Exploring the utility and scalability of a telehomecare intervention for patients with chronic kidney disease undergoing peritoneal dialysis-a study protocol

Mobile Apps for Patients with Peritoneal Dialysis: Systematic App Search and Evaluation

BACKGROUND

Peritoneal dialysis (PD) is one type of renal replacement therapy. If patients have problems during the dialysis process, healthcare providers may not be able assist the patients immediately. mHealth can provide patients with information and help them to solve problems in real-time, potentially increasing their willingness to choose PD.

OBJECTIVE

The objectives of this study were to conduct a comprehensive review of free mobile applications for patients with PD on the Internet and to recommend suitable mobile applications to facilitate patient self-management and health.

METHODS

We conducted a systematic search for PD mobile applications on Google Play and the Apple iTunes Store from 3 to 16 June 2023.

RESULTS

A total of 828 identifiable mobile applications were initially identified, and ultimately, 21 met the inclusion criteria. The Mobile App Rating Scale (MARS) assessment of the applications revealed the highest score in the functionality domain, followed by the aesthetics, information, app-specific, subjective quality, and engagement domains, respectively. In the comprehensive self-management of PD, the highest percentage was related to disease-related information.

CONCLUSION

The findings of this study suggest that some applications, with the highest quality, can be recommended to patients for use in English or traditional Chinese.

Delivering Person-Centered Peritoneal Dialysis

Peritoneal dialysis (PD) enables people to have a home-based therapy, permitting greater autonomy for individuals along with enhanced treatment satisfaction compared with in-center dialysis care. The burden of treatment on PD, however, remains considerable and underpins the need for person-centered care. This reflects the need to address the patient as a person with needs and preferences beyond just the medical perspective. Shared decision making is central to the recent International Society for Peritoneal Dialysis recommendations for prescribing PD, balancing the potential benefits of PD on patient well-being with the burden associated with treatment. This review considers the role of high-quality goal-directed prescribing, incremental dialysis, and remote patient monitoring in reducing the burden of dialysis, including an approach to implementing incremental PD. Although patient-related outcomes are important in assessing the response to treatment and, particularly life participation, the corollary of dialysis burden, there are no clear routes to the clinical implementation of patient-related outcome measures. Delivering person-centered care is dependent on treating people both as individuals and as equal partners in their care.

Benefits and Challenges of Remote Patient Monitoring as Perceived by Health Care Practitioners: A Systematic Review

BACKGROUND

Remote patient monitoring (RPM), or telemonitoring, offers ways for health care practitioners to gather real-time information on the physiological conditions of patients. As telemedicine, and thus telemonitoring, is becoming increasingly relevant in today's society, understanding the practitioners' opinions is crucial. This systematic review evaluates the perspectives and experiences of health care practitioners with telemonitoring technologies.

METHODS

A database search was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for the selection of articles measuring health care practitioners' perspectives and experiences with RPM technologies published between 2017 and 2021. Only articles written in English were included. No statistical analysis was performed and thus this is a qualitative review.

RESULTS

A total of 1605 studies were identified after the initial search. After applying the inclusion and exclusion criteria of this review's authors, 13 articles were included in this review. In all, 2351 practitioners' perspectives and experience utilizing RPM technology in a variety of medical specialties were evaluated through close- and open-ended surveys. Recurring themes emerged for both the benefits and challenges. Common benefits included continuous monitoring of patients to provide prompt care, improvement of patient self-care, efficient communication, increased patient confidence, visualization of health trends, and greater patient education. Challenges comprised increased workload, higher patient anxiety, data inaccuracy, disorienting technology, financial issues, and privacy concerns.

CONCLUSION

Health care practitioners generally believe that RPM is feasible for application. Additionally, there is a consensus that telemonitoring strategies will become increasingly relevant. However, there are still drawbacks to the technology that need to be considered.

