Abstract
Objective
To evaluate the effectiveness of the remote management based on the Internet Hospital and Family-Sicked Bed strategy under the Four-Party Linkage model among patients with maintenance peritoneal dialysis (PD).
Methods
Bao’an People’s Hospital (Group) utilized its internet hospital platform to conduct a retrospective cohort observational study on the Remote Management (RM) of PD patients. The study further establisheda four-party collaborative disease management model comprising “residents-communities-community health centers-the hospital”. A total of 150 insured patients were randomly assigned into three groups—Non-RM-PD group, RM-PD group, and Family-Sicked Bed group—using the random number table method. After a six-month intervention period, clinical indicators across the groups were compared, and analyses were conducted on time consumption, economic costs, as well as the potential benefits for patients, healthcare providers, and society in each group.
Results
The clinical outcomes, including hospitalization rates, blood pressure levels, the proportion of patients requiring antihypertensive medications, the number of antihypertensive agents used, fluid overload, edema, hypokalemia, peritonitis incidence, and the rate of Kt/V meet the standard, demonstrated that RM-PD group and Family-Sicked Bed group were superior to the Non RM-PD group(P < 0.05). Multidimensional improvements were observed in the RM-PD and Family-Sickbed groups, such as enhanced quality of home-based PD, improved work efficiency of healthcare staff, greater social benefits, and reduced economic burden on patients. The Non RM-PD group had the highest total annual medical costs after reimbursement, whereas the Family-Sicked Bed group had the lowest (mean ± SD)(Non RM-PD = 39,383 ± 2678, RM-PD = 34,369 ± 2898, Family-Sicked Bed = 25,250 ± 2763, based on Chinese Yuan CNY, P < 0.05).
Conclusion
Within the 6-month follow-up period of this study, remote management supported by the internet hospital and Family-Sicked Bed management under the Four-Party Linkage model have demonstrated effectiveness in PD patients; their long-term sustainability requires further verification with extended follow-up.
Clinical trial number
Not applicable.
Keywords: Remote management, Internet hospital, Four-Party Linkage, Family-Sicked Bed, Maintenance peritoneal dialysis
Background
With the global burden of chronic kidney disease continuing to escalate, peritoneal dialysis (PD), as one of the effective forms of renal replacement therapy, offers advantages such as convenient home-based operation, preservation of residual renal function, and reduced reliance on healthcare providers. By the end of 2017, approximately 250,000 patients worldwide were receiving PD treatment, accounting for 12% of renal replacement therapies. In China, the number of registered PD patients had reached approximately 103,348 by the end of 2019.
Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was declared a pandemic by the World Health Organization (WHO) on March 11, 2020. Among all populations affected, patients receiving dialysis emerged as one of the most vulnerable groups during this public health emergency. Compared with maintenance hemodialysis, home-based PD offers distinct advantages: it obviates the need for frequent hospital commutes and advods centralized in-hospital dialysis settings—thus enabling safe implementation even under travel restrictions [1]. In response, the International Society of Peritoneal Dialysis (ISPD) released practical guidelines, explicitly encouraging clinicians to prioritize PD as the preferred maintenance dialysis modality during the pandemic [2].
Maintenance PD patients require continuous medical care, as short-term hospitalization alone is insufficient to improve their self-care capabilities. Without sustained post-discharge support, patients may show reduced treatment adherence, potentially leading to higher hospital readmission rates and increased healthcare costs. Currently, the exploration of remote management and Family-Sicked Bed management for PD patients remains in its early stages. To address challenges in home treatment and follow-up processes, the second Affiliated Hospital of Shenzhen University has innovatively implemented the “resident-community-community health service center-hospital (group)” four-party collaborative disease management model [3]. Through this model, nephrology specialists provide Family-Sicked Bed services and facilitate joint management of patients by hospitals and community health centers. Meanwhile, the internet hospital platform is leveraged to facilitate remote follow-up [4], monitor high-risk patients, and enable early identification of issues and timely intervention.
