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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 16  |  Issue : 2  |  Page : 155-157

A single-center prospective observational study evaluating telemedicine for kidney transplant patients in the Coronavirus disease-19 pandemic: Breaking the access barrier


1 Department Nephrology, Fortis Escorts Heart Institute, Fortis Escorts, New Delhi, India
2 Department Nephrology, Fortis Escorts Heart Institute, Fortis Escorts; Department Nephrology and Kidney Transplant, Fortis Flt. Lt. Rajan Dhall Hospital, Vasant Kunj, New Delhi, India
3 Department of Pathology, Jawaharlal Nehru Medical College, Aligarh, Uttar Pradesh, India
4 Research Cell, Fortis Flt. Lt. Rajan Dhall Hospital, Vasant Kunj, New Delhi, India

Date of Submission28-Sep-2021
Date of Acceptance24-Feb-2022
Date of Web Publication30-Jun-2022

Correspondence Address:
Dr. Sanjeev Gulati
Department of Nephrology and Kidney Transplant, Fortis Escorts Heart Institute, Okhla, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_96_21

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  Abstract 


Introduction: The coronavirus pandemic has restricted access to health-care services for kidney transplant patients because of concerns of COVID-19 infection. This single-center prospective study was done to assess the feasibility, acceptability, and effectiveness of telemedicine services for regular follow-up of kidney transplant patients as well as for triaging patients for admission. Methods: The study was undertaken during the lockdown period in India from March 23, 2020 to June 30, 2020. A formatted message seeking all relevant information was sent before teleconsultation. WhatsApp/email using smartphones and Electronic Medical Records system were used to provide telemedicine services. At the end of the e-consult, the patient was asked to rate his experience on a scale of 0–10. Results: A total of 296 consults for 122 patients were given. Of these, 239 (80.7%) consults (96 patients) were for domestic patients and 57 (19.3%) consults (26 patients) were for international patients. The mean age of the patients was 43 ± 15 years. The mean patient satisfaction score for e-consults was 9.5 ± 0.7. Four (3.3%) patients were seen for the first time after transplant via teleconsultation. Nine (7.4%) patients were advised admission and the rest were advised follow-up teleconsultation. Among those admitted, 6 (4.9%) were COVID positive and 1 (0.8%) patient died of COVID-19 pneumonia. Conclusions: Telemedicine offers a viable modality for health-care delivery when access to health care is restricted for transplant patients. Our model of telemedicine can be replicated easily without the burden of high cost for infrastructure.

Keywords: Coronavirus disease-19 pandemic, kidney transplant, telemedicine


How to cite this article:
Mazumder MA, Gulati S, Shehwar D, Sengar A. A single-center prospective observational study evaluating telemedicine for kidney transplant patients in the Coronavirus disease-19 pandemic: Breaking the access barrier. Indian J Transplant 2022;16:155-7

How to cite this URL:
Mazumder MA, Gulati S, Shehwar D, Sengar A. A single-center prospective observational study evaluating telemedicine for kidney transplant patients in the Coronavirus disease-19 pandemic: Breaking the access barrier. Indian J Transplant [serial online] 2022 [cited 2022 Oct 1];16:155-7. Available from: https://www.ijtonline.in/text.asp?2022/16/2/155/349340




  Introduction Top


Telemedicine is the delivery of health care using electronic systems.[1] It has been used by developed countries, having populations spread over large geographically isolated areas, to provide health-care services to remote areas. There are few studies from these countries with encouraging results for patients with kidney diseases.[2],[3],[4] However, the use of telemedicine for kidney transplant recipients has been lagging behind as compared to its use in other specialties.[5] During the COVID-19 pandemic, few reports on the use of telemedicine for kidney transplant patients were published but none from developing countries like India.[6],[7]

The unprecedented lockdown imposed due to the pandemic created logistic as well as psychological barriers for patients with kidney transplants to access nephrology services in our country. The kidney transplant recipients have the highest risk of contracting COVID-19 infection from others in view of their immunosuppressed state. This creates another barrier to their management during the pandemic. This single-center, prospective study was conducted to assess the feasibility, acceptability, and effectiveness of telemedicine for regular follow-up of kidney transplant as well as for prioritizing patients for admission in setting of the coronavirus pandemic.


  Methods Top


The study period was the lockdown period in the country from March 23, 2020, to June 30, 2020. Kidney transplant recipients were informed about the availability of telemedicine services through text messages sent from our database as well through social media such as Facebook and WhatsApp by our research assistant. The patient data were stored in Electronic Medical Records (EMRs) using the Healthplix platform. WhatsApp was used as a medium in view of its wide reach, accessibility, and simplicity. The patients were asked to send their acceptance request for teleconsultation through email/WhatsApp. On receiving the request, a formatted message was sent by the coordinator requesting information seeking current concerns by the patient, weight, vital signs including blood pressure records as well as current and previous investigations. These were entered in the EMR using the Healthplix database. An appointment time was set up.