Opportunities in the cloud or pie in the sky? Current status and future perspectives of telemedicine in nephrology

The use of telehealth to support, enhance or substitute traditional methods of delivering healthcare is becoming increasingly common in many specialties, such as stroke care, radiology and oncology. There is reason to believe that this approach remains underutilized within nephrology, which is somewhat surprising given the fact that nephrologists have always driven technological change in developing dialysis technology. Despite the obvious benefits that telehealth may provide, robust evidence remains lacking and many of the studies are anecdotal, limited to small numbers or without conclusive proof of benefit. More worryingly, quite a few studies report unexpected obstacles, pitfalls or patient dissatisfaction. However, with increasing global threats such as climate change and infectious disease, a change in approach to delivery of healthcare is needed. The current pandemic with coronavirus disease 2019 (COVID-19) has prompted the renal community to embrace telehealth to an unprecedented extent and at speed. In that sense the pandemic has already served as a disruptor, changed clinical practice and shown immense transformative potential. Here, we provide an update on current evidence and use of telehealth within various areas of nephrology globally, including the fields of dialysis, inpatient care, virtual consultation and patient empowerment. We also provide a brief primer on the use of artificial intelligence in this context and speculate about future implications. We also highlight legal aspects and pitfalls and discuss the 'digital divide' as a key concept that healthcare providers need to be mindful of when providing telemedicine-based approaches. Finally, we briefly discuss the immediate use of telenephrology at the onset of the COVID-19 pandemic. We hope to provide clinical nephrologists with an overview of what is currently available, as well as a glimpse into what may be expected in the future.

Fushen Granule, A Traditional Chinese Medicine, ameliorates intestinal mucosal dysfunction in peritoneal dialysis rat model by regulating p38MAPK signaling pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Fushen Granule (FSG) is a Chinese medicinal formular prepared in hospital to treat intestinal mucosal dysfunction induced by peritoneal dialysis (PD). However, the mechanisms of this formular has not been studied yet.

AIM OF THE STUDY

The present study was designed to investigate the effect of FSG against intestinal dysfunction during PD treatment and explore the potential mechanisms using a rat PD model.

METHODS AND METHODS

In the present study, the effect of FSG on improving intestinal mucosal architecture injury was intuitively shown by hematoxylin-eosin staining, the serum levels of DAO and D-lactate were measured to evaluate the intestinal permeability by the DAO Assay Kit and D-Lactic Acid ELISA Kit. The expression of the intestinal mucosal barrier related inflammation factor by real-time PCR. The main effective constituents of FSG were characterized by UPLC/Q-TOF analysis, and the targets and pathways of the constituents were predicted via TCMSP database and IPA. the activation of p38MAPK signaling pathway by western blotting.

RESULTS

HE staining results showed that FSG protected against intestinal mucosal injury in pathology in PD rats. FSG decreased the intestinal mucosal permeability by increasing the transepithelial electrical resistance (TER) level and decreasing the intestinal clearance of fluorescein-isothiocyanate dextran (FD4) and the level of D-lactate and diamine oxidase (DAO). FSG significantly decreased the expression of ICAM-1, IL-1β, iNOS and TNF-α, and further inhibited the activation of p38MAPK signaling pathway via down-regulating the expression of P-p38MAPK and up-regulating the expression of DUSP1, occludin, and ZO-1.

CONCLUSION

This study demonstrates that FSG ameliorated intestinal mucosal dysfunction in PD by decreasing expression of pro-inflammatory cytokines and inhibiting the activation of p38MAPK signaling pathway. The results provide a promising basis for the alternative medicine treatment of intestinal mucosal dysfunction in PD.

eHealth interventions for people with chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) is associated with high morbidity and death, which increases as CKD progresses to end-stage kidney disease (ESKD). There has been increasing interest in developing innovative, effective and cost-efficient methods to engage with patient populations and improve health behaviours and outcomes. Worldwide there has been a tremendous increase in the use of technologies, with increasing interest in using eHealth interventions to improve patient access to relevant health information, enhance the quality of healthcare and encourage the adoption of healthy behaviours.