Internet Hospital In April 2018,the General Office of the State Council issued the “Opinions on Promoting the Development of ‘Internet + Medical Health’”, which permits medical institutions to utilize Internet technology to deliver safe and appropriate medical services based on the support of physical hospitals. It also allows for the online follow-up management of common and chronic diseases. Since then, the development of Internet hospitals has entered a period of rapid growth [5].
The second Affiliated Hospital of Shenzhen University Internet Hospital was officially launched on March 2, 2020. For patients with questions regarding dialysis or related conditions, this platform enables convenient consultations with specialists or general practitioners, ensuring they receive timely medical advice. A range of medications can be prescribed through the Internet Hospital, including prescription drugs such as antihypertensives, anti-anemic agents, and oral medications for bone diseases, as well as peritoneal dialysate. After a doctor issues a prescription, patients can directly settle consultation fees and medication costs via their mobile devices. Post-payment, the hospital pharmacy coordinates with courier services for the timely delivery of regular medications, while peritoneal dialysate distribution is arranged through collaboration with the supplier. This allows patients to receive their medications within 1–2 days at home, eliminating the need for hospital visits. Notably, registration fee, consultation fees, and medication costs are eligible for medical insurance reimbursement, with reimbursement rate consistent with that of offline medical services (Fig. 1).
Fig. 1.
Internet hospital visit mode diagram
Four-Party Linkage Under the support of the second Affiliated Hospital of Shenzhen University and through collaboration with the community and its community health service center, a professional PD medical team has been jointly established [6]: (1) Hospital PD Team: Responsible for PD catheter placement surgery, establishment of initial patient records, training guidance for community PD teams, specialist consultations, management of complex complications, and inpatient care. (2) Community PD team: Responsible for ongoing management of PD patients’ health conditions, provision of health education, regular home visits, and management of simple complications. (3) Community Organization: Play a coordinating role in the overall planning, integration, management, and service delivery for specific PD patient groups. (4) Patients and their families: Cooperate with healthcare professionals in daily health management and strive to enhance self-management and caregiving capabilities. (Fig. 2)
Fig. 2.
Four-Party Linkage mode diagram
Family-Sicked Bed Family-Sicked Bed is an innovative medical service mode where healthcare institutions set up qualified sickbeds in patients’ homes to provide on-site diagnosis, treatment, and care for those in need [7].As an advanced community health service initiative, Family-Sicked Bed not only delivers continuous health management for patients but also extend clinical care to their family environments, with proven positive outcomes in practice [8]. For PD patients, if the online diagnosis and treatment of Internet Hospitals cannot satisfy the remote management of patients specifically, when remote management via internet-based hospitals fails to meet clinical needs, nephrologists can implement in-home patient management through the Family-Sicked Bed model to ensure optimal care (Fig. 3).
Fig. 3.
Family-Sicked Bed flow chart
Objects and methods
Research subjects
This research is a assigned retrospectively using a random number method, controlled, retrospective and observational clinical trial investigating the impact of three management models-“non-remote management, remote management based on internet hospitals, and family sicked bed management based on the four-party linkage model”-on PD patients. As of October 31,2024, a total of 150 PD patients registered at the Peritoneal Dialysis Center of the Department of Nephrology, the Second Affiliated Hospital of Shenzhen University were selected as the study population. Participants were retrospectively assigned to one of the three management groups using a random number method. All patients provided written informed consent prior to enrollment. The study protocol was approved by the institutional Review Board/Research Ethics Committee of the Second Affiliated Hospital of Shenzhen University. All included patients were receiving treatment covered by medical insurance reimbursement. After a six-month intervention period, clinical indicators were compared across the three groups, with a focus on time investment, economic costs, and an analysis of potential benefits for patients, healthcare providers, and society.
Inclusion criteria: (1) Undergoing maintenance PD for more than 3 months; (2) Age 18 years or older; (3) Possessing normal cognitive and communication abilities and willingness to openly share authentic experiences; (4) Voluntary participation in the study with provision of written informed consent. Exclusion criteria: (1) Concurrent receipt of hemodialysis; (2) History of psychiatric disorders; (3) Clinically assessed as having a severe condition that may interfere with study completion. A total of 150 patients were divided into non-remote management group, remote management group, and family bed management group using a random table method. This study was approved by the Ethics Committee of People’s Hospital of Baoan and all the selected participants provided written informed consent form.
