditional telephone and home visits, it is intuitive and quick to assist patients in carrying out HHD and improve the safety of treatment. HHD broadens the choices for uremia patients in China.

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

BACKGROUND AND OBJECTIVES

Mobile health is the health care use of mobile devices, such as smartphones. Mobile health readiness is a prerequisite to successful implementation of mobile health programs. The aim of this study was to examine the status and correlates of mobile health readiness among individuals on dialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A cross-sectional 30-item questionnaire guided by the Khatun mobile health readiness conceptual model was distributed to individuals on dialysis from 21 in-center hemodialysis facilities and 14 home dialysis centers. The survey assessed the availability of devices and the internet, proficiency, and interest in using mobile health.

RESULTS

In total, 949 patients (632 hemodialysis and 317 home dialysis) completed the survey. Of those, 81% owned smartphones or other internet-capable devices, and 72% reported using the internet. The majority (70%) reported intermediate or advanced mobile health proficiency. The main reasons for using mobile health were appointments (56%), communication with health care personnel (56%), and laboratory results (55%). The main reported concerns with mobile health were privacy and security (18%). Mobile health proficiency was lower in older patients: compared with the 45- to 60-years group, respondents in age groups <45, 61-70, and >70 years had adjusted odds ratios of 5.04 (95% confidence interval, 2.23 to 11.38), 0.39 (95% confidence interval, 0.24 to 0.62), and 0.22 (95% confidence interval, 0.14 to 0.35), respectively. Proficiency was lower in participants with Hispanic/Latinx ethnicity (adjusted odds ratio, 0.49; 95% confidence interval, 0.31 to 0.75) and with less than college education (adjusted odds ratio for "below high school," 0.09; 95% confidence interval, 0.05 to 0.16 and adjusted odds ratio for "high school only," 0.26; 95% confidence interval, 0.18 to 0.39). Employment was associated with higher proficiency (adjusted odds ratio, 2.26; 95% confidence interval, 1.18 to 4.32). Although home dialysis was associated with higher proficiency in the unadjusted analyses, we did not observe this association after adjustment for other factors.

CONCLUSIONS

The majority of patients on dialysis surveyed were ready for, and proficient in, mobile health. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER DIALYSIS MHEALTH SURVEY,: NCT04177277.

Telehealth for Home Dialysis in COVID-19 and Beyond: A Perspective From the American Society of Nephrology COVID-19 Home Dialysis Subcommittee

The coronavirus disease 2019 (COVID-19) pandemic, technological advancements, regulatory waivers, and user acceptance have converged to boost telehealth activities. Due to the state of emergency, regulatory waivers in the United States have made it possible for providers to deliver and bill for services across state lines for new and established patients through Health Insurance Portability and Accountability Act (HIPAA)- and non–HIPAA-compliant platforms with home as the originating site and without geographic restrictions. Platforms have been developed or purchased to perform videoconferencing, and interdisciplinary dialysis teams have adapted to perform virtual visits. Telehealth experiences and challenges encountered by dialysis providers, clinicians, nurses, and patients have exposed health care disparities in areas such as access to care, bandwidth connectivity, availability of devices to perform telehealth, and socioeconomic and language barriers. Future directions in telehealth use, quality measures, and research in telehealth use need to be explored. Telehealth during the public health emergency has changed the practice of health care, with the post–COVID-19 world unlikely to resemble the prior era. The future impact of telehealth in patient care in the United States remains to be seen, especially in the context of the Advancing American Kidney Health Initiative.

Remote Treatment Monitoring on Hospitalization and Technique Failure Rates in Peritoneal Dialysis Patients

BACKGROUND

An integrated kidney disease healthcare company implemented a peritoneal dialysis (PD) remote treatment monitoring (RTM) application in 2016. We assessed if RTM utilization associates with hospitalization and technique failure rates.

METHODS

We used data from adult (age ≥18 years) patients on PD treated from October 2016 through May 2019 who registered online for the RTM. Patients were classified by RTM use during a 30-day baseline after registration. Groups were: nonusers (never entered data), moderate users (entered one to 15 treatments), and frequent users (entered >15 treatments). We compared hospital admission/day and sustained technique failure (required >6 consecutive weeks of hemodialysis) rates over 3, 6, 9, and 12 months of follow-up using Poisson and Cox models adjusted for patient/clinical characteristics.

