|Year : 2022 | Volume
| Issue : 1 | Page : 107-112
Role of telemedicine in kidney transplant recipient in COVID 19 era
Vivek B Kute1, Vaibhav Gupta1, Himanshu V Patel1, Subho Banerjee1, Divyesh P Engineer1, Harishankar Meshram1, Vijay Navadia1, Ansy H Patel2
1 Department of Nephrology and Clinical Transplantation, Institute of Kidney Disease and Research Center, Dr. HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
2 Department of Medicine, B. J. Medical College, Ahmedabad, Gujarat, India
|Date of Submission||10-Dec-2020|
|Date of Acceptance||03-Jun-2021|
|Date of Web Publication||31-Mar-2022|
Prof. Vivek B Kute
Department of Nephrology and Clinical Transplantation, Institute of Kidney Disease and Research Center, Dr. HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat
Source of Support: None, Conflict of Interest: None
Introduction: Telemedicine represents an innovative but untested approach to maintain patient care and reduce the risk of COVID-19 exposure to patients, health-care workers, and the public. In this study, we evaluated the applicability and efficacy of telemedicine in a kidney transplant recipient (KTR) cohort in COVID 19 era. Materials and Methods: An observational cohort study was conducted at a tertiary-care public-sector kidney disease institute in western India between March and September 2020. We evaluated the reasons, modes, and outcomes of patient contacts by telemedicine in the KTR cohort. We also evaluated the utility of telemedicine across three age groups. Results: Of 840 participants, whose mean age was 38.78 ± 12.39 years, male to female ratio was 4:1. The most common mode of communication was WhatsApp (653, 77.7%) followed by in-person surrogates (126, 15%). Acceptability of telemedicine was significantly better in younger and middle-age groups (P < 0.00001) compared to the elderly. Request for drug delivery (n = 756) was the most common reason for contact overall and managed through postal parcels. KTRs (n = 200) and donors (n = 75) were evaluated for medical illnesses. The most common medical reasons for contact were for febrile illness (n = 120) and graft dysfunction (n = 60). COVID-19-related disease was diagnosed and managed in 80 KTRs and 2 donors. COVID-19 updates were given to all contacts. Conclusion: Telemedicine is underutilized in the care of the KTR cohort. Telemedicine can be used across all ages although it's best suited for young and middle age groups. The impact of telemedicine on short- and long-term patient outcomes is unclear and warrants further study.
Keywords: Coronavirus, COVID-19, kidney transplant recipients, telehealth, telemedicine
|How to cite this article:|
Kute VB, Gupta V, Patel HV, Banerjee S, Engineer DP, Meshram H, Navadia V, Patel AH. Role of telemedicine in kidney transplant recipient in COVID 19 era. Indian J Transplant 2022;16:107-12
|How to cite this URL:|
Kute VB, Gupta V, Patel HV, Banerjee S, Engineer DP, Meshram H, Navadia V, Patel AH. Role of telemedicine in kidney transplant recipient in COVID 19 era. Indian J Transplant [serial online] 2022 [cited 2022 May 25];16:107-12. Available from: https://www.ijtonline.in/text.asp?2022/16/1/107/342432
* Vivek B Kute and Vaibhav Gupta are Co-first authors
| Introduction|| |
Kidney transplantation is the treatment of choice for patients with advanced kidney disease who are fit to undergo the procedure and have a reasonable life expectancy. It provides improved survival and quality of life for recipients and is the most cost-effective form of renal replacement therapy. In the phase leading up to the transplant and in the posttransplant period, transplant centers interface with recipients who live across a wide geographic area, with many patients traveling significant distances to a transplant center. With this continually growing patient population and a limited number of transplant providers, transplant centers require innovative models of health care delivery that allow them to reach and monitor patients, particularly those that live far away and improve utilization of transplant center resources. Telemedicine, the practice of medicine using technology to deliver care at a distance, represents an opportunity to do both.
Telemedicine has surged dramatically during the recent coronavirus disease (COVID-19) pandemic in an effort to maintain patient care and reduce the risk of COVID-19 exposure to patients, health care workers, and the public. It offers an immediate virtual patient-provider interface. Telemedicine also helps to preserve the supply of personal protective equipment (PPE) by limiting the number of times providers need to don PPE to clinically evaluate patients.
