Evaluation of the experience with the use of telemedicine in a home dialysis program—a qualitative and quantitative study

Assisted home hemodialysis (HHD) is a hemodialysis modality performed at home by trained nurses and is indicated for patients with motor or functional limitations that prevent them from attending satellite clinics or performing their own treatment [1].

Adherence to this therapeutic modality is directly related to increased comfort at home [1, 2]. However, HHD patients have concerns about undergoing hemodialysis at home, such as feelings of social isolation, a lack of connection with medical care and doubts and fear of complications [3‐5], which suggests that patients on home dialysis may need additional support to improve their satisfaction and treatment adherence [6].

Telemedicine allows remote contact between patients and health professionals to improve adherence to the hemodialysis regimen and allow patients to feel connected to health professionals [3]. In addition, telemedicine is an excellent tool for monitoring treatment, adjusting medications, answering questions and providing continuing education to patients and health professionals [7, 8].

Currently, patient experience is recognized as one of the three pillars of care quality. Empathic information, communication and respect for the patient’s beliefs can keep patients more involved in treatment. [9‐11].

The objective of this study was to evaluate experiences with medical telemonitoring among patients diagnosed with chronic kidney disease who were enrolled in an assisted HHD program and among nurses who performed the treatment.

After the study protocol was submitted to and approved by the Research Ethics Committee, 17 patients and 12 nurses were selected. Physicians, social workers and dieticians were not evaluated. Patients who had been in the HHD program for at least 3 months, were aged 18 years or older and agreed to answer the evaluation questionnaire were included. Patients who did not have internet access or had a poor internet signal, patients who were clinically unable to interact with the doctor during telemonitoring and nurses who were removed from the program for any reason were excluded. All participants provided written informed consent to participate in the study.

Telemonitoring was performed from June 2, 2020, to January 20, 2021, which corresponded to 6 months of monitoring. The investigator was responsible for all online consultations throughout the study period. Weekly telemonitoring was performed with each patient individually for an average duration of 20 min. Telemonitoring was performed during hemodialysis. Only one patient requested that hemodialysis be performed outside of this period because he liked to sleep during the treatment. During telemonitoring, we used the ZOOM platform because it is easy to handle and allowed recording of all interviews.

In total, 280 interviews were conducted during the study period. The interviews were digitally recorded and transcribed by the researchers.

A total of 17 patients and 12 nurses were selected. The study patients had a mean age of 80 years, and most were male, white and had completed higher education. All patients have family members or caregivers who help with daily care. Their mean time on HHD was 3.2 years. The main cause of renal function loss was hypertension, followed by diabetes (see Table 1).

The HHD patients in this sample had a large number of comorbidities, and 82% had more than three comorbidities. When the Index of Coexisting Disease (ICED) was applied, 82% were classified as severe, 6% as moderate and 12% as mild. Each patient used a mean of 9 medications continuously.

Most hemodialysis sessions were performed three times a week and lasted 4 h. Only two patients underwent daily dialysis to aid in the treatment of heart failure and volume management. Two other patients were selected for incremental hemodialysis twice a week because they had good residual urine output.

The sociodemographic data of the nurses showed a mean age of 43 years; 76% were women, and 70% were white. They had a mean duration of professional experience of 5.5 years (see Table 2).

Our study showed that elderly patients with comorbidities who were on HHD accepted telemonitoring but would not give up receiving face-to-face medical care whenever possible. The nurses who performed HHD, despite initial resistance to remote medical supervision, also provided positive evaluations of telemonitoring.

Many studies have described the use of telemedicine as a form of intervention for patients with chronic kidney disease according to the systematic review by Shen et al. [15], but only three studies specifically referred to home dialysis.

Home dialysis combined with telemedicine was considered one of the main tools for supporting distancing and was considered a public health measure by some countries, reflecting Truong et al.’s [16] study regarding new policies for dialysis treatment in the United States. No randomized study on the use of telemedicine by patients undergoing HHD has been conducted to date.

This study evaluated the experience of patients and nurses enrolled in an HHD program with synchronous telemonitoring performed by a physician for 6 months.

