Telehealth offers opportunities in the COVID-19 pandemic
COVID-19 is a novel virus that has caused a pandemic affecting more than 5 million people worldwide.1 Mortality rates have varied but are estimated to range between 1.4% to 3.6% based on recent data.2,3
Certain risk factors exist for respiratory distress syndrome and death including advanced age and certain chronic conditions, namely hypertension, diabetes and organ dysfunction.4 Patients with end-stage kidney disease are known to have weakened immune systems and are more susceptible to severe infections.5,6 Thus, these patients represent a particularly vulnerable group at high risk of complications from COVID-19.
To protect at-risk patients, telehealth has expanded as a model to deliver care without risking in-person contact in health care settings. Telehealth has been studied in the delivery of patients with chronic kidney disease in the past, predominantly in rural communities with limited access to care.
The Zuni Telenephrology Clinic is a well-recognized example that used a collaborative approach of a nephrologist, primary care physician, nurse case manager, pharmacist and community health nurse to deliver care to patients with advanced CKD in rural New Mexico. Zuni Pueblo, a small community located in western New Mexico, is home to 10,000 people and has high rates of diabetes and diabetic kidney disease. A nephrologist practicing in Zuni initially held weekly interdisciplinary CKD clinics until his departure to the National Institute of Diabetes and Digestive and Kidney Diseases. After that time, he established telehealth services for Zuni from 2007 to 2016 with two clinics per month. They conducted 1,870 telenephrology visits. Some of the key factors identified for the success of this initiative included nurse care managers, access to electronic health records and communication with referring clinicians.7
Some challenges faced by patients and nephrologists included technical difficulties, lack of feasibility for acutely ill patients, patient discomfort and challenges conveying emotional support. Despite these limitations, 44 patients were referred for dialysis initiation, and two died during the course of 9 years.7 Additionally, the incidence rates of ESRD among patients with diabetes decreased significantly in the past 15 years with broader diabetes management programs, including diabetic kidney disease.1
A randomized controlled trial by Ishani and colleagues compared telehealth intervention in both rural and urban settings to standard care.9 The primary endpoint, which was a composite outcome of death, hospitalizations, ED visits or admissions to nursing homes, showed no significant differences. There was a trend toward improved primary outcomes in rural patients for telehealth, although it did not achieve statistical significance.
Use of telehealth for the delivery of care to patients on dialysis has also been investigated for patients doing dialysis at home. A study in Spain by Gallar and colleagues showed the mean hospitalization rate to be significantly shorter for the telehealth group of stable patients performing home-based peritoneal dialysis.10 Another study using telehealth to support patients showed better cost savings during the course of 3 years and improved health outcomes.11
Reduce the risk from COVID-19
Given the changing health care climate due to COVID-19, telehealth is now being utilized for not only ambulatory CKD care and patients on home therapy, but also patients on in-center (ICH) hemodialysis. Recently, CMS has modified the requirement for an in-person visit monthly for all patients on ICH. If the patient is clinically stable, CMS recommends telehealth services where feasible. CMS has also waived the requirement of a comprehensive assessment within 30 calendar days or 13 in-center dialysis treatments for all new patients.12
With the loosening of Medicare guidelines for reimbursement and the overall acceptance of telehealth, at least presently, care can continue to be delivered to the at-risk ESRD population. The benefits of telehealth in this setting are rather robust and include less use of personal protective equipment and less risk of spreading infection among physicians, staff and patients. As physicians often do rounds in many different dialysis units, telehealth provides an advantage of time efficiency by limiting travel among locations. The use of telehealth also increases provider availability, given the on-demand nature of technology, which could potentially result in improved outcomes, including the prevention of unnecessary emergency room visits.2 There is a growing trend of providing on-site dialysis in rehabilitation facilities, nursing homes and rural hospitals. Using telehealth could help reduce unnecessary transfers to larger facilities with potential cost savings and improvement in patient satisfaction. Lastly, the management of patients with ESKD consists of a multidisciplinary approach involving physicians, nursing, dietitians and social work. Telehealth may enhance participation among these integral team members and, at the same time, allow family members to participate in critical monthly care plans. As many states face ongoing travel restrictions, the ability of family members to communicate remotely with health care teams has become vitally important.
Limitations to telehealth
There are also limitations of telehealth to consider as this system becomes more widely adopted. First, significant cost could be incurred by setting up telehealth systems, and lack of obtaining facility fees may encourage health care systems to favor in-person visits. Technical difficulties may exist, which could not only delay necessary care but make the process less efficient for health care providers. Concerns exist regarding the inability to perform a physical assessment of vascular access and volume status via telehealth. Some telehealth systems have capabilities for auscultation and detailed inspection, but palpation cannot be replicated.3 From the patient perspective, there may be a preference for in-person visits as patients may feel the provider is not listening to their concerns when they are not physically present. The concept of “seeing the doctor” is one that may be difficult to change, especially among our older patients. Another limitation is the challenge of conveying emotional support as would often be done in an in-person encounter.7
Despite these limitations, the utilization of telehealth is likely to continue to grow as both patients and providers adapt to technology and workflow. The success of this approach will need to be compared in proper trials against conventional dialysis care to truly answer the questions of safety, efficiency and effectiveness. It will be important to understand how patients perceive this change in the health care delivery model, as those more engaged with telehealth may tend to have different outcomes.
In the interim, this model of health care delivery may shape the way nephrology care will be delivered long after the COVID-19 pandemic has passed, provided telehealth reimbursements remain in place.
- COVID-19 Dashboard by the Center for Systems Science and Engineering at Johns Hopkins University. Johns Hopkins Coronavirus Research Center. May 27, 2020. https://coronavirus.jhu.edu/map.html.
- Huang C, et al. Lancet. 2020;doi:10.1016/S0140-6736(20)30183-5.
- Guan WJ et al. N Engl J Med. 2020;doi:10.1056/NEJMoa2002032.
- Wu C, et al. JAMA Intern Med. 2020;doi:10.1001/jamainternmed.2020.0994.
- Betjes MG. Nat Rev Nephrol. 2013;doi:10.1038/nrneph.2013.44.
- Syed-Ahmed M, et al. Adv Chronic Kidney Dis. 2019;doi:10.1053/j.ackd.2019.01.004.
- Narva AS, et al. Adv Chronic Kidney Dis. 2017;doi:10.1053/j.ackd.2016.11.019.
- Narva AS. Adv Chronic Kidney Dis. 2008;doi:10.1053/j.ackd.2008.01.011.
- Ishani A, et al. Am J Kidney Dis. 2016;doi:10.1053/j.ajkd.2016.01.018.
- Gallar P, et al. J Telemed Telecare. 2007;doi:10.1258/135763307781644906.
- Minatodani DE, et al. Telemed J E Health. 2013;doi:10.1089/tmj.2012.0196.
- End Stage Renal Disease (ESRD) Facilities: CMS Flexibilities to Fight COVID-19. March 28, 2020. www.cms.gov.
- Lew SQ, et al. Am J Kidney Dis. 2019;doi:10.1053/j.ajkd.2019.01.023.
- Bieber SD, et al. Clin J Am Soc Nephrol. 2018;doi:10.2215/CJN.03010318.
- For more information:
- Waqas Ahmed, MD, is with American TelePhysicians Inc. in Jacksonville, Florida, and can be reached at firstname.lastname@example.org.
- Umar Farooq, MD, MS, is with Penn State University College of Medicine in Hershey, Pennsylvania, and can be reached at email@example.com.
- Christin Spatz, MD, is with Geisinger Commonwealth School of Medicine in Scranton, Pennsylvania, and can be reached at firstname.lastname@example.org.