Smartphone users in India are approximately 502.2 million and internet users are 560 million., With growing health awareness and the ongoing mobile technology boom, Indian is well suited to embrace telemedicine as a mode of health care delivery. The Medical Council of India has published an amendment to the Indian Medical Council (Professional conduct, etiquette, and ethics) Regulations, 2002 (”code of conduct”) that gave statutory support and basis for the practice of telemedicine in India.
Telemedicine may help increase access to care for kidney transplant recipients (KTRs) during and beyond the pandemic as it offers a prompt, safe, and convenient platform for the delivery of care for these patients. Yet, to advance the practice of telemedicine in the field of kidney transplantation, barriers to increasing the widespread implementation of telemedicine should be addressed and its limitations acknowledged. Research studies are needed to assess the effectiveness of telemedicine in the care of KTRs. In this paper, we present our experience of reaching our transplant cohort through an unorganized telemedicine service created during the unprecedented COVID-19 pandemic.
Aims and objectives
This study aims to evaluate the applicability and efficacy of telemedicine in kidney transplant patients in the COVID 19 era.
| Materials and Methods|| |
Ahybrid descriptive cum observational cohort study was conducted at our 450-bedpublic sector, tertiary care kidney disease institute in western India from March 2020 to September 2020. During the pandemic peak in our state, our institute had reserved 202 beds for patients with COVID-19 and the remaining 248 beds for non-COVID patients. Between March and July 2020, national lockdown and various travel restrictions existed. Kidney transplant patients from other cities within the state and those from other states were not able to reach the institute. The majority of our patients are dependent on government welfare schemes for free or subsidized health care. Even for those who are not direct beneficiaries of such schemes, healthcare, and drug costs are very low. We did not have an established telemedicine service at our institute before the lockdown.
In our study, 4 nephrologists and 12 trainees acted as health care providers via telemedicine. One liaison officer was appointed solely for drug delivery. Contact was done through a common mobile number as well as personal mobiles. The number was shared through messages and person to person. Case by case evaluation and management as per institute protocols and on-site local resources were done.
We collected demographic data (age, gender, level of education, and coverage under health scheme) of patients contacted via telemedicine. We evaluated the attitude of the patients toward smart devices (details included ownership, actual usage, and ease of usage). Perceived ease of usage of mobile devices was scored as easy (2), mild difficulty (1) or very difficult to use (0). We compared these scores across age groups. We evaluated the reasons for patient contact through telemedicine (febrile illness, graft dysfunction, donor and recipient follow-up, drug delivery request, and COVID-19 related symptoms). COVID update was given to all patients during telemedicine contact via E-poster, messages as per government guidelines.
The mode of communication with patients was telephonic, text messages, WhatsApp messages, and in-person with patient-surrogates. We evaluated the outcomes of the telemedicine contact, in KTRs and donors.
Data were represented as numbers with percentages, mean with standard deviation, or median with interquartile range (IQR) as appropriate. The groups were stratified for age and compared using Kruskal–Wallis test for ability and acceptability of telemedicine. A P < 0.05 was taken as statistically significant. Statistical analysis was performed with SPSS Statistics for Windows, version 20. (Armonk, NY, USA: IBM Corp).
Declaration of patient consent
Written informed consent was taken from recipient and donor before the transplantation.
Ethical approval for this study was obtained from IKDRC-ITS Ethics Committee (Number IKDRC-ITS EC/App/01 Oct 20/21).All transplants were performed as per Transplant human organ act, India. We also abided by the Declaration of Helsinki and Declaration of Istanbul principles.
| Results|| |
This was an observational cohort of 840 patients comprised of KTRs and donors during the study period March 2020–September 2020. Overview of the study is shown in [Figure 1]. Demographics of patients in our study are summarized in [Table 1]. In our study patients were analyzed on basis of age groups, gender, education and coverage under the health scheme. A total of 672 (80%) were males and 168 (20%) were females. The male to female ratio was 4:1. The age groups were defined as young (≤40 years), middle-aged (41–59 years), and old (≥60 years). We had 252, 480 and 168 patients in the young, middle and old age groups, respectively. The mean age was found to be 38.78 ± 12.39 years.