OBJECTIVES

This review aims to evaluate the benefits and harms of using eHealth interventions to change health behaviours in people with CKD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 14 January 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs using an eHealth intervention to promote behaviour change in people with CKD were included. There were no restrictions on outcomes, language or publication type.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility, extracted data and assessed the risk of bias. The certainty of the evidence was assessed using GRADE.

MAIN RESULTS

We included 43 studies with 6617 participants that evaluated the impact of an eHealth intervention in people with CKD. Included studies were heterogeneous in terms of eHealth modalities employed, type of intervention, CKD population studied and outcomes assessed. The majority of studies (39 studies) were conducted in an adult population, with 16 studies (37%) conducted in those on dialysis, 11 studies (26%) in the pre-dialysis population, 15 studies (35%) in transplant recipients and 1 studies (2%) in transplant candidates We identified six different eHealth modalities including: Telehealth; mobile or tablet application; text or email messages; electronic monitors; internet/websites; and video or DVD. Three studies used a combination of eHealth interventions. Interventions were categorised into six types: educational; reminder systems; self-monitoring; behavioural counselling; clinical decision-aid; and mixed intervention types. We identified 98 outcomes, which were categorised into nine domains: blood pressure (9 studies); biochemical parameters (6 studies); clinical end-points (16 studies); dietary intake (3 studies); quality of life (9 studies); medication adherence (10 studies); behaviour (7 studies); physical activity (1 study); and cost-effectiveness (7 studies).Only three outcomes could be meta-analysed as there was substantial heterogeneity with respect to study population and eHealth modalities utilised. There was found to be a reduction in interdialytic weight gain of 0.13kg (4 studies, 335 participants: MD -0.13, 95% CI -0.28 to 0.01; I² = 0%) and a reduction in dietary sodium intake of 197 mg/day (2 studies, 181 participants: MD -197, 95% CI -540.7 to 146.8; I² = 0%). Both dietary sodium and fluid management outcomes were graded as being of low evidence due to high or unclear risk of bias and indirectness (interdialytic weight gain) and high or unclear risk of bias and imprecision (dietary sodium intake). Three studies reported death (2799 participants, 146 events), with 45 deaths/1000 cases compared to standard care of 61 deaths/1000 cases (RR 0.74, CI 0.53 to 1.03; P = 0.08). We are uncertain whether using eHealth interventions, in addition to usual care, impact on the number of deaths as the certainty of this evidence was graded as low due to high or unclear risk of bias, indirectness and imprecision.

AUTHORS' CONCLUSIONS

eHealth interventions may improve the management of dietary sodium intake and fluid management. However, overall these data suggest that current evidence for the use of eHealth interventions in the CKD population is of low quality, with uncertain effects due to methodological limitations and heterogeneity of eHealth modalities and intervention types. Our review has highlighted the need for robust, high quality research that reports a core (minimum) data set to enable meaningful evaluation of the literature.

Uptake and Scalability of a Peritoneal Dialysis Virtual Care Solution: Qualitative Study

Background

Early research in the area of virtual care solutions with peritoneal dialysis (PD) patients has focused on evaluating the outcomes and impact of these solutions. There has been less attention focused on understanding the factors influencing the uptake, usability, and scalability of virtual care for chronic kidney disease (CKD) patients receiving PD at home.

Objective

In this context, a study was undertaken to (1) assess and understand the factors influencing the uptake of a virtual care solution and (2) provide recommendations for the scalability of a virtual care solution aimed at enhancing CKD patients’ outcomes and experiences.

Methods

This study used a qualitative design with semistructured interviews and a thematic analysis approach. A total of 25 stakeholders—6 patients and 3 caregivers, 6 health care providers, 2 vendors, and 8 health system decision makers—participated in this study.