Each of these patients was thereafter evaluated clinically using a WhatsApp video call on a smartphone. A detailed history was taken regarding the presenting complaints and vital signs such as temperature, blood pressure, and weight reconfirmed. A detailed review was done over video call regarding the current investigations as well as the medications. Thereafter, the patients were triaged for investigations and follow-up teleconsultation or admission as per their clinical status. At the end of the e-consult, patients were asked to rate their experience on a scale of 0 to 10 (0 being not satisfied and 10 being fully satisfied). The data were entered in EMR and a digitally signed electronic prescription was generated. The e-prescription was sent through email using the inbuilt software. Those patients who were not comfortable with an email attachment were sent a prescription copy by WhatsApp. The data regarding patient age, gender, date of transplant, demographic location, diagnosis, reason for consultation, diagnosis, triage decision, and patient satisfaction score were recorded and analyzed.

Statistical analysis

Descriptive analysis was carried out by mean and standard deviation for quantifiable variables, frequency, and proportion for categorical variables. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY was used for statistical analysis.

Declaration of patient consent

The patient consent has been taken for participation in the study and for publication of clinical details and images. Patients understand that the names and initials would not be published, and all standard protocols will be followed to conceal their identity.

Ethics statement

Ethics committee for research, Fortis Flt. Lt. Rajan Dhall Hospital. IRB no. ECR/2020/TH/02. The study was performed according to the guidelines in Declaration of Helsinki.


  Results Top


During the study period, a total of 296 consults for 122 patients were included. Of these, 239 (80.7%) consults were for domestic patients and 57 (19.3%) were for international patients. The domestic patients were from the distant states of Uttar Pradesh, Bihar, Chhattisgarh, Madhya Pradesh, Punjab, Rajasthan, Uttarakhand, Gujarat, Karnataka, Assam, and Manipur. The international patients were from Sharjah, Nigeria, Cambodia, Nepal, and Bangladesh.

The study group comprised 122 patients and there were 85 (69.7%) males and 37 (30.3%) females. Twenty-six (21.3%) were international patients and 96 (78.7%) were domestic patients. The mean age of the patients was 43 years (range 11–69 years). One patient (0.8%) opted out and decided to come for an outpatient clinic visit as he was not comfortable with either WhatsApp or email prescription. Four (3.3%) patients were seen for the first time after transplant through teleconsultation who underwent kidney transplant during the COVID-19 pandemic. The remaining (118, 96.7%) were follow-up patients, who were previously being followed up in our outpatient clinics. A total of 9 (7.4%) patients were advised admission after the teleconsultation. Among those admitted, six (4.9%) patients were suspected to have developed COVID-19 infection based on detailed history and clinical evaluation through a WhatsApp video call. They were advised a home collection of nasopharyngeal reverse transcription–polymerase chain reaction samples. Once the diagnosis was confirmed based on follow-up teleconsultation, they were triaged for admission to a COVID-positive care unit. The remaining (3, 2.5%) patients were directly admitted to the non-COVID ward. After hospitalization, eight patients recovered and were discharged and 1 (0.8%) patient died of COVID-19 pneumonia. The mean patient satisfaction score for e-consults was 9.5.


  Discussion Top


Telemedicine has been used as health-care education tool in medicine for the last many years. It has also been used for providing consultations to patients with kidney diseases, but there are limited data on its usage in kidney transplant patients. In a study from Australia, Mitchell and Disney in their pioneering work in renal telemedicine concluded that telemedicine enabled the renal unit to provide improved services.[2] Telemedicine has also been successfully utilized for hemodialysis patients.[3]

The growth of telemedicine in India as well as other developing countries has been limited by the cost of infrastructure. The coronavirus pandemic highlighted the need of telemedicine to bridge the gap in the delivery of health care. The widespread penetration of smartphones and broadband technology has made it feasible to deliver consultation through smartphone-based applications. These applications include email/WhatsApp and teleconsultation software. So far, most developing countries including India have followed a traditional health-care model which involves face-to-face patient–physician contact. The scenario is changing fast and recent data from a health technology platform “Practo” showed that 50 million Indians have accessed online health care between March and May 2020, and there was a 500% increase in e-consults and in-person doctor visits were down by 67%.[8] Interestingly, 80% of all telemedicine users were experiencing it for the first time. This single-center pilot study, the first of its kind from a developing country during this pandemic, was conducted to evaluate the feasibility and applicability of telemedicine services for kidney transplant patients who are among the most vulnerable to infections.

