Telemedicine Poised to Help Some Patients with CKD

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For patients with chronic kidney disease (CKD), getting to regularly scheduled doctors’ appointments can pose a challenge. Whether a patient lives too far from a clinic, has limited mobility owing to various comorbidities, or does not realize the severity of their illness, some may not make the trip. However, a new study presented at ASN Kidney Week 2015 shows that patients may not always have to travel far to receive care.

“Few studies, if any, have evaluated renal clinic visit compliance among patients with CKD,” said Rajeev Rohatgi, of the Mt. Sinai School of Medicine in New York, NY, and the study’s main author. However, evidence points to the fact that patients who live far from a nephrology practice are hospitalized more frequently and with higher mortality than those who live closer, he said. Thus, he became interested in evaluating whether care delivered remotely via videoconferencing technology, also known as telemedicine or telenephrology, could be as beneficial to patients as in-person conventional care for managing the disease.

Rohatgi and his team conducted a retrospective observational study and analyzed clinical outcomes of 238 patients with CKD who were enrolled at the Bronx Veterans Affairs Medical Center. Among these patients, 121 lived near the medical center (an average of 10.2 ± 1.3 miles), and 117 lived much further away (an average of 63.5 ± 2.2 miles). The 117 patients who lived further away were then enrolled in telenephrology sessions at the much closer Castle Point campus of the Hudson Valley VAMC for their CKD care, and were evaluated remotely by a Bronx VAMC nephrologist from 2008 to 2014 (1).

Both the Hudson Valley and Bronx VAMC institutions had telemedicine resources available, such as videoconferencing equipment, HIPAA-compliant internet lines, and technical support.

The team found that the kidney disease characteristics—initial creatinine, eGFR, distribution of CKD stage, and urine protein—of the two groups were similar. However, the frequency of attending appointments was greater in the telenephrology group (70.8%) versus the conventional care group (61.8%), which was driven by a greater frequency of cancelled visits in the conventional care group (27.9%) versus the telenephrology group (15.8%).

Moreover, prior to enrolling in telenephrology sessions, more than 50% of patients who lived far from a VA nephrologist either cancelled or missed their scheduled appointments at the Bronx VAMC. However, after enrolling in telenephrology, this was reduced by nearly half. The researchers speculate that missing a large number of appointments leads to worse renal outcomes, but delivering care to patients with CKD locally improves the likelihood that they will attend their scheduled visits, potentially resulting in clinical outcomes equal to those for conventional care.

“These data imply that remote delivery of care via telenephrology has the potential to deliver equitable, patient-centered care to a geographically diverse patient population while alleviating disparity in care,” Rohatgi said. “Although not appropriate in all instances, remote monitoring can help deliver excellent care in areas of nephrology such as peritoneal dialysis, hemodialysis, kidney transplantation, and in-patient renal consultation.”

The concept of telemedicine is nothing new, but it is becoming more feasible and common as technology improves at an ever faster pace. On January 1, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a new provider reimbursement code for “non-face-to-face care coordination services” for Medicare beneficiaries with multiple chronic conditions (2). In all, 27 states along with the District of Columbia have laws enforcing coverage for telemedicine (3).

Still, current rules in the US limit telehealth services, which can only be administered in rural counties and in more urban health facilities known as “originating sites” near areas with a shortage of health care providers. Patients cannot receive telehealth services from their homes. In addition, only certain practitioners are authorized to administer a limited number of services, and remote patient monitoring is not covered by Medicare (4).

To combat these limitations, four members of the US House of Representatives [Mike Thompson (D-CA), Gregg Harper (R-MS), Diane Black (R-TN), and Peter Welch (D-VT)] introduced the Medicare Telehealth Parity Act of 2015 in the summer of 2015, which would consider a patient’s residence an originating site for home dialysis services, and also allow them to take part in monthly telehealth appointments (4). ASN is strongly supportive of this legislation and is actively advocating for its passage. In addition, Senators Roger Wicker (R-MS) and Brian Schatz (D-HI) are spearheading a bipartisan working group introducing similar legislation in the Senate aimed at improving telehealth services.

Among other barriers to telemedicine, doctors may have to work with someone in another state, where they aren’t licensed. However, the Interstate Medical Licensure Compact of the Federation of State Medical Boards was recently introduced to help make it easier for physicians to become licensed in multiple states. As of July 2015, 10 states have enacted the compact (5).

Despite the roadblocks, Rohatgi is optimistic about the future. “Although face-to-face services will likely always be needed, we hope our preliminary data can act as a first step in developing a clinical trial to confirm remote monitoring is safe and effective for kidney patients, he said. “If this can be confirmed, we believe that the private sector should strongly consider implementing this model of patient-centered care.”

References

1. 

Rohatgi R, et al. Telenephrology for the Remote Management of Chronic Kidney Disease (CKD): A Retrospective Cohort Study. J Am Soc Nephrol 26 (Suppl); 2015: 791A. SA-PO714.

2. 

3. 

Milestone – Most states now have telehealth parity laws. American Telemedicine Association http://www.americantelemed.org/news-landing/2015/05/27/milestone-most-states-now-have-telehealth-parity-laws#.VWcZ1inxtNw.

4. 

Lukaszewski M. Telehealth in the United States: New Opportunities? Kidney News August 2015; 7(8):7.

5. 

Interstate Medical Licensure Compact; News. LicensePortablity.orghttp://licenseportability.org/news.html.