Results

The following three primary mechanisms emerged to influence the usability of the virtual care solution: (1) receiving hands-on training and ongoing communication from a supportive team, (2) adapting to meet user needs and embedding them into workflow, and (3) being influenced by patient and caregiver characteristics. Further, two overarching recommendations were developed for considerations around scalability: (1) co-design locally, embed into the daily workflow, and deploy over time and (2) share the benefits and build the case.

Conclusions

Study findings can be used by key stakeholders in their future efforts to enhance the implementation, uptake, and scalability of virtual care solutions for CKD and managing PD at home.

Improving safety and efficiency in care: multi-stakeholders' perceptions associated with a peritoneal dialysis virtual care solution

BACKGROUND

Although there is a growing body of literature on the outcomes and impacts of remote home management with peritoneal dialysis (PD) patients, less is understood how this virtual care solution impacts the quality and efficiency of the healthcare system care. In this context, a study was undertaken to understand the perceptions of patients and their caregivers, healthcare providers, health system decision makers, and vendors associated with a remote monitoring and tracking solution aimed at enhancing the outcomes and experiences of chronic kidney disease (CKD) patients receiving PD at home.

METHODS

A qualitative design using semi-structured interviews with 25 stakeholders was used in this study. Narrative data were analyzed by a thematic analysis approach.

RESULTS

The following two themes emerged from the data: (1) leveraging data to monitor and intervene to keep patients safe and (2) increasing efficiencies and having control over supplies.

DISCUSSION

Our study findings elucidated the ability of patients (and in some cases, caregivers) to monitor and trend their data and order and track directly on-line their dialysis supplies were key to their active participation in managing their CKD and keeping them safe at home. Their active participation and functionality of the virtual care solution also led to enhanced efficiencies (eg, process faster, easier, convenient, time savings) for both patients and healthcare providers.

CONCLUSION

The virtual care solution showed promising signs of a patient-centric approach and may serve as a blueprint for other virtual care solutions for chronic disease management.

Exploring Barriers and Potential Solutions in Home Dialysis: An NKF-KDOQI Conference Outcomes Report

Home dialysis therapy, including home hemodialysis and peritoneal dialysis, is underused as a modality for the treatment of chronic kidney failure. The National Kidney Foundation-Kidney Disease Outcomes Quality Initiative sponsored a home dialysis conference in late 2017 that was designed to identify the barriers to starting and maintaining patients on home dialysis therapy. Clinical, operational, policy, and societal barriers were identified that need to be overcome to ensure that dialysis patients have the freedom to choose their treatment modality. Education of patients and patient partners, as well as health care providers, about home dialysis therapy, if offered at all, is often provided in a cursory manner. Lack of exposure to home dialysis therapies perpetuates a lack of familiarity and thus a hesitancy to refer patients to home dialysis therapies. Patient and care partner support, both psychosocial and financial, is also critical to minimize the risk for burnout leading to dropout from a home dialysis modality. Thus, the facilitation of home dialysis therapy will require a systematic change in chronic kidney disease education and the approach to dialysis therapy initiation, the creation of additional incentives for performing home dialysis, and breakthroughs to simplify the performance of home dialysis modalities. The home dialysis work group plans to develop strategies to overcome these barriers to home dialysis therapy, which will be presented at a follow-up home dialysis conference.

Case management in primary care for frequent users of healthcare services with chronic diseases and complex care needs: an implementation and realist evaluation protocol

INTRODUCTION

Significant evidence in the literature supports case management (CM) as an effective intervention to improve care for patients with complex healthcare needs. However, there is still little evidence about the facilitators and barriers to CM implementation in primary care setting. The three specific objectives of this study are to: (1) identify the facilitators and barriers of CM implementation in primary care clinics across Canada; (2) explain and understand the relationships between the actors, contextual factors, mechanisms and outcomes of the CM intervention; (3) identify the next steps towards CM spread in primary care across Canada.