RESULTS

Among 6343 patients, 65% were nonusers, 11% were moderate users, and 25% were frequent users. Incidence rate of hospital admission was 22% (incidence rate ratio [IRR]=0.78; P=0.002), 24% (IRR=0.76; P<0.001), 23% (IRR=0.77; P≤0.001), and 26% (IRR=0.74; P≤0.001) lower in frequent users after 3, 6, 9, and 12 months, respectively, versus nonusers. Incidence rate of hospital days was 38% (IRR=0.62; P=0.013), 35% (IRR=0.65; P=0.001), 34% (IRR=0.66; P≤0.001), and 32% (IRR=0.68; P<0.001) lower in frequent users after 3, 6, 9, and 12 months, respectively, versus nonusers. Sustained technique failure risk at 3, 6, 9, and 12 months was 33% (hazard ratio [HR]=0.67; P=0.020), 31% (HR=0.69; P=0.003), 31% (HR=0.69; P=0.001), and 27% (HR=0.73; P=0.001) lower, respectively, in frequent users versus nonusers. Among a subgroup of survivors of the 12-month follow-up, sustained technique failure risk was 26% (HR=0.74; P=0.023) and 21% (HR=0.79; P=0.054) lower after 9 and 12 months, respectively, in frequent users versus nonusers.

CONCLUSIONS

Our findings suggest frequent use of an RTM application associates with less hospital admissions, shorter hospital length of stay, and lower technique failure rates. Adoption of RTM applications may have the potential to improve timely identification/intervention of complications.

Telehealth awareness in a US urban peritoneal dialysis clinic: From 2018 to 2019

The 2018 Bipartisan Budget Act in the United States extended telehealth access to Medicare beneficiaries who receive home dialysis in which two of three monthly visits in a quarter may be performed by telehealth after three initial face-to-face monthly visits. The originating site (where the patient is located) can be a dialysis unit or the patient's home and without geographic restriction. Patient awareness and interest in this new telehealth benefit in urban patients has not been well characterized. Patients receiving peritoneal dialysis (PD) treatment located in an urban facility completed a survey to ascertain knowledge of telehealth and readiness and willingness to participate in telehealth for their monthly visit. A total of 30 patients participated: 37% who completed the survey had heard of telehealth and 40% were able to define telehealth in words and correctly identify an example of telehealth. None of the patients were aware of the 2018 US Bipartisan Budget Act which extended telehealth assess to Medicare beneficiaries. Almost everyone had a mobile phone (83%), owned a computer (50%), and had access to Internet services (90%). The majority of patients (73%) were willing to use telehealth services for their monthly visit with the physician. PD patients living in an urban setting appear to be ready and interested in using telehealth to perform their monthly visit with the physician.

Measuring quality and impact of telehealth services in home dialysis patients

US Medicare beneficiaries receiving home dialysis will have the opportunity to engage in telehealth beginning in 2019. This new paradigm, if successful, will be instituted internationally. Any changes in healthcare delivery, such as using telehealth, will affect the process and quality. Quality of care metrics is discussed, and they can be used to evaluate the three domains of structure, process, and outcome when applied to assess telehealth’s impact and quality on the dialysis population.

Operationalizing Telehealth for Home Dialysis Patients in the United States

Until January 2019, Medicare beneficiaries requiring maintenance dialysis therapy were eligible for telehealth services only if the originating site was located in a rural area and the patient was situated in an authorized facility. Free-standing dialysis facilities and the patient's home were clearly restricted sites. Beginning in 2019, new opportunities are available for home dialysis patients in the United States to engage in telehealth; these include existing waivers within End-Stage Renal Disease (ESRD) Seamless Care Organizations (ESCOs) participating in the Comprehensive ESRD Care demonstration project and, more broadly, for most prevalent home dialysis patients based on legislation within the 2018 Bipartisan Budget Act. Under this act, Medicare will pay for a monthly comprehensive telehealth encounter with the patient that originates from his or her home or a dialysis unit without geographic restrictions. The home dialysis patient has the sole power to choose the telehealth option, which may occur twice over a 3-month cycle and cannot occur during the first 3 months of home dialysis therapy. With studies suggesting that effective use of remote monitoring and telehealth encounters may improve patient satisfaction and outcomes while reducing the cost of care, increased use of telehealth has the potential to improve patient-centered care for home dialysis patients. In this perspective, we review the legislative changes, regulatory requirements, and technical and operational challenges for conducting telehealth encounters for home dialysis patients.