Beneficiaries of government health schemes who were provided free drugs included 132 (15.71%) patients who were below the poverty line and 43 (5.1%) patients covered under scheduled castes and scheduled tribes class. Also, 158 (18.8%) patients were of the low-income group were provided drugs at 50% cost. Self-financed patients (n = 507, 60.35%) were benefitted by getting the drugs at subsidized costs. In our cohort, 236 (28.1%) and 480 (57.1%) patients were school and higher-secondary pass-outs, respectively. Graduates comprised 124 (14.8%) of the cohort.
The mode of communication used for teleconsultation is summarized in [Table 2]. Teleconsultation was done by text message in 12 (1.4%) patients, via WhatsApp in 653 (77.7%) patients, by telephonic conversation in 49 (5.8%) patients, and in-person with patients' surrogate in 126 (15%) patients.
Trends of attitude toward smart devices across age groups are summarized in [Table 3]. In the younger age group (age ≤40 years), there was a statistically significant trend towards owning and using smartphones or tablet devices (P < 0.00001). Most participants in this group used common applications facilitating easy to and fro communication needed for telemedicine (P < 0.00001). Most persons in this group had an overall positive attitude toward technology: median ease of use score was 1.8 out of 2.
The middle-aged group (Age 41–59 years), which was the largest of the 3 age groups. Persons in the middle-aged group tended to have a positive attitude toward technology. The majority (386 of 420, 91.9%) owned and used (363 of 420, 86.4%) a smartphone and/or tablet device. This proportion was however significantly lesser than in the younger age group (P < 0.001). The median ease of use score was 1.4 out of 2.
A major proportion of patients in the older age group (Age ≥60 years) did not use smartphones and/or tablets. While 59 patients out of 168 owned and used a smartphone, only 51 patients were able to use common applications. This proportion was significantly lower than other age groups (P < 0.01). The median ease of use score was 0.9 out of 2. This score was significantly lower than both age groups (P < 0.001).
Among our participants, education level affected perceived ease of mobile use. The median ease of use scores were 1.05, 1.65, and 1.925 in school level, higher secondary level, and graduates respectively (P = 0.043). The difference in scores between higher secondary and graduates was not significant (0.068).
The reason for communication through telemedicine is summarized in [Table 4]. In our study, febrile illness was the reason for teleconsultation in 120 (14.2%) transplant recipients. Of these patients, 80 (66.6%) turned out to be COVID-19 positive on testing at local COVID centers. Ten (12.5%) patients were advised home quarantine, and the remaining 70 (87.5%) patients were advised hospitalization. Some of the patients (n = 56) with shortness of breath, persistent high fever, oxygen saturation <94% on room air, severe vomiting and diarrhea or general worsening of symptoms were able to reach our COVID-19 dedicated center. The remaining (n = 14) patients were managed at local COVID centers. Patients quarantined at home were followed up through telemedicine. Patients were instructed to check their temperature twice per day, monitoring for the progression of existing symptoms and monitor their oxygen saturation level three times per day. Government advisory in English and local languages were shared via telemedicine. Eighty COVID-19 positive patients were followed up for a median (IQR) duration of 14 (12–23) days. Out of which home-based patients (n = 10) no mortality was reported in the follow-up. One of the 14 patients died who was admitted at local center. Five cases died of the 56 patients admitted at our transplant center. The cause of death was respiratory failure among all the patients.
The remaining 40 (33.3%) patients with febrile illness were found to have urinary tract infection, upper respiratory tract infection, or nonspecific viral illness and were treated through telemedicine or in collaboration with nearby nephrologists or physicians.
Two hundred recipients followed up with routine reports, out of which 60 (30%) patients were found to have graft dysfunction. Forty-two (70%) out of 60 patients with graft dysfunction were treated with the help of local nephrologists. Eighteen (30%) patients were called to our institute for further workup. Graft dysfunction (n = 60) cases were followed up for 27 (14–31) days. The outcome of graft dysfunction in our study (n = 60) was complete recovery in 56 cases and 4 graft losses. The cause of graft losses were chronic rejection in two cases and calcineurin inhibitor toxicity in two cases.
Donor follow-up was done through telemedicine in 75 (8.9%) cases, out of which 5 (6.6%) patients had a fever, among them 2 were found to be COVID-19 positive on testing. Donors were advised not to visit the hospital unnecessarily without significant symptoms.
