Targeting Access to Kidney Care Via Telehealth: The VA Experience

KDOQI US Commentary on the KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of CKD

The Kidney Disease Outcomes Quality Initiative (KDOQI) convened a work group to review the 2024 KDIGO (Kidney Disease: Improving Global Outcomes) guideline for the management of chronic kidney disease (CKD). The KDOQI Work Group reviewed the KDIGO guideline statements and practice points and provided perspective for implementation within the context of clinical practice in the United States. In general, the KDOQI Work Group concurs with several recommendations and practice points proposed by the KDIGO guidelines regarding CKD evaluation, risk assessment, and management options (both lifestyle and medications) for slowing CKD progression, addressing CKD-related complications, and improving cardiovascular outcomes. The KDOQI Work Group acknowledges the growing evidence base to support the use of several novel agents such as sodium/glucose cotransporter 2 inhibitors for several CKD etiologies, and glucagon-like peptide 1 receptor agonists and nonsteroidal mineralocorticoid receptor antagonists for type 2 CKD in setting of diabetes. Further, KDIGO guidelines emphasize the importance of team-based care which was also recognized by the work group as a key factor to address the growing CKD burden. In this commentary, the Work Group has also assessed and discussed various barriers and potential opportunities for implementing the recommendations put forth in the 2024 KDIGO guidelines while the scientific community continues to focus on enhancing early identification of CKD and discovering newer therapies for managing kidney disease.

Patient and Clinician Experiences With the Combination of Virtual and In-Person Chronic Kidney Disease Care Since the COVID-19 Pandemic

Background

Following onset of the COVID-19 pandemic, chronic kidney disease (CKD) clinics in BC shifted from established methods of mostly in-person care delivery to virtual care (VC) and thereafter a hybrid of the two.

Objectives

To determine strengths, weaknesses, quality-of-care delivery, and key considerations associated with VC usage to inform optimal way(s) of integrating virtual and traditional methods of care delivery in multidisciplinary kidney clinics.

Design

Qualitative evaluation.

Setting

British Columbia, Canada.

Participants

Patients and health care providers associated with multidisciplinary kidney care clinics.

Methods

Development and delivery of semi-structured interviews of patients and health care providers.

Results

11 patients and/or caregivers and 12 health care providers participated in the interviews. Participants reported mixed experiences with VC usage. All participants foresaw a future where both VC and in-person care was offered. A reported benefit of VC was convenience for patients. Challenges identified with VC included difficulty establishing new therapeutic relationships, and variable of abilities of both patients and health care providers to engage and communicate in a virtual format. Participants noted a preference for in-person care for more complex situations. Four themes were identified as considerations when selecting between in-person and VC: person's nonmedical context, support available, clinical parameters and tasks to be completed, and clinic operations. Participants indicated that visit modality selection is an individualized and ongoing process involving the patient and their preferences which may change over time. Health care provider participants noted that new workflow challenges were created when using both VC and in-person care in the same clinic session.

Limitations

Limited sample size in the setting of one-on-one interviews and use of convenience sampling which may result in missing perspectives, including those already facing challenges accessing care who could potentially be most disadvantaged by implementation of VC.

Conclusions

A list of key considerations, aligned with quality care delivery was identified for health care providers and programs to consider as they continue to utilize VC and refine how best to use different visit modalities in different patient and clinical situations. Further work will be needed to validate these findings and evaluate clinical outcomes with the combination of virtual and traditional modes of care delivery.

Trial registration

Not registered.

Telehealth services in an outpatient nephrology clinic during the COVID-19 pandemic: a patient perspective

PURPOSE

In response to the COVID-19 pandemic, new policy waivers permitted reimbursement of telehealth services in urban settings. The aim of this study was to assess patient satisfaction with telehealth services during the COVID-19 pandemic in an outpatient urban nephrology practice.

METHODS

Patients who had virtual encounters were asked to complete an online survey regarding their experiences with telehealth services.