Research method
Non-remote management group
Patients accept traditional management of monthly outpatient visit of nephrology department.
Remote monitoring group
Internet hospital patients utilizing internet hospitals can access services ranging from online counseling, medical consultation, prescription issuance, and medication delivery to home without incurring additional costs. Internet hospitals are capable of providing a comprehensive service process, including consultation, diagnosis, prescription, payment, and home delivery, without the need for direct patient-doctor contact or hospital visits, thereby ensuring the effective utilization of internet hospital resources.
Data transmission and analysis PD is a home-based therapeutic modality, primarily categorized into continuous ambulatory PD (CAPD) and automated PD (APD) utilizing an APD machine. Daily PD-related parameters, including abdominal fluid type, dwell time, ultrafiltration volume, blood pressure, urine volume and body weight, can be transmitted to the healthcare providers via Internet technology. For patients undergoing remote monitoring (RM)-APD patients, each PD session automatically uploads data from the APD machine to the Share source center affiliated with the Internet hospital. Healthcare professionals, including physicians and nurses, can access and review patient data through mobile applications or web-based platforms. CPAD patients manually input relevant treatment data into a mobile application linked to Internet hospital after each PD session, enabling medical staff to monitor patient progress remotely.
Time monitoring and Early warming Through the healthcare mobile application or web-based platform, medical staff can access and review patient PD data, perform data analysis, set alert levels for abnormal PD parameters, and receive timely notifications to monitor and respond to patient dialysis abnormalities.
Prescription modification for RM-PD For patients utilizing RM-PD, healthcare providers have the capability to directly adjust prescription parameters. In contrast, for patients using conventional PD machines, in-person hospital visits are required, during which physicians guide patients in manually modifying their dialysis prescriptions (Fig. 4).
Fig. 4.
Remote monitoring mode diagram
Family-Sicked Bed group
For inpatients with stable conditions, timely referral to community health services can be arranged upon hospital discharge. These patients will then receive follow-up care from family doctors. If continuous professional care is still required, a home hospital bed can be established. And then family doctors and nurses will conduct regular assessments for the patients’ conditions, deliver targeted treatments, and provide comprehensive services including health counseling, condition evaluation, laboratory testing, medication dispensing, nursing care, rehabilitation training, and exercise guidance.
When family doctors assess a patient’s condition and determine that specialist consultation is necessary, they can first obtain appropriate treatment recommendations through remote consultation via the Internet hospital. If remote consultation fails to address the patient’s needs, particularly in cases requiring PD-specific specialized interventions (e.g., replacement of PD catheters, management of PD obstruction, a home visit consultation can be arranged to deliver specialist treatment. In instances where a patient under community health management presents with an unstable condition, and assessments indicate the need for consultation at a higher-level hospital, the family sickbed service can be discontinued. Family doctors will then coordinate with specialists to facilitate priority referral to the hospital’s outpatient department or inpatient ward for further treatment.
All expenses incurred during the establishment of family sickbed services in social health settings, including consultation fees, laboratory fees, examination fees, medicine fees and nursing expenses are eligible for reimbursement through medical insurance. Additionally, consultation fees associated with specialist consultations conducted during the period are also covered by medical insurance. This comprehensive reimbursement policy significantly alleviates the financial burden on patients and contributes to the rational utilization and distribution of medical resources (Fig. 5).
Fig. 5.
Family-Sicked Bed mode diagram
Clinical results evaluation method
Baseline data of 150 subjects were collected from the PD Center. Specifically, demographic and clinical baseline information, including gender, age, PD, education, laboratory parameters (e.g., hemoglobin, hypokalemia, hypoproteinemia), was extracted from the hospital’s Donghua electronic medical record system for statistical analysis. Additionally, the evaluation encompassed clinical outcomes, technical failure rates, complications, peritonitis incidence, PD adequacy, and patient medical expenses. Furthermore, the study analyzed the potential benefits for patients, healthcare professionals, and society individually.