In a pioneering manner, our study addresses a population with several comorbidities and motor limitations that hinder their ability to travel to hemodialysis centers and receive help from nurses for home treatment. In contrast, previously published studies, such as that of Liu et al. [3], portray HHD as a form of self-care or a means of overcoming geographical barriers, reflecting the uniqueness of our study.

The HEMO study applied the ICED to a population of patients undergoing dialysis at a satellite clinic to evaluate their profile in terms of the risk of hospitalization and morbidity [17]. The distributions of normal, mild, moderate and severe patients according to the ICED were 0.2%, 34.9%, 31.2% and 33.7%, respectively. In our study population, the high severity index of 82% stood out, indicating the frailty of our patients.

To evaluate patients’ experience with telemonitoring, we divided the analysis into three main points: the ease of technology use, the quality of synchronous telemonitoring and comparison of synchronous telemonitoring with face-to-face visits.

Although the population comprised elderly individuals, they had no difficulty using the technology. Diamantidis et al. [18] in 2015 used an application to assist with medication use in a patient population similar to that in our study and described that their population, although elderly, made regular use of the technology at home through laptops and had no difficulty with it.

At the beginning of telemonitoring, the nurses felt a lack of confidence and distrust associated with a feeling of a loss of privacy due to the evaluation, but they soon adjusted to the technology and began viewing it as an ally in their work. These professionals were instrumental in the implementation of telemonitoring as device facilitators and drivers of adherence. In 2021, during the period of the COVID-19 pandemic, the American Society of Nephrology COVID-19 Home Dialysis Subcommittee published incentive measures and guidelines for the use of telemedicine in which nurses are described as having a prominent role in the implementation of this technology [19].

When we evaluated the quality of care provided by videoconferencing, the patients reported feelings of insecurity due to the distance from the doctor during the HHD procedure, and an increased need for day-to-day care for a population with multiple comorbidities was evident. The patients reported having a positive experience, a high degree of satisfaction and a sense that the intervention was favorable for their treatment based on the greater sense of confidence and accommodation that telemonitoring provided them. They were able to have their treatment-related questions answered and obtain more detailed information on diet and medication use. In addition, empathy and individual-focused care helped the patients overcome the anguish caused by social distancing without negatively affecting their privacy. The increased frequency of medical consultations can identify complications earlier, thereby preventing exacerbations, and can provide specific guidance for care, thus generating trust, which also increases the safety of the nurses’ work. These data are consistent with the available literature. Nadeau-Fredette et al. [20] conducted a multicenter study in Canada in which several potential complications during home dialysis were identified through telemedicine, and patients were satisfied with the care that they received [20]. Review studies on telemedicine and patient satisfaction showed increased satisfaction with the use of technology for monitoring, which can have a positive impact on the entire treatment by improving patients’ engagement with their treatment, their health and their quality of life [3, 21]. Liu et al. [3] evaluated the experiences of patients and nurses in Australia with remote monitoring using safety alarms for clinical parameters, which were sent to nurses over a 128-day monitoring period. As in our study, both the patients and nurses had positive experiences, and the major positive points were the saving of time previously spent commuting, greater empathy and consequent adherence to treatment.

When comparing care provided via video calls with face-to-face visits with the doctor, we found that telemedicine was acceptable to both the patients and the nurses, especially during the pandemic, but was considered complementary to face-to-face visits. Its main limitation was the lack of physical examinations. Walker et al. [22] conducted a systematic review of patients’ telemedicine for monitoring chronic diseases. For patients with chronic diseases, remote monitoring increased their disease-specific knowledge, triggered earlier clinical assessment and treatment and improved self-management and shared decision-making. However, these potential benefits were balanced against concerns about losing interpersonal contact and the additional personal responsibility associated with remote monitoring [22].

The patients’ and health professionals’ experiences with telemedicine were positive mainly because it increased their confidence and sense of care during HHD. The initial resistance of nurses was probably greater than that of patients due to the possibility of evaluating their care performance, creating a feeling of discomfort. Telemedicine was deemed an acceptable way to receive health care but was regarded as complementary to face-to-face visits with the doctor. Telemedicine could be considered a valuable tool for coping with distancing while providing HHD, and health professionals expressed their confidence in and acceptance of this delivery method.

Further studies are needed to show the impact of telemedicine on physicians, nurses, social workers and dieticians participating in an HHD program and possible correlations with clinical and laboratory parameters.