NUR 410

2

Impact of Telemedicine in the Care of Kidney Transplant Recipients

April Showers

University of Maryland Global Campus

NURS 410: Applying Evidence-Based Practice in Nursing

Professor Shakur

March 1, 2023

Impact of Telemedicine in the Care of Kidney Transplant Recipients

Every humanity should have equitable access to healthcare to improve quality of life. Finding a cure for patients with kidney failure to avoid relentless dialysis therapy through organ transplantation has made a great leap in medicine to restore their normal life. Having a new organ comes with strict discipline to ensure its graft survival. Consistent patient engagement to the transplant team is the key to success of a stable kidney function. Telemedicine has become an alternative option to stay in touch with their provider instead of the traditional in-person visit. The COVID-19 pandemic outbreak has forced our organization to adopt this new model of care in our practice to provide continuity of care. The benefits of this delivery of care during pandemic is paramount, however, with infection rates deescalating and some life normalcy returning, it begs the question if the utilization of telemedicine is sustainable in a long run. The purpose of this assignment is to provide a literature review to support the PICO(T) looking at telemedicine and transplant patients.

Background

Telemedicine of telehealth is evidenced-based practice that has been employed by other disciplines for years but not in transplantation. Telemedicine is described as the use of telecommunication technologies to connect between two parties – a patient and the provider in real-time through video to deliver health care related services at a distance, or basically a remote virtual interaction in real time. As mentioned earlier, the effects of the pandemic have triggered a practice to adapt to this new delivery of care which eventually contributed a positive impact to our patient population by restoring consistent engagement to their provider. However, as the rate of COVID cases started to wean down, the management has decided to cut down virtual visits which then prompted further inquiry to this issue. The PICOT question formulated for this topic is – will the utilization of telemedicine or telehealth appointments result in improved compliance to treatment regimen and overall plan of care compared to face-to-face traditional follow up care?

There are a few patients in the practice who were not seen for months that resulted in losing their kidney transplant, which unfortunately leading them back to dialysis. Schmid et al. (2017) iterated that consistency in follow-up care is the key to long-term survival of the graft as well as to maintain a stable kidney function. Using telehealth will be an alternative to in-person consultations so patients can stay engaged with their provider. After so many months of using telehealth then reverting to the traditional way of face-to-face visits, it begs the question the influence of telemedicine to patient care compliance.

To look for related topics of interest is by using the UMGC Library OneSearch engine and plugging in key words such as telemedicine or telehealth, renal/kidney transplant recipients, adherence or compliance, and positive outcomes which confines the search to peer-reviewed scholarly articles within the past five years. Surprisingly, there were quite a few research literatures that have been developed relating to the importance of integrating telemedicine to follow-up kidney/renal transplant recipients even before the emergence of COVID pandemic. Most studies were done in Europe and Australia, and very restricted studies were done in the United States prior to pandemic.

Literature Review

Telemedicine is not new in healthcare but lagging its integration to the transplant community until the pandemic hits the community worldwide. According to Wei et al. (2022), many patients favored telemedicine because of the feasibility of not travelling long distances while saving money for transportation, food, and lodging. Additionally, patients are pleased to conduct these virtual visits at the convenience of their homes and at work (Varsi et al., 2021). Thus, not missing any workdays or trying to get a day off to see their practitioner is a huge benefit of doing telehealth. On the contrary, many providers worry that this convenience from patient may compromise adherence to other therapies such as not doing routine blood work, mismanaged blood pressure and blood glucose levels, inappropriate or missing immune medications, etc., which can be more costly if there is a loss in graft function which would require more hospitalizations. On the other hand, with the feasibility of telemedicine, providers can negate any unplanned hospital admissions. Schmid et al. (2017) conducted a randomized, controlled trial of 46 individuals divided into 2 groups between standard of care group versus tele-medically supported case management group which indicates that the tele group having the liberty to have access to the team can prevent further development of serious complications. Authors also stated that the medical team can intervene sooner which shortened the length of unplanned hospital stays.

Telemedicine has the potential of keeping the patient engaged. With providers being unable to make an assessment physically in-person, patients would likely heighten their self-care management skills such as understanding the parameters of their lab values, blood pressure and heart rate readings, cholesterol and blood sugar levels, and immunosuppressant (IS) therapeutic levels. Schmid et al. (2017) observed that patients in the telemedicine group have higher GFR function than those patients receiving the standard of care. Therefore, authors implied that the group of tele-medically supported care are more adherent. Furthermore, with the use of telemedicine, patients can do their blood work closer to their homes in other laboratory clinics, thus avoiding duplication of lab examination and travel costs (Pape et al., 2017). Despite the benefits of using virtual visits, in a qualitative study conducted by Varsi et. al. (2021) to 15 patients, their subjects/patients expressed some technical difficulties such as poor sound quality, reception, and image quality which led them to resort to using the telephone to complete the meeting. Regardless of these technical challenges, researchers emphasized that patients were not deterred from using video consultation expressing that the problems could be typical glitches when starting a new system.

Moreover, telemedicine can provide a holistic approach into patient follow-up care. Pape et al. (2017) integrated into their study a video/virtual visits to assess psychosocial and cardiovascular function: psychosocial team can evaluate overall mental and psychosocial disabilities and what not and make appropriate interventions to enhance adherence to care while a cardiac team or physiologist has designed an exercise program that patient can use at home to improve their general physical endurance. Similarly, in a study by Schmid et al. (2017), individuals in telemedicine/care management group who have higher percentage of adhering to follow up care lead them to have better cardiac and kidney function and eventually afforded them to return to work during the first year of posttransplant compared to group receiving standard of care who are less adherent and failed to return to work within same period.