The impact of a remote monitoring system of healthcare resource consumption in patients on automated peritoneal dialysis (APD): A simulation study

Aims: Remote monitoring (RM) can improve management of chronic diseases. We evaluated the impact of RM in automated peritoneal dialysis (APD) in a simulation study. Materials and methods: We simulated 12 patient scenarios with common clinical problems and estimated the likely healthcare resource consumption with and without the availability of RM (RM+ and RM– groups, respectively). Scenarios were evaluated 4 times by randomly allocated nephrologist-nurse teams or nephrologist-alone assessors. Results: The RM+ group was assessed as having significantly lower total healthcare resource consumption compared with the RM– group (36.8 vs. 107.5 total episodes of resource consumption, p = 0.002). The RM+ group showed significantly lower “unplanned hospital visits” (2.3 vs. 11.3, p = 0.005), “emergency room visits” (0.5 vs. 5.3, p = 0.003), “home visits” (0.5 vs. 5.8, p = 0.016), “exchanges over the telephone” (18.5 vs. 57.8, p = 0.002), and “change to hemodialysis” (0.5 vs. 2.5, p = 0.003). Evaluations did not differ between nephrologist-nurse teams vs. nephrologist-alone assessors. Conclusion: RM can be expected to reduce healthcare resource consumption in APD patients.

Exploring Barriers and Potential Solutions in Home Dialysis: An NKF-KDOQI Conference Outcomes Report

Home dialysis therapy, including home hemodialysis and peritoneal dialysis, is underused as a modality for the treatment of chronic kidney failure. The National Kidney Foundation-Kidney Disease Outcomes Quality Initiative sponsored a home dialysis conference in late 2017 that was designed to identify the barriers to starting and maintaining patients on home dialysis therapy. Clinical, operational, policy, and societal barriers were identified that need to be overcome to ensure that dialysis patients have the freedom to choose their treatment modality. Education of patients and patient partners, as well as health care providers, about home dialysis therapy, if offered at all, is often provided in a cursory manner. Lack of exposure to home dialysis therapies perpetuates a lack of familiarity and thus a hesitancy to refer patients to home dialysis therapies. Patient and care partner support, both psychosocial and financial, is also critical to minimize the risk for burnout leading to dropout from a home dialysis modality. Thus, the facilitation of home dialysis therapy will require a systematic change in chronic kidney disease education and the approach to dialysis therapy initiation, the creation of additional incentives for performing home dialysis, and breakthroughs to simplify the performance of home dialysis modalities. The home dialysis work group plans to develop strategies to overcome these barriers to home dialysis therapy, which will be presented at a follow-up home dialysis conference.

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.

Remote Patient Management for Home Dialysis Patients

Remote patient management (RPM) offers renal health care providers and patients with end-stage kidney disease opportunities to embrace home dialysis therapies with greater confidence and the potential to obtain better clinical outcomes. Barriers and evidence required to increase adoption of RPM by the nephrology community need to be clearly defined. Ten health care providers from specialties including nephrology, cardiology, pediatrics, epidemiology, nursing, and health informatics with experience in home dialysis and the use of RPM systems gathered in Vienna, Austria to discuss opportunities for, barriers to, and system requirements of RPM as it applies to the home dialysis patient. Although improved outcomes and cost-effectiveness of RPM have been demonstrated in patients with diabetes mellitus and heart disease, only observational data on RPM have been gathered in patients on dialysis. The current review focused on RPM systems currently in use, on how RPM should be integrated into future care, and on the evidence needed for optimized implementation to improve clinical and economic outcomes. Randomized controlled trials and/or large observational studies could inform the most effective and economical use of RPM in home dialysis. These studies are needed to establish the value of existing and/or future RPM models among patients, policy makers, and health care providers.

Satisfaction and Improvements in Peritoneal Dialysis Outcomes Associated with Telehealth

BACKGROUND AND SIGNIFICANCE

End stage renal disease (ESRD) affects approximately 660,000 persons in the US each year, representing a significant financial burden to the health care system and affected individuals. Telehealth approaches to care offer an important means of reducing costs as well as increasing autonomy for patients. Understanding patient satisfaction with telehealth provides a key towards eventual scalability.

MATERIALS AND METHODS

Quarterly surveys were conducted to characterize satisfaction with remote biometric monitoring (RBM) for blood pressure, weight, glucose and peritoneal dialysis (PD)-specific educational online videos for ESRD patients using PD.

RESULTS

Of 300 participants, 67% participated in the surveys and provided baseline and at least one follow-up assessment. The majority were 45 to 64 years of age (50.5%), Black (64.5%), married or living with significant other (52.0%), and had more than a high school degree (73.0%). RBM was associated with perceived autonomy and confidence in health care activities and decreased negative perceptions of PD care and ESRD. The majority of participants (80.1%) indicated that they were satisfied or completely satisfied with the system. Participants found that the interface increased confidence, reduced frustration, and related perceptions were significantly and positively altered (p<0.05) for each of the separate telehealth components. Educational videos were well utilized with nearly half of the participants (42.5%) reporting that they watched at least one of the videos, and the majority reporting that the videos seen had an overall positive impact on health.

