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.
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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.com Interview with:
Dr. Rashid Bashshur PhD
Director of Telemedicine
University of Michigan Health System
Emeritus Professor of Health Management and Policy
University of Michigan, School of Public Health
Medical Research: What is the background for this study? What are the main findings?
Dr. Bashshur: The impetus for this research derives from the confluence of several factors, including the increasing incidence and prevalence of chronic diseases, their associated morbidity and mortality and their high cost. The search for solutions has taken center stage in health policy. Patients must be engaged in in managing their health and health care, and they must assume greater responsibility for adopting and maintaining a healthy life style to reduce their dependence on the health system and to help themselves in maintaining an optimal level of health. The telemedicine intervention promises to address all these issues and concerns, while also providing ongoing monitoring and guidance for patients who suffer from serious chronic illness.
The preponderance of the evidence from robust scientific studies points to the beneficial effects of the telemedicine intervention (through telemonitoring and patient engagement) in terms of reduction in use of service (including hospital admissions/readmissions, length of hospital stay, and emergency department visits) as well as improved health outcomes. The single exception was reported in a study among frail elderly patients with co-morbidities who did not benefit from the telemedicine intervention.
There is an ever-growing and complex body of empirical evidence that attests to the potential of telemedicine for addressing the triad problems of limited access to care, uneven distribution of quality across communities, and cost inflation. Research demonstrates the effectiveness of the telemedicine intervention in addressing all three problems, especially when patients are engaged in managing their personal health and healthcare. The enabling technology can be used to promote healthy life styles, informed decision making, and prudent use of health resources.
Unintended consequences of delaying mortality for older adults may also increase the use of resources, especially in the long run, and society must decide on the ultimate values it chooses to promote.