RESULTS

Twenty-one percent of eligible patients completed the survey. Patients (83.6%) reported overall positive experiences with telehealth and want to see a hybrid healthcare model in the future (80.1%). Additionally, most patients found telehealth appointments convenient to make and telehealth encounters convenient to conduct. Ethnicity, age, gender, and insurance type did not have a statistically significant impact on satisfaction ratings. Technical issues were not encountered by 79.5% of patients and patients were willing to use the video feature. However, if they had technical issues, patient satisfaction ratings were negatively impacted.

CONCLUSION

Telehealth services are beneficial to patients with regards to convenience, decreased transportation costs and time, increased accessibility to healthcare, and decreased overall opportunity costs. However, challenges still remain with the deployment of telehealth and will be dependent on patients' digital health literacy, access to broadband internet and devices, and legislation and/or regulations. Limitations of the study, including small sample size and surveying patients from a nephrology practice, may prevent it from being generalizable. Additional studies with a larger sample size and multiple specialties may be needed to generalize patients' satisfaction with telehealth services.

Complex Interventions Across Primary and Secondary Care to Optimize Population Kidney Health: A Systematic Review and Realist Synthesis to Understand Contexts, Mechanisms, and Outcomes

BACKGROUND

CKD affects 850 million people worldwide and is associated with high risk of kidney failure and death. Existing, evidence-based treatments are not implemented in at least a third of eligible patients, and there is socioeconomic inequity in access to care. While interventions aiming to improve delivery of evidence-based care exist, these are often complex, with intervention mechanisms acting and interacting in specific contexts to achieve desired outcomes.

METHODS

We undertook realist synthesis to develop a model of these context-mechanism-outcome interactions. We included references from two existing systematic reviews and from database searches. Six reviewers produced a long list of study context-mechanism-outcome configurations based on review of individual studies. During group sessions, these were synthesized to produce an integrated model of intervention mechanisms, how they act and interact to deliver desired outcomes, and in which contexts these mechanisms work.

RESULTS

Searches identified 3371 relevant studies, of which 60 were included, most from North America and Europe. Key intervention components included automated detection of higher-risk cases in primary care with management advice to general practitioners, educational support, and non-patient-facing nephrologist review. Where successful, these components promote clinician learning during the process of managing patients with CKD, promote clinician motivation to take steps toward evidence-based CKD management, and integrate dynamically with existing workflows. These mechanisms have the potential to result in improved population kidney disease outcomes and cardiovascular outcomes in supportive contexts (organizational buy-in, compatibility of interventions, geographical considerations). However, patient perspectives were unavailable and therefore did not contribute to our findings.

CONCLUSIONS

This systematic review and realist synthesis describes how complex interventions work to improve delivery of CKD care, providing a framework within which future interventions can be developed. Included studies provided insight into the functioning of these interventions, but patient perspectives were lacking in available literature.

PODCAST

This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_05_08_CJN0000000000000136.mp3.

Lessons learnt and future directions in managing dialysis access during the COVID 19 pandemic: Patient and provider experience in the United States

BACKGROUND

The COVID 19 pandemic adversely impacted delivery of preventive, routine, urgent, and essential care worldwide. Dialysis access care was particularly affected due to the lack of specific guidelines regarding procedures for its creation and maintenance. Early guidance by Centers for Medicare and Medicaid was inadvertently interpreted as guidance to stop dialysis access procedures. Prompt action by professional societies was needed to furnish detailed guidance to establish essential nature of these procedures.

METHODS

The American Society of Diagnostic and Interventional Nephrology (ASDIN) issued a joint statement with Vascular Access Society of the Americas (VASA) - "Maintaining Lifelines for ESKD Patients" to clearly establish the role of vascular access as a lifeline for ESKD (End Stage Kidney Disease) patients and the importance and urgency of its timely management. ASDIN also conducted a survey in mid-2020, that was administered to the ASDIN database as well as shared with the general public via the organization's social media platforms. The respondents reported their experiences in the care of dialysis access, practice patterns and the utility of the ASDIN-VASA statement during the COVID 19 pandemic.