There was a high acceptance of telemedicine in our study, as evident from the fact that 99.7% of the patients who were offered teleconsultation accepted it. The single patient who rejected teleconsultation was an elderly gentleman who was not comfortable with electronic modes of communication and data delivery such as WhatsApp and email and had no family support. We found that our model was an effective modality in triaging patients for follow-up and admission. Teleconsultation avoided the need for hospital visits in 92.6% of the patients sparing them from the logistical as well as psychological nightmare of travel for nephrology consultation during the lockdown. In a study by Chang et al. from New York, 116 virtual visits of kidney transplant recipients were done during the pandemic with satisfactory results.[7] In another study by Abuzeineh et al., three kidney transplant recipients with coronavirus infection were monitored at home via telemedicine.[6] In contrast, we were able to establish a diagnosis of COVID in 4.9% of patients. However, we preferred not to monitor them at home but triaged them for admission.

As far as the modality of telemedicine was concerned, we used a low-cost model involving a combination of EMR system (Healthplix) along with WhatsApp video call, text, and or email. The simplicity and widespread WhatsApp penetration made it a preferred medium for delivering telemedicine services. In the absence of a physical examination, the EMR data were of valuable assistance in tracking the trend of vital signs and laboratory values as well as previous medication uses. It also enabled the delivery of a signed digital prescription which is medicolegally appropriate as well as storage of the same for future reference as per the Medical Council of India guidelines.[8]

So based on this pilot study, we conclude that telemedicine offered a viable modality for delivery of nephrology services for kidney transplant patients during lockdown period when access to health care was restricted because of concerns regarding COVID infection risk as well logistical reasons. Another advantage is the minimal cost and infrastructure required, making it user-friendly and widely applicable and acceptable. This modality can not only be used during current and future pandemics but also in natural disasters such as cyclones, earthquakes, and floods. It also opens up new vistas for the nephrologist to deliver consultations and follow-up in remote areas as well as in countries where currently expertise in kidney transplants is not available.

Limitation

Study needs to be validated in a larger cohort.


  Conclusion Top


Telemedicine is an efficient modality for healthcare delivery to kidney transplant recipients with restricted access during the COVID-19 pandemic. Our model of telemedicine can be replicated easily without the burden of high cost for infrastructure and is particularly relevant for developing nations like India.

Acknowledgments

This study was presented as a poster in the World Congress of Nephrology, 2021, and was published as an abstract/conference paper.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
WHO Global Observatory for eHealth. Telemedicine: Opportunities and Developments in Member States: Report on the Second Global Survey on eHealth. World Health Organization; 2010. Available from: https://apps.who.int/iris/handle/10665/44497. [Last accessed on 2021 Sep 20].  Back to cited text no. 1
    
2.
Mitchell JG, Disney AP. Clinical applications of renal telemedicine. J Telemed Telecare 1997;3:158-62.  Back to cited text no. 2
    
3.
Bernstein K, Zacharias J, Blanchard JF, Yu BN, Shaw SY. Model for equitable care and outcomes for remote full care hemodialysis units. Clin J Am Soc Nephrol 2010;5:645-51.  Back to cited text no. 3
    
4.
Reed ME, Parikh R, Huang J, Ballard DW, Barr I, Wargon C. Real-time patient-provider video telemedicine integrated with clinical care. N Engl J Med 2018;379:1478-9.  Back to cited text no. 4
    
5.
Concepcion BP, Forbes RC. The role of telemedicine in kidney transplantation: Opportunities and challenges. Kidney360 2020;1:420-3.  Back to cited text no. 5
    
6.
Abuzeineh M, Muzaale AD, Crews DC, Avery RK, Brotman DJ, Brennan DC, et al. Telemedicine in the care of kidney transplant recipients with coronavirus disease 2019: Case reports. Transplant Proc 2020;52:2620-5.  Back to cited text no. 6
    
7.
Chang JH, Diop M, Burgos YL, Blackstock DM, Fernandez HE, Morris HK, et al. Telehealth in outpatient management of kidney transplant recipients during COVID-19 pandemic in New York. Clin Transplant 2020;34:e14097.  Back to cited text no. 7
    
8.
Telemedicine Practice Guidelines. Board of Governors in Supersession of the Medical Council of India; 2020. Availablefrom: https://www.mohfw.gov.in/pdf/Telemedicine.pdf. [Last accessed on 2020 Jun 23].  Back to cited text no. 8
    




 

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