CKD Management in the Age of Telenephrology An Observational Analysis of a Hybrid Telenephrology System within a Veteran’s Affairs Medical Center

Abstract

Background Nephrology has seen an uptake in transition to remote care delivery. The effect of telenephrology care on CKD progression is not well defined. Methods We analyzed data from patients naturally selected for telenephrology versus standard in-person visits. Patients were seen across 4230 visits over a 2-year period at a nephrology clinic within the Veterans Affairs (VA) health system. Baseline characteristics and health profile data were assessed on the basis of grouping of individuals to the telenephrology group (.50% virtual visits) or in-person group (#50% virtual visits). The slope of eGFR change over time was estimated for each patient using a random effects regression model and compared across groups using weighted linear regression models. Results A total of 1098 patients comprised the final analysis. The groups were similar across baseline demographics and health profiles, although more cardiovascular disease, congestive heart failure, and diabetes mellitus were present in the in-person group. There was no significant difference in eGFR decline between groups, although those in telenephrology group trended toward less steep decline compared with those seen predominately in-person (telenephrology slope versus in-person slope; difference50.81 ml/min per 1.73 m2; 95% confidence interval, 20.447 to 2.08; P 5 0.21). Those seen primarily in-person had a similar degree of proteinuria compared with those in telenephrology (P 5 0.12). All-cause mortality and incidence of outpatient RRT initiation was similar. Telenephrology patients had an average of 1.3 fewer emergency department visits per individual compared with their in-person counterpart (2.17 versus 3.44, P, 0.001), as well as fewer hospital admissions (1.59 versus 2.08, P 5 0.02). Those in the in-person group were more often prescribed sodium glucose cotransporter 2 inhibitors, statins, nonsteroidal anti-inflammatory drugs, and potassium supplements. Conclusions Data from this observational study within a VA health care system suggest that medically complex patients with multimorbid CKD can expect a similar rate of eGFR decline when care is delivered through a hybrid system that includes a majority of telenephrology when compared with those managed in face-to-face visits. Further studies are needed to corroborate findings and ensure generalizability outside of this VA system.