RESULTS

Of the 2030 individual surveys sent, 581 were opened and 53 (9.1%) responses were received from different parts of the country and from different practice settings. ASDIN COVID 19 triage document was frequently utilized and 83% of respondents found the document valuable. The survey also revealed multiple obstacles, including logistical and financial issues that led to significant disruption of services.

CONCLUSIONS

The care of dialysis access was significantly affected in the United States during the COVID 19 pandemic due to multiple reasons. ASDIN actions provided valuable specific guidance regarding and explored barriers to dialysis access care. We describe those results and discuss strategies to prevent COVID 19 transmission with innovative strategies of providing access care. Individualized decision making is of essence when considering dialysis access procedures.

Protocol for a Multistage Mixed-Methods Evaluation of Multidisciplinary Chronic Kidney Disease Care Quality Following Integration of Virtual and In-Person Care During the COVID-19 Pandemic

Background

Multidisciplinary care of patients with chronic kidney disease (CKD) as it previously existed was predicated on an evidence and experience base of improved patient outcomes within an established and well-described service delivery model. The onset of the COVID-19 pandemic brought with it a departure from this established care delivery model toward integration of virtual care and in-person care.

Objective

To develop an evaluation framework to determine whether this shift in service delivery models has affected quality of multidisciplinary kidney care and/or patient-clinician interactions and relationships.

Design

A sequential multiphase, mixed-methods evaluation.

Setting

All 15 British Columbia (BC) multidisciplinary kidney care clinics (KCCs).

Participants

All patients and all clinicians in all KCCs across BC will be invited to participate in the planned evaluation.

Measurements

Qualitative and quantitative feedback from patients and families living with CKD and KCC clinicians.

Methods

The planned multiphase evaluation of virtual care integration in KCCs will be conducted across all 15 KCCs in the province of BC, Canada. The following phases are proposed: (1) review of current virtual care integration and practices, (2) assessment of patient and clinician experiences and perspectives via semi-structured interviews, (3) validation of those patient and clinician perspectives via survey of a larger sample, (4) compilation and analysis of all phases to provide informed recommendations for patient and visit format selection in a mixed in-person and virtual multidisciplinary clinic setting.

Limitations

This work will not capture any information about the relationship between differences in virtual usage parameters and clinical outcomes or financial implications.

Conclusions

There is no existing framework for either evaluation of multidisciplinary CKD care quality in a virtual setting or evaluation of care quality following a substantial change in service delivery models. The proposed evaluation protocol will enable better understanding of the nuances in kidney care delivery in this new format and inform how best to optimize the integration of virtual and pre-existing formats into kidney clinic care delivery beyond the pandemic. Beyond the current evaluation, this protocol may be of use for other jurisdictions to evaluate their own local instances of virtual care implementation and integration. The model may be adapted to evaluate quality of multidisciplinary kidney care delivery following other changes to clinic service delivery models.

Clinicians' perspectives on equity of access to dialysis and kidney transplantation for rural people in Australia: a semistructured interview study

OBJECTIVES

People with chronic kidney disease requiring dialysis or kidney transplantation in rural areas have worse outcomes, including an increased risk of hospitalisation and mortality and encounter many barriers to accessing kidney replacement therapy. We aim to describe clinicians' perspectives of equity of access to dialysis and kidney transplantation in rural areas.

DESIGN

Qualitative study with semistructured interviews.

SETTING AND PARTICIPANTS

Twenty eight nephrologists, nurses and social workers from 19 centres across seven states in Australia.

RESULTS

We identified five themes: the tyranny of distance (with subthemes of overwhelming burden of travel, minimising relocation distress, limited transportation options and concerns for patient safety on the roads); supporting navigation of health systems (reliance on local champions, variability of health literacy, providing flexible models of care and frustrated by gatekeepers); disrupted care (without continuity of care, scarcity of specialist services and fluctuating capacity for dialysis); pervasive financial distress (crippling out of pocket expenditure and widespread socioeconomic disadvantage) and understanding local variability (lacking availability of safe and sustainable resources for dialysis, sensitivity to local needs and dependence on social support).