DISCUSSION AND CONCLUSIONS

Supplementing PD with telehealth has the potential to have a positive impact on patient perceptions of PD care and consequently improve clinical outcomes.

Dialysis Modality and Readmission Following Hospital Discharge: A Population-Based Cohort Study

BACKGROUND

Readmissions following hospital discharge among maintenance dialysis patients are common, potentially modifiable, and costly. Compared with patients receiving in-center hemodialysis (HD), patients receiving peritoneal dialysis (PD) have fewer routine dialysis clinic encounters and as a result may be more susceptible to a hospital readmission following discharge.

STUDY DESIGN

Population-based retrospective-cohort observational study.

SETTINGS & PARTICIPANTS

Patients treated with maintenance dialysis who were discharged following an acute-care hospitalization during January 1, 2003, to December 31, 2013, across 164 acute-care hospitals in Ontario, Canada. For those with multiple hospitalizations, we randomly selected a single hospitalization as the index hospitalization.

PREDICTOR

Dialysis modality PD or in-center HD. Propensity scores were used to match each patient on PD therapy to 2 patients on in-center HD therapy to ensure that baseline indicators of health were similar between the 2 groups.

OUTCOME

All-cause 30-day readmission following the index hospital discharge.

RESULTS

28,026 dialysis patients were included in the study. 4,013 PD patients were matched to 8,026 in-center HD patients. Among the matched cohort, 30-day readmission rates were 7.1 (95% CI, 6.6-7.6) per 1,000 person-days for patients on PD therapy and 6.0 (95% CI, 5.7-6.3) per 1,000 person-days for patients on in-center HD therapy. The risk for a 30-day readmission among patients on PD therapy was higher compared with those on in-center HD therapy (adjusted HR, 1.19; 95% CI, 1.08-1.31). The primary results were consistent across several key prespecified subgroups.

LIMITATIONS

Lack of information for the frequency of nephrology physician encounters following discharge from the hospital in both the PD and in-center HD cohorts. Limited validation of International Classification of Diseases, Tenth Revision codes.

CONCLUSIONS

The risk for 30-day readmission is higher for patients on home-based PD compared to in-center HD therapy. Interventions to improve transitions in care between the inpatient and outpatient settings are needed, particularly for patients on PD therapy.

Telehealth in the Delivery of Home Dialysis Care: Catching up With Technology

Geographic and socioeconomic barriers may pose a significant difficulty in delivering home dialysis care to remote underserved populations leading to low utilization rates and poor outcomes. Telehealth may serve as a solution to overcome geographic barriers in delivering home dialysis care. Although technologic advances in telehealth have progressed rapidly making it accessible and inexpensive, it has been underused by nephrologists. Components of a regular face-to-face visit that can be successfully accomplished remotely using telehealth techniques include physician-patient communication, physical examination, laboratory and treatment data monitoring, nursing and nutrition education. Regulatory and reimbursement-related policies continue to present barriers that need to be overcome in operationalizing telehealth and widespread adoption of telehealth solutions. Although more quality evidence is needed to study the impact of telehealth on home dialysis outcomes and uptake, telehealth holds the promise of increasing access to care, improving quality of life, and improving quality of care for current and would be home dialysis patients.

A Syllabus for Teaching Peritoneal Dialysis to Patients and Caregivers

Being aware of controversies and lack of evidence in peritoneal dialysis (PD) training, the Nursing Liaison Committee of the International Society for Peritoneal Dialysis (ISPD) has undertaken a review of PD training programs around the world in order to develop a syllabus for PD training. This syllabus has been developed to help PD nurses train patients and caregivers based on a consensus of training program reviews, utilizing current theories and principles of adult education. It is designed as a 5-day program of about 3 hours per day, but both duration and content may be adjusted based on the learner. After completion of our proposed PD training syllabus, the PD nurse will have provided education to a patient and/or caregiver such that the patient/caregiver has the required knowledge, skills and abilities to perform PD at home safely and effectively. The course may also be modified to move some topics to additional training times in the early weeks after the initial sessions. Extra time may be needed to introduce other concepts, such as the renal diet or healthy lifestyle, or to arrange meetings with other healthcare professionals. The syllabus includes a checklist for PD patient assessment and another for PD training. Further research will be needed to evaluate the effect of training using this syllabus, based on patient and nurse satisfaction as well as on infection rates and longevity of PD as a treatment.