Lastly, besides the promising benefits of utilizing telemedicine, integrating it into practice does not seem to be a seamless approach. Varsi et al. (2021) argued that its implementation into clinical practice may not be realized if reimbursement is not comparable to that of in-person visits. That means, televisits reimbursements is less than in-person visits. Considering the aforementioned technological challenges, technical systems must meet requirements and function more efficiently to avoid undue interruptions and delays of other patients waiting for their appointments. Furthermore, Wei et al. (2022) conducted a study to 2801 patients and found that patients with government insurance like Medicare and Medicaid are less likely to use telemedicine compared to private-insured patients. Researchers implied that patients with Medicare or Medicaid are 65 years old and above, with disability, or with ESRD (end-stage renal disease) could possibly have low socioeconomic status which related to poor access to smartphones or computers and Wi-Fi coverage that are essential for tele-visits. Likewise, older populations have a low usage of telemedicine likely due to “mistrust of technologies, suboptimal cognition and motor skills, and visual perception difficulties” (Wei et al., 2022, p. 4). Authors reiterated the importance of having support system to assist them in navigating new tools especially nowadays that advanced technologies continue to evolve in healthcare.The literature review provides evidence that telemedicine is feasible in medical practice. It is effective and efficient but not necessarily applicable to everyone. In kidney transplant, the goal of managing kidney transplant recipients is to prolong graft survival which means finding the best possible intervention to keep patients involved in their care. Most patients who have existing chronic diseases like hypertension, diabetes, renal disease on dialysis which prevent them from holding any jobs and puts them into low socioeconomic status, are unable to sustain internet access to do tele-video capability. Other patients who have jobs prior to transplants and wanted to resume their jobs after the surgery may find tele-visits more convenient to avoid frequent trips to the doctor’s office and avoid multiple absences from work. On the contrary, depending on their socioeconomic status or if they hold employment or not, telemedicine may or may not be applicable because of complex health and social conditions surrounding their disease process.

Utilizing telemedicine is not a seamless approach. Both patients and providers expressed frustrations in dealing with technological difficulties – poor reception, poor quality of image and sound that can impede the process, however, these hiccups are of minute importance and will not dissuade them from using it in the future. And last, it is important to point out that the success of the studies is related to how researchers design their investigation – their methods and procedures. In one study, they hired part-time workers dedicated in doing the research and the other study subjects get a thorough evaluation by psychosocial and cardiac team. Resources allocated in research can highly influence the findings of the study.

Application to Nursing Practice

As mentioned previously, telemedicine is not new in healthcare. It gained its popularity with the outbreak of COVID pandemic. Though patients and healthcare teams find telemedicine to be an enormous potential in clinical practice, there is not enough evidence or studies to suggest that it is financially sound for the organization. Learning it from current practice and the reviewed literature, telemedicine reimbursement is not equivalent to face-to-face visit which may likely be the reason why all articles ended their narrative of encouraging academia and researchers to conduct more scientific testing to explore its relevance in clinical practice. Therefore, more studies in telemedicine should be pursued in this population to demonstrate its feasibility and sustainability into clinical practice, and perhaps with improved positive outcomes as illustrated by longer graft survival can present cost compensation in all stakeholders.

Conclusion

Telemedicine came into our practice by chance in perfect timing. Kidney transplant recipients require frequent monitoring to ensure longevity of their graft survival. A standard of care like face-to-face visits with the provider demonstrates that it is not feasible to every patient or in every scenario due to many reasons. The uptake of telehealth is positive in all literatures: patients find it convenient for so many levels while providers can implement early intervention prior to complications and avert unnecessary hospital admissions. Therefore, telehealth is a great alternative and/or supplement to in-person visit. Transplant centers may still have trepidation of fully integrating it into clinical practice likely due to unable to scale the cost in terms of reimbursements, long-term cost of technologies with associated software, and allocations of appropriate staffing.

References

Pape, L., Zwaan, M. D., Tegtbur, U., Feldhaus, F., Wolff, J. K., Schiffer, L., Lerch, C., Hellrung, N., Kliem, V., Lonnemann, G., Nolting, H. D., & Schiffer, M. (2017). The KTx360°-study: A multicenter, multisectoral, multimodal, telemedicine-based follow-up care model to improve care and reduce health-care costs after kidney transplantation in children and adults. BMC Health Services Research, 17. https://doi.org/10.1186/s12913-017-2545-0

Schmid, A., Hils, S., Kramer-Zucker, A., Bogatyreva, L., Hauschke, D., De Geest, S., & Pisarski, P. (2017). Telemedically supported case management of living-donor renal transplant recipients to optimize routine evidence-based aftercare: A single-center randomized controlled trial. American Journal of Transplantation, 17(6), 1594-1605. https://doi.org/10.1111/ajt.14138

Varsi, C., Stenehjem, A. E., Borosund, E., & Nes, L. S. (2021). Video as an alternative to in-person consultations in outpatient renal transplant recipient follow-up: A qualitative study. BMC Nephrology, 22. https://doi.org/10.1186/s12882-021-02284-3

Wei, T. R., Berner, E. S., Qu, H., & Agarwal, G. (2022). Factors associated with telemedicine utilization among post-transplant patients at a university kidney and pancreas transplant centers. Clinical Transplantation, 36(4) . https://doi.org/10.1111/ctr.14578