Statistical analysis
Data analysis was conducted using SPSS 19.0 statistical software. Continuous variables were presented as mean ± standard deviation (SD), while categorical variables were expressed as frequency (percentage). Statistical analyses were performed using ANOVA, chi-square test, independent sample t-test, and two independent sample nonparametric Mann-Whitney U test, etc.P < 0.05 was considered statistically significant.
Results
Statistical analysis revealed no statistically significant differences among the three patient groups with respect to demographic and clinical characteristics, including Gender distribution(P > 0.05), mean age (P > 0.05), Dialysis age (P > 0.05), Marital status (P > 0.05), Educational level (P > 0.05), employment status (P > 0.05), household income level(P > 0.05), and the number of comorbid conditions(P > 0.05) (Table 1). The consistency of these baseline variables across groups suggests that the study populations were well-balanced in terms of these potential confounding factors.
Table 1.
Baseline patient characteristics, n (%) or mean ± standard deviation (SD)
| Non RM-PD(n = 50) | RM-PD(n = 50) | Family Sicked Bed(n = 50) | p | |
|---|---|---|---|---|
|
Gender: Male, n (%) Female, n (%) |
29(58) 21(42) |
32(64) 18(36) |
31(62) 19 (38) |
0.734 |
| Age (years) | 69.6 ± 13.9 | 68.3 ± 13.5 | 65.7 ± 14.3 | 0.089 |
| Dialysis age(months) | 57.81 ± 31.80 | 56.37 ± 33.44 | 58.22 ± 31.44 | 0.325 |
|
Marital status: Married Unmarried Divorced |
41(82) 5(10) 4(8) |
42(84) 6(12) 2(4) |
40(80) 6(12) 4(8) |
0.659 |
|
Education level: Primary school Middle school College degree or above |
19(38) 23(46) 8(16) |
22(44) 21(42) 7(14) |
22(44) 24(48) 4(8) |
0.157 |
|
Work: Yes No |
22(44) 28(56) |
21(42) 29(58) |
20(40) 30(60) |
0.953 |
|
Monthly household income, CNY < 5000 >5000 |
15(30) 35(70) |
13(26) 37(74) |
16(32) 34(68) |
0.076 |
| Number of comorbidities | 1.0 ± 0.9 | 0.7 ± 0.8 | 1.1 ± 0.9 | 0.345 |
Improving the quality of home PD
A comparative analysis of clinical outcomes demonstrated significant differences among the Non-RM-PD, RM-PD, and Family Sicked Bed groups. Both the RM-PD and Family Sicked Bed groups exhibited superior clinical management compared to the Non RM-PD group, as indicated by lower hospitalization rates (8% and 6% vs. 16%, P = 0.025), improved blood pressure control (systolic: 134.3 ± 20.73 and 128.9 ± 17.18 vs. 148.7 ± 25.18 mmHg, P = 0.014; diastolic: 81.2 ± 15.90 and 76.7 ± 11.22 vs. 90.1 ± 13.45 mmHg, P = 0.007), and a higher proportion of patients requiring antihypertensive medications (68% and 82% vs. 60%, P = 0.016), suggesting more intensive hypertension management. Additionally, these groups showed significantly lower rates of volume overload (24% and 16% vs. 50%, P < 0.001), anemia (30% and 26% vs. 40%, P = 0.034), and peritonitis infection (4% and 2% vs. 8%, P = 0.031). Moreover, a greater proportion of patients in the RM-PD and Family Sicked Bed groups achieved the target Kt/V standard (82% and 88% vs. 72%, P = 0.022), indicating improved dialysis adequacy (Table 2).
Table 2.
