Maintaining Pandemic-Level Use of Telemedicine in Kidney Care Hinges on Lasting Policy Changes

Dialysis day to day

Expanded use of telemedicine in day-to-day dialysis care also helped mitigate potential exposures for dialysis patients. Prior to the pandemic, Medicare would cover telehealth services conducted at local clinics for individuals in rural areas, some home dialysis visits, and remote patient check-ins. But a waiver issued under the CARES Act expanded access beyond rural areas and enabled patients to receive certain types of care via phone or video conferencing in their home, at a dialysis center, or in a hospital.

“There has been urgency to expand the use of technology to help people who need routine care and at the same time keep vulnerable people and those with mild [COVID-19] symptoms in their homes,” said Janice Lea, MD, a professor of medicine at Emory University and Chief Medical Officer at Emory Dialysis during a video session at the American Association of Kidney Patients' 2021 Annual Policy Summit (4).

For example, physicians used tablets or other two-way video-conferencing technology to communicate with dialysis patients hospitalized with COVID-19 or for other conditions that put them at risk of COVID-19 to limit both physicians' and patients' potential exposure and to preserve limited personal protective equipment for clinicians providing essential hands-on care, Lea said. It also helped increase the physician workforce during this period of high demand, by allowing physicians on quarantine to continue working remotely, she said.

Many home dialysis patients were already receiving two out of every three visits via telemedicine prior to the pandemic, so that gave providers some familiarity with the services. But the waiver enabled physicians to conduct video telehealth visits at outpatient dialysis centers as well, Lea said. This allowed them to—with the help of an on-site nurse—conduct a physical exam, check vascular access, talk with the patient, or even use a digital stethoscope to listen to the patient's heart. Telehealth was also used for visits with dieticians, social workers, and other staff at dialysis centers to minimize unnecessary exposures, she said. It also enabled virtual meetings with patients' families at a time when family and other visitors weren't allowed in facilities.

Patients really liked the flexibility and privacy of doing some visits via telemedicine at home, said Lea, for example, having discussions with dieticians or reviewing their monthly labs.

“They feel like they are getting more privacy,” she said. “They can talk longer, and staff can spend more time with them.”

Because of its usefulness and popularity, Lea said, she sees some form of telemedicine continuing in dialysis care after the pandemic. For example, she suggested that using telehealth tools in outpatient dialysis clinics might help reduce emergency department visits for dialysis patients by enabling a nurse or physicians to see and consult with patients virtually to decide whether they need to be seen in person immediately in an emergency room or if they can wait for their next scheduled visit.

“It really is a win-win for everyone,” Lea said. “It maximizes the use of the clinician workforce. We don't know if we are going to have future pandemics, so it would be great for us to be able to work out this process and perfect it so we can apply it in the future.”

Virtual education could boost use of home dialysis

Another use for telemedicine that is poised to grow post-pandemic is patient education. Manisha Singh, MD, a nephrologist and assistant professor of medicine at the University of Arkansas for Medical Sciences, was part of a team that developed and tested a tele-education program for patients with CKD. The program was designed to help patients understand their condition, how to help slow progression, and make an informed choice about options for care.

“For most patients, I feel home dialysis is a wonderful idea,” Singh said. “But for some patients, it is not; they need to know what works best for them.”

The team compared the tele-education intervention with face-to-face patient education in the Telemedicine Patient Education Study and found both modalities were remarkably effective (5). Prior to the education programs, 47.1% of the patients randomized to face-to-face education and 52.2% of those randomized to tele-education said they didn't have enough information to choose a modality for kidney replacement therapy. But by the third session, only 7.4% of the face-to-face patients and 13.2% of the telehealth patients felt that way. The number of patients in both groups who chose home dialysis options more than doubled in both groups, with 67.7% of the face-to-face group choosing a home modality and 50.1% of the telemedicine group choosing a home modality.

“The impact was enormous,” said Singh. She explained that many patients come in afraid that their diagnosis means their life is over, but they leave feeling empowered by the curriculum.

Interest in transplant also shifted in both groups. About 92% of both groups were interested in a transplant prior to beginning the education program, and that interest dipped to about 88% in both groups after they learned more about transplant. Some patients chose palliative care as well, Singh said.

“When they came into class, the majority of patients wanted transplants,” she said. “As some of them learned what transplant entails, they realized it is not for them.”

The team did run into some challenges with the telehealth program. For example, people living in rural areas often had very poor internet connections. But they found that even though many patients were older and needed family help to initially log in, they adapted quickly. Having the sessions available at home also enabled family members or caregivers to listen in to live sessions or watch recordings.

When the pandemic hit, Singh and her colleagues were able to continue the tele-education program when they had to temporarily stop some in-person options. Now, the program is offered routinely at the University of Arkansas clinics and is available throughout the state of Arkansas. They are working to overcome some of the barriers they encountered with internet access by aiming to make the program available at public health departments or libraries and working with policymakers to expand access to high-quality internet.

They are also working on making the program available nationally through a website currently in development.

“We want to reach out to providers all over the country,” Singh said. “Our program is validated and works.”

Policy changes needed

Continued use of telehealth is also important to help boost living kidney donations and to boost patient adherence to posttransplant care, said Yadav. She explained that telehealth can help potential donors make an informed decision and limit their costs and inconvenience. Although some funds are available to offset costs, the average living donor spends more than $5000 on costs ranging from travel and lodging for in-person visits and surgery to childcare and time off work (6). But by using telehealth, she and her colleagues have been able to limit pre-surgery visits to one, 2 weeks before surgery. The team has also found the telehealth visits have improved adherence for posttransplant patients who struggle with transportation to in-person visits.

But continued use of telemedicine in transplant care hinges on more permanent policies that support the use of telemedicine beyond rural areas and across dialysis settings. In a recent editorial (7), Fawaz Al Ammary, MD, PhD, Medical Director of Living Donor Kidney Transplantation at Johns Hopkins University School of Medicine, and colleagues argued that geographic restrictions on telehealth for kidney transplantation services should be removed permanently.

State licensing requirements were temporarily lifted during the pandemic, and that helped, but some of those requirements are now back in place. As a result, Yadav and her team have had to limit some telehealth services to in-state patients as they try to complete a prolonged process of getting cross-state licenses. This is a particular challenge for practices like hers that routinely see patients in Pennsylvania, New Jersey, and Delaware. She said more advocacy is needed to permanently change cross-state licensing and enable reimbursement for expanded use of telehealth in transplant care.

“It serves the patients better,” Yadav said. “It improves their adherence and their experience.”