Views on Telehealth vs In-Person Care Diverge Among Patients With CKD, Clinicians

Some clinicians and older patients shared divergent views on whether patient-centered telehealth care is better for patients with chronic kidney disease (CKD) compared with in-person care, investigators concluded in a recent study.

The qualitative study, published in JAMA Network Open, showed the disparate opinions that health care professionals and older patients have regarding the impact of telehealth services on clinical effectiveness, patient experience, access to care, and clinician-patient relationships.

“Understanding older patients’ and kidney clinicians’ perceptions of telehealth elucidate barriers that should be addressed to promote high-quality care and telehealth use,” wrote the investigators.

Telehealth use increased dramatically in 2020 due to the COVID-19 pandemic, especially for older patients with chronic conditions, such as CKD. About 38% of US adults 65 years or older have CKD, which translates to 20% of traditional Medicare payments ($114 billion annually). Telehealth is expected to remain a significant part of CKD care well after the pandemic ends. However, not much is known about whether telehealth promotes patient-centered care among older adults with complex conditions like CKD.

Although some patients with CKD have been open to using telehealth and have seen comparable results compared with in-person care in small, observational reports, telehealth may have drawbacks among older patients, who often have less access or comfortability with technology than younger patients. Additionally, telehealth can compromise care because of inadequate physical examinations and laboratory tests, and some studies have shown lower willingness to use and satisfaction with telehealth among patients who are older, are Black, or have less education.

“The impact of telehealth on engagement and experience of older, chronically ill adults remain insufficiently understood. Most studies involving patients have relied on surveys or claims data, which, although instructive, are insufficient for understanding telehealth experiences of older persons with chronic conditions,” the investigators noted.

The investigators conducted 60 phone interviews between August and December 2020. The study was part of the Decision Aid for Renal Therapy (DART) Trial, which examined the effectiveness of decision aids for older patients making decisions regarding dialysis. The DART Trial recruited 400 English-speaking patients aged 70 years or older with nondialysis CKD from Boston, Massachusetts; Portland, Maine; San Diego, California; and Chicago, Illinois. The subsample for the present analysis was selected from those who were followed up with for 12 months.

Among the interviewees, 19 (32%) were clinicians, 30 (50%) were patients, and 11 (18%) were care partners. Among the patients, 43% were non-Hispanic Black, 20 (67%) were women, and 22 (73%) were 75 years or older. Nephrologists comprised 16 of the clinicians (84%).

Most clinicians responded that they viewed the inability to conduct adequate physical examinations and laboratory tests, including edema and blood pressure measurements, as examples of telehealth compromising the quality of care. Some patients also expressed issues with conducting blood pressure measurements at home and concerns that the equipment used for home examinations may not be as good as the equipment in a clinician’s office.

Patients, care partners, and clinicians viewed telehealth as a convenient, less costly, and efficient alternative to in-person visits. They also expressed appreciation for telehealth as a method to reduct COVID-19 exposure risks. However, some patients expressed challenges with finding a quiet, private place to have a meaningful discussion for telehealth visits and clinicians cited more missed appointments and a drop in patient engagement.

Some clinicians reported that they struggled with understanding patient emotions and being empathic over a virtual interface, with 1 stating that they felt uncomfortable discussing heavy decisions remotely with patients. Clinicians and patients also expressed difficulties with using telehealth in situations where the patient may have limited English proficiency or hearing impairments.

Strategies that clinicians suggested to combat interpersonal issues included, only using telehealth for established patients and implementing follow-up policies for advanced care practitioners. The investigators also said that the use of detailed electronic medical record summaries, leaving patients time to process information, and explicitly asking about patient emotions where nonverbal cues are unavailable in addition to training for clinicians could be helpful remedies to improving telehealth in CKD care spaces.

Limitations of the study included recall bias and underrepresentation of Hispanic patients and non-English speakers, who represent 2 populations highly vulnerable to and disproportionately affected by COVID-19 and CKD.

Reference

Laden K, Porteny T, Perugini JM, et al. Perceptions of telehealth vs in-person visits among older adults with advanced kidney disease, care partners, and clinicians. 2021;4(12):e2137193. doi:10.1001/jamanetworkopen.2021.37193