Clinical indicators: Non-RM-PD vs. RM-PD & Family Sicked Bed group
| Non RM-PD (n = 50) |
RM-PD (n = 50) |
Family Sicked Bed (n = 50) |
P value | |
|---|---|---|---|---|
| Patients with technique failure, n (%) | 1(2) | 0 | 0 | 0.154 |
| Patients with hospitalization, n (%) | 8(16) | 4(8) a | 3(6) a | 0.025 |
|
Systolic blood pressure, mean (SD), mm Hg |
148.7(25.18) | 134.3(20.73) a | 128.9(17.18) ab | 0.014 |
|
Diastolic blood pressure, mean (SD), mm Hg |
90.1(13.45) | 81.2(15.90) a | 76.7(11.22) a | 0.007 |
| Patients requiring antihypertensive medicines, n (%) | 30(60) | 34(68) a | 41(82) ab | 0.016 |
| Number of antihypertensive medicines, mean (SD) | 1.3(1.04) | 1.8(1.23) a | 2.0(1.11) a | 0.000 |
| Capacity overload, n (%) | 25(50) | 12(24) a | 8(16) ab | 0.000 |
| Anemia, n (%) | 20(40) | 15(30) a | 13(26) a | 0.034 |
| Hypoproteinemia, n (%) | 18(36) | 16(32) | 10(20) a | 0.132 |
| Hypokalemia, n (%) | 13(26) | 8(16) a | 6(12) a | 0.091 |
| Peritonitis infection, n (%) | 4(8) | 2(4) a | 1(2) a | 0.031 |
| Kt/V meet the standard rate, n (%) | 36(72) | 41(82) a | 44(88) a | 0.022 |
[a] Comparison with the Non RM-PD group: P < 0.05, [b] Comparison with the RM-PD group: P < 0.05
Multidimensional improvement
The analysis of time expenditure revealed statistically significant differences in healthcare-related time costs among the three patient groups (P < 0.05). Compared to the Non RM-PD group (760 ± 39 min/month), both the RM-PD (31 ± 5 min/month) and Family Sicked Bed (160 ± 25 min/month) groups experienced substantially lower time burdens. Major reductions in the RM-PD group included near-complete elimination of registration time (1 ± 0.5 vs. 10 ± 2 min), travel to the hospital (0 ± 0 vs. 120 ± 10 min), waiting for treatment (0 ± 0 vs. 30 ± 5 min), and waiting for test results (0 ± 0 vs. 180 ± 13 min). Similarly, the Family Sicked Bed group exhibited no time expenditure on hospital travel, registration, or waiting. However, this group required significantly longer consultation hours (120 ± 20 vs. 30 ± 5 min) compared to the other two groups, which may be attributed to the involvement of integrated family care involvement.
Family accompaniment time was markedly reduced in the RM-PD group (10 ± 5 vs. 360 ± 30 min in Non RM-PD), whereas the Family Sicked Bed group exhibited a moderate level of requirement (40 ± 5 min). These findings indicate that structured management models (RM-PD and Family Sicked Bed) enhance operational efficiency by minimizing the time investment required from patients, with RM-PD achieving the greatest reduction in overall healthcare-related time expenditure (Table 3).
Table 3.
The average monthly time expenditure associated with patient visits was analyzed across the three patient groups
Patients’ time cost ( ± s, min) | |||
|---|---|---|---|
| Non RM-PD (n = 50) |
RM-PD (n = 50) |
Family Sicked Bed (n = 50) |
|
| Registration time | 10 ± 2 | 1 ± 0.5 * | 0 ± 0 * |
| Consultation hours | 30 ± 5 | 10 ± 5 | 120 ± 20* |
| Time to hospital | 120 ± 10 | 0 ± 0 * | 0 ± 0 * |
| Waiting for treatment | 30 ± 5 | 0 ± 0 * | 0 ± 0 * |
| Waiting for test results | 180 ± 13 | 0 ± 0 * | 0 ± 0 * |
| Time to get the medicine | 30 ± 12 | 10 ± 2 * | 0 ± 0 * |
| Family accompany | 360 ± 30 | 10 ± 5 * | 40 ± 5 * |
| Sum | 760 ± 39 | 31 ± 5 * | 160 ± 25* |
Comparison with the Non RM-PD group: * P < 0.05
The analysis of medical staff workload and compensation identified distinct patterns across the three patient management models (Table 3). Although total time investment was comparable between the Non RM-PD and RM-PD groups (30 ± 5 min vs. 30 ± 5 min, P > 0.05), the Family Sicked Bed model required a significantly higher time commitment from medical staff (150 ± 25 min, P < 0.05), primarily attributable to extended face-to-face consultation durations (120 ± 20 min vs. 30 ± 5 min in Non RM-PD).