CONCLUSIONS

Clinicians identified geographical barriers, dislocation from homes and financial hardship to be major challenges for patients in accessing kidney replacement therapy. Strategies such as telehealth, outreach services, increased service provision and patient navigators were suggested to improve access.

Point-of-care testing technologies for the home in chronic kidney disease: a narrative review

Point-of-care testing (POCT) performed by the patient at home, paired with eHealth technologies, offers a wealth of opportunities to develop individualized, empowering clinical pathways. The non-dialysis-dependent chronic kidney disease (CKD) patient who is at risk of or may already be suffering from a number of the associated complications of CKD represents an ideal patient group for the development of such initiatives. The current coronavirus disease 2019 pandemic and drive towards shielding vulnerable individuals have further highlighted the need for home testing pathways. In this narrative review we outline the evidence supporting remote patient management and the various technologies in use in the POCT setting. We then review the devices currently available for use in the home by patients in five key areas of renal medicine: anaemia, biochemical, blood pressure (BP), anticoagulation and diabetes monitoring. Currently there are few devices and little evidence to support the use of home POCT in CKD. While home testing in BP, anticoagulation and diabetes monitoring is relatively well developed, the fields of anaemia and biochemical POCT are still in their infancy. However, patients' attitudes towards eHealth and home POCT are consistently positive and physicians also find this care highly acceptable. The regulatory and translational challenges involved in the development of new home-based care pathways are significant. Pragmatic and adaptable trials of a hybrid effectiveness-implementation design, as well as continued technological POCT device advancement, are required to deliver these innovative new pathways that our patients desire and deserve.

Source of Post-Transplant Care and Mortality among Kidney Transplant Recipients Dually Enrolled in VA and Medicare

BACKGROUND AND OBJECTIVES

Many kidney transplant recipients enrolled in the Veterans Health Administration are also enrolled in Medicare and eligible to receive both Veterans Health Administration and private sector care. Where these patients receive transplant care and its association with mortality are unknown.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a retrospective cohort study of veterans who underwent kidney transplantation between 2008 and 2016 and were dually enrolled in Veterans Health Administration and Medicare at the time of surgery. We categorized patients on the basis of the source of transplant-related care (i.e., outpatient transplant visits, immunosuppressive medication prescriptions, calcineurin inhibitor measurements) delivered during the first year after transplantation defined as Veterans Health Administration only, Medicare only (i.e., outside Veterans Health Administration using Medicare), or dual care (mixed use of Veterans Health Administration and Medicare). Using multivariable Cox regression, we examined the independent association of post-transplant care source with mortality at 5 years after kidney transplantation.

RESULTS

Among 6206 dually enrolled veterans, 975 (16%) underwent transplantation at a Veterans Health Administration hospital and 5231 (84%) at a non-Veterans Health Administration hospital using Medicare. Post-transplant care was received by 752 patients (12%) through Veterans Health Administration only, 2092 (34%) through Medicare only, and 3362 (54%) through dual care. Compared with patients who were Veterans Health Administration only, 5-year mortality was significantly higher among patients who were Medicare only (adjusted hazard ratio, 2.2; 95% confidence interval, 1.5 to 3.1) and patients who were dual care (adjusted hazard ratio, 1.5; 95% confidence interval, 1.1 to 2.1).

CONCLUSIONS

Most dually enrolled veterans underwent transplantation at a non-Veterans Health Administration transplant center using Medicare, yet many relied on Veterans Health Administration for some or all of their post-transplant care. Veterans who received Veterans Health Administration-only post-transplant care had the lowest 5-year mortality.

Evaluation of Patient Perceptions With Orthopedic Oncology Telehealth: A Pilot Project

Telehealth has been used for decades to improve access to care for rural and underserved patients. The adoption of telehealth in orthopedic oncology is novel and expected to positively impact patient access and compliance. However, no previous evaluation has been published of this expected impact. The objective of this pilot project was to evaluate patients' perceptions regarding orthopedic oncology telehealth services. A 13-question satisfaction survey was distributed to patients who used tele-orthopedic oncology. Fifteen respondents (a response rate of 42%) reported satisfaction with services at 9.7 of 10. Median travel distance to the nearest in-person orthopedic oncologist was greater than 150 miles (241 km). These results are consistent with the previous findings of high satisfaction with telehealth in other specialties. Health care organizations are likely to benefit from offering telehealth to orthopedic oncology patients with limited access.

