18 Jun Telemedicine May Improve Access to Chronic Kidney Disease
MedicalResearch.com Interview with:
Judy K. Tan, MD
Department of Nephrology
Mount Sinai Hospital
New York, New York
MedicalResearch: What is the background for this study? What are the main findings?
Dr. Tan: Chronic kidney disease (CKD) is a common life-threatening medical condition, affecting approximately 26 million adults in the U.S. In Veterans Integrated Service Network (VISN) 3, veterans with CKD who reside in the Hudson Valley Veterans Affair Medical Center (VAMC) catchment area travel to the James J. Peters VAMC, a tertiary care facility in the Bronx for their nephrology care. However, because of several barriers such as (1) distance between the two facilities (approximately 60 miles) and (2) patient complexity (medical and psychiatric illnesses), patients referred to the James J. Peters VAMC renal clinic from Hudson Valley VAMC often cancel or “no show”. This poor compliance increases the long-term risk of rapid progression of CKD and the development of complications associated with it. To address this issue, the division of nephrology at the James J. Peters VAMC, in line with the veterans affairs’ focus on “patient-centered care,” developed a collaborative out-patient telenephrology service as a means to deliver care. The out-patient telenephrology service employs specialized global medical video conferencing equipment with customized medical instruments (ie stethoscopes) and Computerized Patient Record System (CPRS) accessibility to direct real-time evaluation and management of our veterans with CKD while they stay in their local VAMC. As demonstrated by Rohatgi et al, this intervention significantly increased the compliance rate of patients and reduced the travel time, miles, and cost of patients utilizing the telenephrology service.1
The hypothesis of our study is that patients with CKD remotely managed through our telenephrology service would exhibit comparable clinical outcomes and visit compliance as conventional in-person renal care.
Our provisional analysis of the subjects followed in the telenephrology service showed 117 unique patients were evaluated between 2011-2014. The mean age was 71±11years old with 98.3% males. 70% of the patients were white and 26.5% African American. The predominant etiology of chronic kidney disease was diabetic nephropathy (31.6%) followed by hypertensive nephrosclerosis (26.5%). In the 87 patients who had 1-year follow up data, estimated glomerular filtration (eGFR) was well preserved over the year (33 mL/min vs. 32 mL/min; p=0.04). Systolic blood pressure (BP) was reduced from 138±20 to 133±16 mm Hg (p=0.03), but no difference was observed in diastolic BP. Urine protein-creatinine ratio fell from 0.58 to 0.25 (p=0.07). 94% of patients had parathyroid levels checked and 70.9% were on ACE inhibitors during the first year of follow up.
MedicalResearch: What should clinicians and patients take away from your report?
Dr. Tan: Clinicians should actively identify barriers to medical care and once recognized, develop innovative systems or processes to surmount these barriers. Analysis of newly implemented systems should be tested to ascertain whether the new system of care is comparable or non-inferior to current standard of care.
MedicalResearch: What recommendations do you have for future research as a result of this study?
Dr. Tan: Our next step is to identify a comparable traditional in-person care group to test the non-inferiority of telenephrology program in terms of clinical outcomes (ie. progression of CKD, proteinuria, blood pressure control, anemia, etc.) and compliance to visits.
If we demonstrate that the telenephrology service is comparable to conventional care, we would like to expand the service to include patients with other kidney diseases such as patients on hemodialysis or peritoneal dialysis and renal transplant patients. Moreover, we would like to develop an in-patient telenephrology service with our Hudson Valley VAMC partners to cater to patients suffering from electrolytes disturbances or acute kidney injury not requiring renal replacement therapy. Further studies in these areas will be needed.