Notably, the RM-PD group exhibited a complete transition from traditional in-person consultations to remote monitoring (30 ± 5 min vs. 0 ± 0 min in Non RM-PD, P < 0.05). This transformation in service delivery did not result in a significant increase in total staff time burden, while it may have contributed to improved care accessibility.
Financial analysis showed significant disparities in staff compensation across the three groups. The Family Sicked Bed model generated significantly higher income (600 ± 0 CNY) compared to both the Non RM-PD (25 ± 0 CNY) and RM-PD (50 ± 25 CNY) groups (P < 0.05), reflecting the comprehensive nature of its service package, which includes door-to-door consultations (300 ± 0 CNY) and enhanced registration fees (425 ± 80 CNY). These findings suggest that, although the Family Sicked Bed model requires a greater staff investment, it offers substantially improved financial compensation, which may contribute to enhanced service sustainability(Table 4).
Table 4.
Medical staff monthly Time-Economic comparisons: three groups
| Medical staff | ||||
|---|---|---|---|---|
| Non RM-PD (n = 50) |
RM-PD (n = 50) |
Family Sicked Bed (n = 50) |
||
|
Time Cost ( |
Face to face consultation | 30 ± 5 | 0 ± 0* | 120 ± 20* |
| Remote consultation | 0 ± 0 | 30 ± 5* | 30 ± 5* | |
| Sum | 30 ± 5 | 30 ± 5 | 150 ± 25* | |
|
Income ( |
Registration fee | 25 ± 0 | 50 ± 25 | 425 ± 80* |
| Remote consultation fee | 0 ± 0 | 0 ± 0 | 70 ± 0* | |
| Door-to-door consultation | 0 ± 0 | 0 ± 0 | 300 ± 0* | |
| Sum | 25 ± 0 | 50 ± 25 | 600 ± 0* | |
Comparison with the Non RM-PD group: * P < 0.05
The social and healthcare system benefits exhibited considerable variation across the three management models. Both the RM-PD and Family Sicked Bed models demonstrated superior psychosocial outcomes compared to conventional Non RM-PD care, as evidenced by patient reports of increased confidence levels, significantly reduced family burden, and decreased work-related disruptions.
Service quality metrics revealed substantial differences in care delivery paradigms. The RM-PD model enhanced operational efficiency through real-time data monitoring and remote interventions, which resulted in timely identification of issues and reduced prescription delays. In contrast, the Family Sicked Bed model delivered comprehensive, face-to-face specialist care with interdisciplinary collaboration, leading to improved medication adherence and lower hospitalization rates.
Notably, both innovative models demonstrated significant advantages in medical resource utilization. The RM-PD group exhibited a 42% reduction in emergency department visits and a 35% decrease in hospitalization frequency compared to the Non RM-PD group. Meanwhile, the Family Sicked Bed model achieved effective bidirectional referral mechanisms and increased utilization of primary care service (Table 5).
Table 5.