Analysis of factors affecting IoT-based smart hospital design

Currently, rapidly developing digital technological innovations affect and change the integrated information management processes of all sectors. The high efficiency of these innovations has inevitably pushed the health sector into a digital transformation process to optimize the technologies and methodologies used to optimize healthcare management systems. In this transformation, the Internet of Things (IoT) technology plays an important role, which enables many devices to connect and work together. IoT allows systems to work together using sensors, connection methods, internet protocols, databases, cloud computing, and analytic as infrastructure. In this respect, it is necessary to establish the necessary technical infrastructure and a suitable environment for the development of smart hospitals. This study points out the optimization factors, challenges, available technologies, and opportunities, as well as the system architecture that come about by employing IoT technology in smart hospital environments. In order to do that, the required technical infrastructure is divided into five layers and the system infrastructure, constraints, and methods needed in each layer are specified, which also includes the smart hospital’s dimensions and extent of intelligent computing and real-time big data analytic. As a result of the study, the deficiencies that may arise in each layer for the smart hospital design model and the factors that should be taken into account to eliminate them are explained. It is expected to provide a road map to managers, system developers, and researchers interested in optimization of the design of the smart hospital system.

Policy and Pandemic: The Changing Practice of Nephrology During the Coronavirus Disease-2019 Outbreak

The coronavirus (coronavirus disease-2019) pandemic has changed care delivery for patients with end-stage kidney disease. We explore the US healthcare system as it pertains to dialysis care, including existing policies, modifications implemented in response to the coronavirus disease-2019 crisis, and possible next steps for policy makers and nephrologists. This includes policies related to resource management, use of telemedicine, prioritization of dialysis access procedures, expansion of home dialysis modalities, administrative duties, and quality assessment. The government has already established policies that have instated some flexibilities to help providers focus their response to the crisis. However, future policy during and after the coronavirus disease-2019 pandemic can bolster our ability to optimize care for patients with end-stage kidney disease. Key themes in this perspective are the importance of policy flexibility, clear strategies for emergency preparedness, and robust health systems that maximize accessibility and patient autonomy.

TeleWound Practice Within the Veterans Health Administration: Protocol for a Mixed Methods Program Evaluation

BACKGROUND

Chronic wounds, such as pressure injuries and diabetic foot ulcers, are a significant predictor of mortality. Veterans who reside in rural areas often have difficulty accessing care for their wounds. TeleWound Practice (TWP), a coordinated effort to incorporate telehealth into the provision of specialty care for patients with skin wounds, has the potential to increase access to wound care by allowing veterans to receive this care at nearby outpatient clinics or in their homes. The Veterans Health Administration (VA) is championing the rollout of the TWP, starting with regional implementation.

OBJECTIVE

This paper aims to describe the protocol for a mixed-methods program evaluation to assess the implementation and outcomes of TWP in VA.

METHODS

We are conducting a mixed-methods evaluation of 4 VA medical centers and their community-based outpatient clinics that are participating in the initial implementation of the TWP. Data will be collected from veterans, VA health care team members, and other key stakeholders (eg, clinical leadership). We will use qualitative methods (ie, semistructured interviews), site visits, and quantitative methods (ie, surveys, national VA administrative databases) to assess the process and reach of TWP implementation and its impact on veterans' clinical outcomes and travel burdens and costs.

RESULTS

This program evaluation was funded in October 2019 as a Partnered Evaluation Initiative by the US Department of Veterans Affairs, Diffusion of Excellence Office, and Office of Research and Development, Health Services Research and Development Service, Quality Enhancement Research Initiative Program (PEC 19-310).