METHODS AND ANALYSIS

We will conduct a multiple-case embedded mixed methods study. CM will be implemented in 10 primary care clinics in five Canadian provinces. Three different units of analysis will be embedded to obtain an in-depth understanding of each case: the healthcare system (macro level), the CM intervention in the clinics (meso level) and the individual/patient (micro level). For each objective, the following strategy will be performed: (1) an implementation analysis, (2) a realist evaluation and (3) consensus building among stakeholders using the Technique for Research of Information by Animation of a Group of Experts method.

ETHICS AND DISSEMINATION

This study, which received ethics approval, will provide innovative knowledge about facilitators and barriers to implementation of CM in different primary care jurisdictions and will explain how and why different mechanisms operate in different contexts to generate different outcomes among frequent users. Consensual and prioritised statements about next steps for spread of CM in primary care from the perspectives of all stakeholders will be provided. Our results will offer context-sensitive explanations that can better inform local practices and policies and contribute to improve the health of patients with complex healthcare needs who frequently use healthcare services. Ultimately, this will increase the performance of healthcare systems and specifically mitigate ineffective use and costs.

Telemonitoring system for patients with chronic kidney disease undergoing peritoneal dialysis: Usability assessment based on a case study

There are two million people with chronic kidney disease (CKD) worldwide. In Mexico, it is estimated that by 2025, there will be 212 thousand CKD cases. Among the renal replacement treatments, peritoneal dialysis (PD) exists either in the continuous ambulatory (CAPD) or automated (APD) mode, which requires continuous monitoring and strict control. Thus, several software systems have been proposed to perform reliable remote monitoring of patients using PD but also to achieve the goal with effectiveness, efficiency and satisfaction; i.e., in software engineering, this is called usability. However, few studies have addressed usability issues using case studies with patients and medical staff in real domains. In this paper, we present a usability assessment of a telemonitoring system for patients with CKD on peritoneal dialysis treatment through a case study with patients and medical staff of the Mexican Institute of Social Security (IMSS). The usability evaluation was carried out through the application of two satisfaction instruments. These instruments evaluated multiple usability criteria, such as navigability, interactivity, motivation, satisfaction, and applicability. The results obtained from the usability evaluation show that, on average, the services offered by the system have 91.3% acceptance by users (patient-doctors), with the APD and CAPD exchange data registration services having the highest acceptance for patients, with a positive perception of 94.5% and 92.3%, respectively. Meanwhile, for the doctors and nurses, the alarm reception for patients in a risk situation was highest with 95% acceptance. Based on the obtained results, the evaluated telemonitoring system holds wide acceptance, satisfaction, and applicability from patients’ and doctors’ perspectives. It is also noted that the evaluated system considers and satisfies the requirements and suitable parameters that should be monitored in PD treatment according to studies presented in the literature.

Examining Tensions That Affect the Evaluation of Technology in Health Care: Considerations for System Decision Makers From the Perspective of Industry and Evaluators

Virtual technologies have the potential to mitigate a range of challenges for health care systems. Despite the widespread use of mobile devices in everyday life, they currently have a limited role in health service delivery and clinical care. Efforts to integrate the fast-paced consumer technology market with health care delivery exposes tensions among patients, providers, vendors, evaluators, and system decision makers. This paper explores the key tensions between the high bar for evidence prior to market approval that guides health care regulatory decisions and the “fail fast” reality of the technology industry. We examine three core tensions: balancing user needs versus system needs, rigor versus responsiveness, and the role of pre- versus postmarket evidence generation. We use these to elaborate on the structure and appropriateness of evaluation mechanisms for virtual care solutions. Virtual technologies provide a foundation for personalized, patient-centered medicine on the user side, coupled with a broader understanding of impact on the system side. However, mechanisms for stakeholder discussion are needed to clarify the nature of the health technology marketplace and the drivers of evaluation priorities.