The Effects Of Telemedicine on Health Outcomes, Costs, and Perceptions of Care Delivery in In-Center Hemodialysis

在美国，大约有75万成年人患有终末期肾病(ESKD)，他们 需要透析或肾移植才能存活。尽管中心内血液透析(HD)是 对于ESKD最常见的治疗方法，它与极高的成本和糟糕的健康结果有关。 通信技术的进步，再加上这些技术的广泛使用，导致了许多 美国政策制定者和医疗保健提供者倡导远程医疗，将其作为改善获得医疗保健和 降低各种医疗保健环境中的成本，包括对慢性病患者的监测和治疗 疾病。直到最近，监管障碍一直有效地禁止医生使用远程医疗来 提供中心内高清护理。这种情况在2020年3月发生了变化，当时发布了紧急豁免，以应对 新冠肺炎大流行让肾病医生(肾病学家和高级医生提供者 (APP))通过远程医疗每月向HD患者提供最多4次会面。在现有护理的背景下 与目前的透析护理医生报销制度相关的差距和低效 远程医疗可能会改善透析护理的几种方式。联邦医疗保险的三级月报 中心HD护理的医生报销(MCP)系统鼓励肾科医生查看 患者每月最多4次，经常就诊很少或根本没有好处。矛盾的是， 最有可能从更密切的肾脏学监督中受益的患者(如最近从 医院)平均而言，不太可能经常出现。通过减少肾病学家的时间 经常前往透析机构看望患者，远程医疗可以使从业者更容易 使他们的查房计划与患者的需求保持一致，并可降低与时间相关的成本 花在旅行上。或者，如果远程医疗被用来取代面对面进行得更好的互动 (如血管通路检查或干体重评估)或经常看不到的病人 如果需要更密切的监督，那么采用远程医疗可能会损害健康并增加成本。我们建议 3个具体目标，将利用最近新冠肺炎爆发后远程医疗使用的增加 为了评估远程医疗在中心内维护HD护理中的应用，了解 使用远程医疗进行中心HD从业者护理会影响医疗成本和患者的健康结果，并 描述患者和提供商对中心内高清远程医疗的看法。我们提出了一种混合方法 这一方法包括对几个大型行政透析数据库进行二次分析，我们将 与对肾病医生的半结构化访谈相补充。当当前的紧急情况豁免时 要广泛使用远程医疗，政策制定者和临床社区将需要确定 远程医疗在中心HD护理中的未来作用。我们的发现将通过提供关键的 关于远程医疗在这种情况下的好处和潜在危险的信息。

Approximately 750,000 adults in the United States (US) have end-stage kidney disease (ESKD), where they require either dialysis or a kidney transplant in order to survive. Although in-center hemodialysis (HD) is the most common treatment for ESKD, it is associated with extremely high costs and poor health outcomes. Advances in communications technologies, combined with broad access to these technologies, have led many US policymakers and healthcare providers to champion telehealth as a way to improve access to care and to reduce costs in various healthcare settings, including the monitoring and treatment of patients with chronic disease. Until recently, regulatory barriers have effectively prohibited physicians from using telemedicine to deliver in-center HD care. This changed in March 2020, when emergency waivers issued in response to the COVID-19 pandemic allowed nephrology practitioners (nephrologists and advanced practitioner providers (APPs)) to deliver up to 4 encounters per month to HD patients via telemedicine. In the context of existing care gaps and inefficiencies associated with the current system of physician reimbursement for dialysis care, there are several ways in which telemedicine might improve dialysis care. Medicare’s 3-tiered monthly capitated payment (MCP) system of reimbursing physicians for in-center HD care encourages nephrologists to see patients up to 4 times per month, often with little or no benefits resulting from frequent visits. Paradoxically, patients most likely to benefit from closer nephrology supervision (such as those recently discharged from the hospital) are, on average, less likely to be seen frequently. By reducing the amount of time nephrologists spend traveling to dialysis facilities to see patients frequently, telehealth could make it easier for practitioners to align their rounding schedules with the needs of their patients and could reduce costs associated with time spent traveling. Alternatively, if telehealth is used to replace interactions that are better conducted face-to-face (such as vascular access examinations or dry weight assessments) or to see patients frequently who don’t require closer supervision, then the adoption of telehealth could impair health and increase costs. We propose 3 specific aims that will leverage the recent increase in the use of telehealth following the COVID-19 outbreak in order to assess the uptake of telemedicine for in-center maintenance HD care, to understand whether the use of telehealth for in-center HD practitioner care affects healthcare costs and patient health outcomes, and to describe patient and provider perspectives on telehealth in in-center HD. We propose a mixed-methods approach that includes secondary analyses of several large administrative dialysis databases which we will complement with semi-structured interviews of nephrology practitioners. When the current emergency waivers granting broad access to telehealth end, policy makers and the clinical community will need to determine the future role of telemedicine for in-center HD care. Our findings will inform these decisions by providing crucial information about the benefits and potential dangers of telemedicine in this setting.