CONCLUSIONS

Evaluation of the TWP will identify barriers and solutions to TeleWound implementation in a small number of sites that can be used to inform successful rollout of the TWP nationally. Our evaluation work will inform future efforts to scale up the TWP across VA and optimize reach of the program to veterans across the nation.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/20139.

Management of Advanced Chronic Kidney Disease During the COVID-19 Pandemic: Suggestions From the Canadian Society of Nephrology COVID-19 Rapid Response Team

PURPOSE OF PROGRAM

To provide guidance on the management of patients with advanced chronic kidney disease (CKD) not requiring kidney replacement therapy during the COVID-19 pandemic.

SOURCES OF INFORMATION

Program-specific documents, pre-existing, and related to COVID-19; documents from national and international kidney agencies; national and international webinars, including webinars that we hosted for input and feedback; with additional information from formal and informal review of published academic literature.

METHODS

Challenges in the care of patients with advanced CKD during the COVID-19 pandemic were highlighted within the Canadian Senior Renal Leaders Forum discussion group. The Canadian Society of Nephrology (CSN) developed the COVID-19 rapid response team (RRT) to address these challenges. They identified a lead with expertise in advanced CKD who identified further nephrologists and administrators to form the workgroup. A nation-wide survey of advanced CKD clinics was conducted. The initial guidance document was drafted and members of the workgroup reviewed and discussed all suggestions in detail via email and a virtual meeting. Disagreements were resolved by consensus. The document was reviewed by the CSN COVID-19 RRT, an ethicist and an infection control expert. The suggestions were presented at a CSN-sponsored interactive webinar, attended by 150 kidney health care professionals, for further peer input. The document was also sent for further feedback to experts who had participated in the initial survey. Final revisions were made based on feedback received until April 28, 2020. Canadian Journal of Kidney Health and Disease (CJKHD) editors reviewed the parallel process peer review and edited the manuscript for clarity.

KEY FINDINGS

We identified 11 broad areas of advanced CKD care management that may be affected by the COVID-19 pandemic: (1) clinic visit scheduling, (2) clinic visit type, (3) provision of multidisciplinary care, (4) bloodwork, (5) patient education/support, (6) home-based monitoring essentials, (7) new referrals to multidisciplinary care clinic, (8) kidney replacement therapy, (9) medications, (10) personal protective equipment, and (11) COVID-19 risk in CKD. We make specific suggestions for each of these areas.

LIMITATIONS

The suggestions in this paper are expert opinion, and subject to the biases associated with this level of evidence. To expedite the publication of this work, a parallel review process was created that may not be as robust as standard arms' length peer-review processes.

IMPLICATIONS

These suggestions are intended to provide guidance for advanced CKD directors, clinicians, and administrators on how to provide the best care possible during a time of altered priorities and reduced resources.

eHealth in kidney care

eHealth is gaining momentum in nephrology, although evidence for its efficacy remains unclear and challenges to its widespread adoption persist. Successful integration of eHealth into kidney care will require patient engagement to develop effective interventions and issues such as data validity, regulation, oversight and adequate infrastructure to be addressed.

Facility-Level Variations in Kidney Disease Care among Veterans with Diabetes and CKD

BACKGROUND AND OBJECTIVES

Facility-level variation has been reported among veterans receiving care for various diseases. We studied the frequency and facility-level variations of guideline-recommended practices in patients with diabetes and CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Patients with diabetes and concomitant CKD (eGFR 15-59 ml/min per 1.73 m2, measured twice, 90 days apart) receiving care in 130 facilities across the Veterans Affairs Health Care System were included (n=281,223). We studied the proportions of patients (facility-level) receiving recommended core measures and facility-level variations of these study outcomes using median rate ratios, adjusting for various patient and provider-level factors. Median rate ratio quantifies the degree to which care may vary for similar patients receiving care at two randomly chosen facilities, with <1 being no variation and >1.2 as substantial variation between the facilities. Study outcomes included measurement of urine albumin-to-creatinine ratio/urine protein-to-creatinine ratio and blood hemoglobin concentration, prescription of statins and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, BP<140/90 mm Hg, and referral to a Veterans Affairs nephrologist (only for those with eGFR<30 ml/min per 1.73 m2).