The social effect results benefit was compared between the three patient groups
| Social effectresults benefit | ||||
|---|---|---|---|---|
| Non RM-PD | RM-PD | Family Sicked Bed | ||
| Patinets’psychology | Confidence | Low | High | High |
| Family burden | Heavy | Light | Light | |
| Delay in work | Great | Small | Small | |
| Quality of service | Service population | Narrow | Wider | Wider |
| Service efficiency | Face to face | Read data timely | Face to face | |
| Prognosis impact | Low follow-up rate | Find problems timely | Specialist consultation | |
| Prescription adjustment delay | See patient via video | Family doctor manage | ||
| Poor compliance |
Remote Adjust ment |
Interdisciplinary collaboration | ||
| High complication | Medication advice timely | Hospitalization reduce | ||
| Medical resources | Hospitalization Increase | Hospitalization decrease | ||
| Emergency attendance Increase | Emergency attendance decrease | Full process management | ||
| First visit in Sanjia Hospital | Decrease medical resources consumption | First visit in communit hospital | ||
| Increase medical resources consumption | Two-way referrals | |||
| Respond to public events | such as COVID-19 Pneumonia | Increase Infection | Reduce Infection | Reduce Infection |
Reduce the financial burden of patient
Comparative analysis of annual healthcare expenditures revealed significant cost-saving benefits associated with the innovative care models. The Family Sicked Bed group demonstrated the most pronounced economic advantage, with total annual costs (¥25,250 ± 2,763) being 36.0% lower than those of conventional Non RM-PD care (¥39,383 ± 2,678) and 26.5% lower than RM-PD (¥34,369 ± 2,898) (P < 0.05 for both comparisons).The Family Sicked Bed model achieved significant reductions across major expenditure categories, including Medication costs (33.6% reduction vs. Non RM-PD, P < 0.05), Laboratory testing (69.1% reduction, P < 0.05), Hospitalization expenses (26.5% reduction, P < 0.05). Both innovative models completely eliminated transportation costs (100% reduction, P < 0.05) and lost productivity costs (100% reduction, P < 0.05) associated with hospital visits. The RM-PD model, although requiring additional courier fees (¥240 ± 78), still achieved a 12.7% overall cost reduction compared to conventional care (P < 0.05), primarily due to reduced hospital utilization (Table 6; Fig. 6).
Table 6.
Post-Insurance annual PD care costs by medical mode (CNY)
| Annual fee per year | Non RM-PD (n = 50) | RM-PD (n = 50) | Family Sicked Bed (n = 50) |
|---|---|---|---|
|
Drugs 95%CI |
15,924 ± 2201 (15314,16534) |
15,804 ± 2018 (15245,16363) |
10,574 ± 3088* (9719,11429) |
|
Test 95%CI |
1422 ± 76 (1401, 1443) |
1358 ± 56 (1342, 1374) |
440 ± 78* (418, 462) |
|
Door to door consultation 95%CI |
0 ± 0 (0, 0) |
0 ± 0 (0, 0) |
1200 ± 80* (1178, 1222) |
|
Registration 95%CI |
132 ± 44 (120, 144) |
132 ± 77 (111, 153) |
462 ± 231* (398, 526) |
|
Transportation 95%CI |
1200 ± 245 (1132, 1268) |
0 ± 0* (0, 0) |
0 ± 0* (0, 0) |
|
Missed work costs 95%CI |
3600 ± 367 (3498, 3702) |
0 ± 0* (0, 0) |
0 ± 0* (0, 0) |
|
Courier fee 95%CI |
0 ± 0 (0, 0) |
240 ± 78* (218,262) |
0 ± 0 (0, 0) |
|
Cost of hospitalization 95%CI |
17,105 ± 1076 (16807, 17403) |
16,835 ± 1087 (16534, 17136) |
12,574 ± 2044* (12008, 13140) |
|
Total 95%CI |
39,383 ± 2678 (38641,40125) |
34,369 ± 2898 (33666,35072) |
25,250 ± 2763* (24485,26015) |
Comparison with the Non RM-PD group: * P < 0.05
Fig. 6.
Annual medical cost composition by PD care modes (CNY)
Discussion
Principal findings
Lockdown and self-isolation remain the primary measures for limiting the spread of recent coronavirus disease (CoViD-19) outbreak, highlighting the significant advantage of PD [9]. Patients can undergo kidney replacement therapy at home, thereby minimizing exposure risks and allowing them to practice social distancing [10]. Home care support is vital to individuals receiving home dialysis treatments. With the emergence of internet + medical era, the application of PD with remote monitoring and management has become a key development trend [11]. Patients with 19 designated chronic diseases can be treated online, completing the entire process of appointment scheduling, consultation, payment and medication collection remotely. As of June 30, 2021, Bao’an People’s Hospital Internet Hospital (Group) had registered 920 medical staff. The hospital conducted a total of 256,028 online consultations, 59,025 video consultations, and issued approximately 39,000 prescriptions. The cumulative number of Internet hospital visits reached 315,053, with 34,694 prescriptions dispensed.
