Renal Disease: Patient Outcomes

Summary

At present, there is extremely limited evidence on the effects of home telehealth on patients’ clinical status, self-efficacy, self-management ability, or quality of life. The quality of the studies that do exist is sub-optimal.  A liberal interpretation of their findings might provide grounds for cautious optimism, but the need for further research is unquestionable.  The scant information available from feasibility studies and technology reviews must be bolstered by randomized controlled trials and more extensive qualitative research into patient and provider experiences.  One recent study did report that e-mail education has the potential to reduce stress levels and improve compliance in elderly patients using home dialysis. As this study was retrieved in a final scan of 2011-2012 literature and was not subject to the same level of analysis as the other studies included in this review, we will not attempt to extrapolate beyond the conclusions provided by its authors.  See An (2011) for more details.

Based on the available evidence – and again, it must be emphasized that this is very limited – high levels of acceptance appear to be achievable.  One author suggests that patients who have had exposure to dialysis and its accompanying technology are likely to be comfortable with incorporating additional technology into their care routine.  However, findings from other studies indicate that some caution may be warranted when selecting this technology.  High technical support needs were seen in one patient population.

Little information was found on patient cost and time savings.  One study found that patient travel time and costs were reduced when teleconsultations replaced in-person appointments.  Furthermore, dialysis training was faster when done through telemedicine.  It is not clear why this was the case.  The impact of mode of delivery on patient training sessions merits further research.

 

Details

While outcomes are reported in both Gallar et al. (2007) and Michael et al. (2009), the quality of the evidence is not sufficient to support conclusions at this time. Readers are advised to exercise caution when interpreting the findings described below.

Uptake and Use of Technology

Summary: Uptake and use of technology are reported in 2 studies, both of which suffered from serious limitations. Findings indicate that home telehealth appears to be well-accepted, but technical requirements may be challenging for some patients. However, the quality of the evidence is not sufficient to support conclusions at this time.

Study Details: Gallar et al. (2007) report that 97% of patients perceived teleconsultation as similar to hospital consultation. Less than 10% of patients felt that the intervention was an invasion of privacy. Recall, however, that those who did not wish to participate in the intervention were assigned to the control group. Michael et al. (2009) also report high levels of acceptance, although 8 of the 35 patients recruited for the study were omitted from analysis due to non-compliance with the telehealth device. In addition, some patients required home visits and 1-on-1 instruction in order to operate the device.

And on the qualitative side . . .Most patients in Cafazzo et al. (2010) were comfortable with the idea of remote monitoring as part of nocturnal home hemodialysis, and even expected it to be a component. The authors suggested this was not surprising because hemodialysis patients tended to be very aware of the value of technology, given their reliance on it on a regular basis. There was some difference of opinion among groups on whether remote patient monitoring would be desirable in the long term, or only for the transition from hospital to home.

 

Self-Management, Self-Efficacy, and Behaviour Change

Self-management, self-efficacy, and behaviour change outcomes were not reported in either of the studies retrieved in our initial search.

Recent Developments: A scan of material from 2011-2012, a time period not covered by our initial searches, found 1 article that addressed outcomes in the area of self-management, self-efficacy, and behaviour change (An, 2011). In this study, elderly patients using a provider-staffed e-mail service significantly improved their compliance. As this study was not subject to the same level of analysis as the other studies included in this review, we will not attempt further analysis. See An (2011) for more details.

And on the qualitative side . . .While many patients in Cafazzo et al. (2010) felt that remote patient monitoring could bring them and their caregivers increased peace of mind, surveys showed that patient confidence in ability to perform nocturnal home hemodialysis did not significantly increase when the option of remote monitoring was added.

 

Clinical Outcomes, Symptoms, and Health Status

Clinical outcomes and symptoms and health status outcomes were not reported in either study retrieved in our initial search, although Michael et al. (2009) cited changes in blood pressure as an area of investigation. These omissions may be an additional indication of the comparative immaturity of research into home telehealth for the management of renal disease.

Recent Developments: A scan of material from 2011-2012, a time period not covered by our initial searches, found 1 article that addressed outcomes in the area of clinical outcomes, symptoms, and health status (An, 2011). In this study, elderly patients using a provider-staffed e-mail service reduced their stress levels significantly more than a non-equivalent control group. See An (2011) for more details.

And on the qualitative side . . .While many patients in Cafazzo et al. (2010) felt that remote patient monitoring could bring them and their caregivers increased peace of mind, surveys showed that patient confidence in ability to perform nocturnal home hemodialysis did not significantly increase when the option of remote monitoring was added.

 

Quality of Life

Summary: Quality of life outcomes were reported in one Level 4 study. Evidence of benefit is insufficient.

Study Details: In a Level 4 study by Gallar et al. (2007), 90% of patients were said to feel that their quality of life improved with telemedicine.

 

Cost and Time Savings

Summary: One study reported on cost and time savings. Findings suggest that home telehealth may have the potential to reduce appointment time and patient travel costs.

Study Details: Gallar et al. (2007) reported that teleconsultations took a mean average of 22 minutes (SD=9), while hospital consultations took an average of 33 min. (SD=8). Dialysis training for patients was also faster when done through telemedicine (mean of 24 minutes for the intervention group vs. 60 minutes. for the comparison group). It is not clear whether these numbers include travel time. It seems probable, however, that they do not include travel and that time savings would increase if this factor were taken into account. A comparison of teleconsultation and hospital consultation costs gives the price of transportation as an estimated € 60; this appears to be per session.

 

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