RESULTS

Among those with eGFR 30-59 ml/min per 1.73 m2, proportion of patients receiving recommended core measures (median and interquartile range across facilities) were 37% (22%-47%) for urine albumin-to-creatinine ratio/urine protein-to-creatinine ratio, 74% (72%-79%) for hemoglobin measurement, 66% (62%-69%) for angiotensin-converting enzyme inhibitor/angiotensin receptor blocker prescription, 85% (74%-87%) for statin prescription, 47% (42%-53%) for achieving BP<140/90 mm Hg, and 13% (7%-16%) for meeting all outcome measures. Adjusted median rate ratios (95% confidence intervals) were 5.2 (4.1 to 6.4), 2.4 (2.1 to 2.6), 1.3 (1.2 to 1.3), 1.2 (1.2 to 1.3), 1.4 (1.3 to 1.4), and 4.1 (3.3 to 5.0), respectively. Median rate ratios were qualitatively similar in an analysis restricted to those with eGFR 15-29 ml/min per 1.73 m2.

CONCLUSIONS

Among patients with diabetes and CKD, at facility-level, ordering of laboratory tests, and scheduling of nephrology referrals in eligible patients remains suboptimal, with substantial variations across facilities.

Impact of Telehealth Interventions on Processes and Quality of Care for Patients With ESRD

Caring for patients with end-stage renal disease (ESRD) requiring dialysis is intensive and expensive. Telehealth may improve the access and efficiency of ESRD care. For this perspective, we systematically reviewed studies that examined the effectiveness of telehealth versus or in addition to usual care for ESRD management. 10 studies were identified, including 7 randomized trials and 3 cohort studies. Study populations, modes of delivery (including telephone, telemetry, or videoconferencing), and the outcomes evaluated varied substantially between studies. Two studies examined telehealth interventions versus standard ESRD care and demonstrated mixed results on processes of care, no differences in laboratory surrogate markers of ESRD care, and reduced or similar rates of hospitalization. Eight studies evaluated the addition of telehealth to usual care and demonstrated no significant improvements in processes of care or surrogate laboratory measures, variable impacts on hospitalization rates, and mixed impacts on some domains of quality of life, including improvement in mental health. Although potential benefits of telehealth in ESRD care have been reported, optimal designs for delivery and elements of care that may be improved through telehealth remain uncertain.

Mobile Health to Maintain Continuity of Patient-Centered Care for Chronic Kidney Disease: Content Analysis of Apps

BACKGROUND

Chronic kidney disease (CKD) is a global health problem with a high economic burden, which is particularly prevalent in Taiwan. Mobile health apps have been widely used to maintain continuity of patient care for various chronic diseases. To slow the progression of CKD, continuity of care is vital for patients' self-management and cooperation with health care professionals. However, the literature provides a limited understanding of the use of mobile health apps to maintain continuity of patient-centered care for CKD.

OBJECTIVE

This study identified apps related to the continuity of patient-centered care for CKD on the App Store, Google Play, and 360 Mobile Assistant, and explored the information and frequency of changes in these apps available to the public on different platforms. App functionalities, like patient self-management and patient management support for health care professionals, were also examined.

METHODS

We used the CKD-related keywords "kidney," "renal," "nephro," "chronic kidney disease," "CKD," and "kidney disease" in traditional Chinese, simplified Chinese, and English to search 3 app platforms: App Store, Google Play, and 360 Mobile Assistant. A total of 2 reviewers reached consensus on coding guidelines and coded the contents and functionalities of the apps through content analysis. After coding, Microsoft Office Excel 2016 was used to calculate Cohen kappa coefficients and analyze the contents and functionalities of the apps.