Medications prescribed were delivered to the patients at their doorstep. The patients shared their fresh reports and current medications and drugs were sent as parcels via postal services. The Indian postal service was functional throughout the lockdown and all parcels were received by consignees albeit with some delays. Dosing instructions were shared along with the parcel. When necessary, payment was received through national electronic funds transfer. COVID-19 update was given to all 840 (100%) patients, with national regulation of the “Stay At Home” initiative. KTRs were instructed to limit exposure with other people, avoid unnecessary outdoor activities, frequent hand washing, universal mask/face cover, avoidance of sick patients along with infection control measures are essential.
| Discussion|| |
Telemedicine is a useful and efficient tool for continued medical care of KTRs in the ongoing COVID-19 pandemic situation. The digital platform is being increasingly used in COIVD-19 era for health care delivery. We report our experience of using telemedicine in a large volume public sector hospital for caring for patients who are dependent on government health care system.
KTRs are known to report about 22%–47% noncompliance to drugs as per existing literature., The cost of immunosuppressive has been linked to nonadherence and graft loss. In a report by Evans et al., over two-thirds of patients have serious problems in affording drugs, and reported deaths as well as graft losses attributable to cost-related immunosuppressive medication nonadherence. Registry data shows that in countries where immunosuppressive medications are government or insurance sponsored for life, graft survival is substantially better compared to countries with a limited duration of coverage. In the setting of a liver transplant, the cost of immunosuppression in the 1st month after transplant in India was estimated to be around Rs. 28000 and around Rs. 8800 at the end of the 1st year, averaging around Rs. 17500 per month from a private sector institute. Given the setting of a public sector hospital, and being beneficiaries of government schemes, our patients were highly likely to be unable to afford medications and be noncompliant. The telemedicine initiative improved their compliance to immunosuppressive medicines by doorstep delivery of essential drugs during national lockdown and travel restrictions.
Age has been reported as a relevant factor regarding attitude towards mobile technology and the acceptability of telemedicine. There is a consistent negative correlation between age and use of mobile phones or medical information technology although other determinants like socio-economic status, education and number of co-morbidities also affect this correlation., Our study had similar trends with the older age group less likely to own smart devices, be able to use it and find it easy or convenient. In summary, our findings reflect the results of Zhu et al., who foundyounger patients to be more likely to use smartphones. In the iNephro initiative by Becker et al., the majority of users were middle-aged and males, which was similar to our study.
We found educational status to affect the ease of mobile use and acceptability significantly. Education level positively correlates with the use of smartphones by patients. Furthermore, the satisfaction levels (and hence the acceptability) of telemedicine modalities are higher in patients with at least high-school education., Krousel-Wood et al. reported that the odds ratio for nonparticipation in telemedicine of patients with a high-school education or less was significantly higher. They concluded educational status should be carefully considered when designing, implementing, and interpreting telemedicine studies.
A major question is whether the health outcomes in telemedicine are the same as in the standard treatment subgroup. Given the setting and observational design of our study, we did not have a comparator arm and hence this question is not answered by our study. In an analysis evaluating health outcomes in 106 kidney transplant patients, the rates of infection, rejection, and hospitalization in a sample of primarily long-term transplant patients did not differ between patients who received telehealth follow-up and patients who received standard care. The authors concluded that this mode of healthcare delivery can be safe and effective to provide follow-up care after transplant.
As discussed above, data on graft outcomes were not collected in our study, given the short follow-up. Although noncompliance usually starts early after transplant, the clinical effects are known to manifest late. In the case of older age group patients, we contacted relatives of the patients and clinical information reported by proxy may not have been accurate.
Hospitals should create dedicated telemedicine services for improving health care to patients especially from remote areas during COVID-19 pandemic. The finding of our study would help us to manage patients during the second wave and surge of COVID-19.
| Conclusion|| |
Medical innovations and telemedicine have a positive impact on health care provided for KTRs during COVID-19 pandemic. Telemedicine can supplement or replace in-person visits, potentially improving access to transplant immunosuppressive medications and reducing patients' cost and saving time. Barriers to broad implementation include finding a mechanism that allows for adequate reimbursement of the service rendered and upfront financial investment by the transplant center in required resources and personnel. The applicability and acceptability across all ages and socio-economic and education groups in also poorly understood. The impact of telemedicine on short- and long-term patient outcomes is unclear and warrants further study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]