Convenient, but plagued by lack of social connection, technical issues, and access disparities

Older patients with chronic kidney disease (CKD) expressed mixed feelings about telehealth visits, as did their care partners and kidney clinicians, according to a survey-based study.

A qualitative study based on semi-structured interviews revealed concerns about clinical effectiveness, limitations of virtual physical examinations, and potentially widening disparities in access, reported Keren Ladin, PhD, MSc, of Tufts University in Medford, Massachusetts, and co-authors in JAMA Network Open.

Based on their thematic analysis, they came up with four “overarching themes” gleaned from the research:

  • Inconsistent quality of care.
  • Patient experience and engagement.
  • Loss of connection and mistrust, such as challenges discussing bad news.
  • Access disparities.

“Our findings… suggest that telehealth may best supplement rather than supplant in-person visits for patients who are older and chronically ill,” Ladin’s group said of the study, which is part of the ongoing DART trial. DART has enrolled 400 English-fluent, non-dialysis patients (ages >70) with CKD, with an estimated glomerular filtration rate of <30mL/min/1.73 m2, who received care at nephrology clinics in Boston, Chicago, San Diego, and Portland, Maine.

For the current study, the authors used a subsample of participants who were followed up for 12 months. These patients took part in semi-structured phone interviews done from August to December 2020. Ladin’s group conducted 60 interviews and half of those were with patients.

More than two-thirds of the patients were female, while almost half were ages 75 to 79, and almost half were White. Also, nearly three-fourths of the caregivers were women, with most ranging in age from 50 to 79, and almost two-thirds were White. As for the participating clinicians, over half were women and >80% were nephrologists.

Participants were asked to describe their telehealth experiences, including factors that aided or impeded their engagement with the visit, the quality of care provided, and their satisfaction with it. The mean interview length was 30 minutes.

The authors reported that patients reported concerns that their home diagnostic equipment was not as accurate as professional equipment at their clinician’s site. They also found that patients complained of a loss of social connection between patient and clinician, with the latter struggling to understand patient emotions and offering sufficient empathy virtually.

In addition, “[m]ost clinicians viewed telehealth as compromising quality care due to an inability to conduct physical examinations and laboratory tests, including inaccurate edema and blood pressure measurement,” Ladin and co-authors wrote.

Clinicians also reported poorer telehealth experiences with older patients, those from low socioeconomic status, patients with limited health literacy or a hearing impairment, and non-English speaking patients.

The authors highlighted that patients of color were less satisfied with telehealth, as they “were more concerned about losing access to in-person visits, skeptical that clinicians could understand their chief complaints.”

As for care partners, they reported that telehealth did allow them to be engaged in the appointment, especially when facilities had in-person visitation restrictions in place.

But both clinicians and patients noted technical challenges, such as spotty internet connectivity and application issues, as telehealth limitations.

However, all of of the participants “described telehealth as more convenient, less costly, and more efficient for patients than clinic visits,” the authors noted. They also pointed out that “[c]linicians were generally dissatisfied with telehealth, while most patients expressed more balanced perspectives, appreciating its convenience.”

Study limitations included recall bias, an underrepresentation of Hispanic and non-English speakers, and modest representation from one of the sites.

Ladin’s group concluded that the best way to address these issues would be “alternating telehealth and in-person visits for older patients with chronic illness, as outlined in the home dialysis telehealth policy in the 2018 Bipartisan Budget Act.

In an invited commentary accompanying the study, Devika Nair, MD, MSCI, of Vanderbilt Center for Health Services Research in Nashville, Tennessee, noted that in deconstructing the telehealth encounter, the authors addressed an underinvestigated yet timely aspect of person-centered kidney disease care: developing systems level solutions to improving patient-clinician communication and remote care delivery.”

The research can be seen as a direct response to a June 2021 JAMA Network Open editorial by Sharon K. Inouye, MD, MPH, of the Marcus Institute for Aging Research/Hebrew SeniorLife in Boston, and co-authors that calls for building an “evidence base for person-centered strategies to eliminate age-related inequities in health outcomes,” Nair explained.

Inouye’s group noted that the pandemic “placed additional stress on societal and health care delivery systems worldwide, exposing deeply entrenched structural ageism and leading to high rates of morbidity and mortality among older populations. Age-associated inequities in health care access, delivery, and outcomes revealed how unprepared health care systems are to meet the needs of a rapidly aging society.”

Lack of preparedness aside, the global nephrology community has certainly been enthusiastic about using telehealth for remote patient monitoring (RPM). For instance, in 2021, the American Society of Nephrology Covid-19 Home Dialysis Subcommittee forecast what telehealth for kidney dialysis would look like post-pandemic.

They noted that “[t]elehealth during the public health emergency has changed the practice of health care, with the post-Covid-19 world unlikely to resemble the prior era,” including heavier reliance on RPM because current “home dialysis RPM platforms allow direct transmission of both biometric information… to providers and home HD [hemodialysis] and automated PD [peritoneal dialysis] treatment parameters… RPM obviates the need for paper dialysis treatment logs and provides information in key domains of dialysis access, blood pressure, target weight, and ultrafiltration management while identifying treatment adherence challenges and in some cases allowing remote changes to the prescription.”

Researchers in China outlined “general operational considerations in PD management,” and stressed that “[h]ealthcare staff should communicate with patients at a given frequency, varying from daily to monthly, depending on each patient’s condition. For example, if the patient is suffering from a severe complication, such as peritonitis or volume overload, communication with the patient should be conducted daily, whereas the frequency of communication will be lower for patients in stable condition. Patients with worsening conditions should go to hospital for further management. Therefore, only patients needing medically essential attention can attend a healthcare institution. RPM ensures the most severe cases are identified and handled efficiently and in a timely manner. As a result, this ensures prolonged home stay for the majority of patients.”

And nephrologists in India pointed out that the “current models of healthcare delivery for patients with CKD, in particular those with advanced stages of the disease, are centered around hospitals, with nephrologists being the main care providers. It has been clear for some time, however, that much of the evaluation and care in early stages of the disease can be effectively delivered in the community by non‐physician health worker teams.” But they acknowledged that the “deficiencies and inequities in kidney care worldwide have been widely documented,” as reported by the Global Kidney Health Atlas project.

However, not all kidney care specialists are fully sold on RPM. German researchers found that, among patients with urologic cancers, “rapid implementation of telehealth” was well received during the pandemic, but that there was also a “clear ’red line’ concerning changes in existing patient-physician relationships.”

“Long-term implementation of the adapted services is less favored. We deduce that patient-physician relationship is crucial for cancer patients and needs to be balanced against measures for social distancing to forge the future management,” they wrote in European Urology Focus.

  1. In seniors with chronic kidney disease (CKD), drawbacks to telehealth included care quality concerns because of limited physical examination and laboratory tests and loss of social connection, as well as technical issues and disparities in access to technology and the internet, according to a survey-based study.

  2. Those surveyed acknowledged the convenience of telehealth and greater care partner engagement, but more resources are needed to support many older adults with CKD, especially those with limited English proficiency, hearing loss, and limited access to internet and technology.

Shalmali Pal, Contributing Writer, BreakingMED™

The study was funded by the Patient-Centered Outcomes Research Institute (PCORI).

Ladin reported support from the Greenwall Foundation. Co-authors reported relationships with Akebia Therapeutics, Kyowa Kirin, LifeSci Capital, Tricida, and Janssen.

Nair reported support from the Agency for Healthcare Research and Quality/PCORI.

Cat ID: 127

Topic ID: 81,127,730,127,192,925