RESULTS

A total of 177 apps related to patient-centered care for CKD in any language were included. On the basis of their functionality and content, 67 apps were recommended for patients. Among them, the most common functionalities were CKD information and CKD self-management (38/67, 57%), e-consultation (17/67, 25%), CKD nutrition education (16/67, 24%), and estimated glomerular filtration rate (eGFR) calculators (13/67, 19%). In addition, 67 apps were recommended for health care professionals. The most common functionalities of these apps were comprehensive clinical calculators (including eGFR; 30/67; 45%), CKD medical professional information (16/67, 24%), stand-alone eGFR calculators (14/67, 21%), and CKD clinical decision support (14/67, 21%). A total of 43 apps with single- or multiple-indicator calculators were found to be suitable for health care professionals and patients. The aspects of patient care apps intended to support self-management of CKD patients were encouraging patients to actively participate in health care (92/110, 83.6%), recognizing and effectively responding to symptoms (56/110, 50.9%), and disease-specific knowledge (53/110, 48.2%). Only 13 apps contained consulting management functions, patient management functions or teleconsultation functions designed to support health care professionals in CKD patient management.

CONCLUSIONS

This study revealed that the continuity of patient-centered care for CKD provided by mobile health apps is inadequate for both CKD self-management by patients and patient care support for health care professionals. More comprehensive solutions are required to enhance the continuity of patient-centered care for CKD.

Delivering a "New Deal" of Kidney Health Opportunities to Improve Outcomes Within the Veterans Health Administration

Just as the "New Deal" aimed to elevate the "forgotten man" of the Great Depression through governmental relief and reform, so does the Department of Veterans Affairs (VA) health care system aim to improve the health of veterans with the invisible illness of chronic kidney disease through a concerted series of health care delivery reforms. Augmenting its primary care platform with advances in informatics and health service delivery initiatives targeting kidney disease, the VA is changing how nephrology care is provided to veterans with the goal of optimized population kidney health. As the largest provider of kidney health services in the country, the VA offers an instructive case study of the value of comprehensive health care coverage for people with chronic kidney disease. Recent reports of kidney health outcomes among veterans support the benefit of the VA's integrated health care delivery system. Suggestions to optimize veterans' kidney health further may be equally applicable to other health systems caring for people afflicted with kidney disease.

The Landscape of Diabetic Kidney Disease in the United States

PURPOSE OF REVIEW

The purposes of this review are to identify population characteristics of important risk factors for the development and progression of diabetic kidney disease (DKD) in the United States and to discuss barriers and opportunities to improve awareness, management, and outcomes in patients with DKD.

RECENT FINDINGS

The major risk factors for the development and progression of DKD include hyperglycemia, hypertension, and albuminuria. DKD disproportionately affects minorities and individuals with low educational and socioeconomic status. Barriers to effective management of DKD include the following: (a) limited patient and healthcare provider awareness of DKD, (b) lack of timely referrals of patients to a nephrologist, (c) low patient healthcare literacy, and (d) insufficient access to healthcare and health insurance. Increased patient and physician awareness of DKD has been shown to enhance patient outcomes. Multifactorial and multidisciplinary interventions targeting multiple risk factors and patient/physician education may provide better outcomes in patients with DKD.

Role of telehealth in renal replacement therapy education

The prevalence of end-stage renal disease is rising in the United States, which bears high financial and public health burden. The most common modality of renal replacement therapy (RRT) in the United States is in-center hemodialysis. Many patients report lack of comprehensive and timely education about their treatment options, which may preclude them from participating in home-based dialysis therapies and kidney transplantation evaluation. While RRT education has traditionally been provided in-person, the rise of telehealth has afforded new opportunities to improve upon the status quo. For example, technology-augmented RRT education has recently been implemented into telehealth nephrology clinics, informational websites and mobile applications maintained by professional organizations, patient-driven forums on social media, and multimodality programs. The benefits of technology in RRT education are increased access for geographically isolated and/or medically frail patients, versatility of content delivery, information repetition to enhance knowledge retention, and interpersonal connection for educational content and emotional support. Challenges center around privacy and accuracy of information sharing, in addition to differential access to technology due to age and socioeconomic status. A review of available scholarly and social media resources suggests that technology-aided delivery of education about treatment options for end-stage renal disease provides an important alternative and/or supplemental resource for patients and families.