There have been few reports on the management of peritoneal dialysis (PD) patients via home-based sickbed care [12]. Bao ‘an People’s Hospital (Group) took the lead in launching home telemedicine services in China. Under the condition of COVID-19 prevention and control, the hospital implemented home-based sickbed management for its PD patients- a measure that not only avoided increasing patients’ economic burden, but also ensured their medical safety and saved their time spent on medical treatment. Community medical staff can access multi-disciplinary consultation with the hospital’s specialists and maintain communication with the patients’ in-hospital attending physicians. If the patient’s condition changes, the hospital will immediately activate a green channel, and the ambulance will transport the patient directly to the hospital for urgent care.
In the present study, the PD-related quality control indicators were significantly improved in the RM-PD and Family-Sicked-Bed groups compared with the Non RM-PD groups. These improvements included hospitalization rates, systolic blood pressure, diastolic blood pressure, the proportion of patients requiring antihypertensive medications, the number of antihypertensive medications used, incidence of capacity overload, anemia, Hypokalemia and peritonitis infection, as well as the Kt/V meet the standard rate. The differences were statistically significant (P < 0.05). However, no statistical differences were observed among the three groups in terms of hypoproteinemia incidence or technique failure rate (P >0.05). Romote patient monitoring offers two-way communication between the patients and the clinical team, facilitating high-quality and timely healthcare services based on transmitted data. Family Sicked Bed management may decrease complications and improve clinical outcomes, leading to better fluid balance and quality of life [13].
In terms of multidimensional improvement, compared with Non RM-PD group, patients in the RM-PD group and Family Sicked Bed group experienced significant savings in both time and economic costs. This allowed them to have more free time for work, contribute to their families and society, and play a positive role in promoting PD treatment. Moreover, compared with the Non RM-PD group, the work efficiency of medical staff in the RM-PD group and Family Sicked Bed group was significantly improved, resulting in greater social and economic benefits.
Cost is a critical factor influencing patients’ medical decision-making. More patients initiated, continued, and switched to PD following dialysis payment reform [14]. In USA, if a patient is a suitable candidate for PD, dialysis providers have an economic incentive to initiate PD as early as possible in order to begin receiving medicare’s more favorable reimbursement rates [15]. In Shenzhen, basic medical insurance covers the costs associated with family beds, diagnostic tests, medications and other medical expenses. A one-time fee of 100 yuan is charged for bed setup, while the remaining costs are reimbursed according to the primary hospital standards in Shenzhen, with a reimbursement rate of 90% under the local medical insurance scheme.
The high prevalence of end-stage renal disease (ESRD), combined with limited medical and economic resources, underscores the importance of implementing strategies to optimize the utilization of PD in China [16–18]. Compared with the Non RM-PD group, the RM-PD group demonstrates health economics advantages primarily through reductions in transportation costs, fewer work absences, and lower total expenditures. Compared with Non RM-PD group, Family Sicked Bed group not only benefits from a higher reimbursement rate for registration, medications, and diagnostic examinations, but also avoids transportation costs and reduces the economic losses associated with missed work. As a result, the total expenditure in the Family Sicked Bed group is the lowest among the three groups.
We followed up with 50 PD patients who had established family beds and found that the average time required to set up a bed was less than 80 days. The number of emergency medical visits decreased by nearly 50% within half a year after bed establishment, hospitalization rates decreased by more than 40%, and the total medical expenses were reduced by 66.7%. These findings indicate substantial savings personal in both personal expenditures and medical insurance funds. Patients receiving care through the Family Sicked Bed model incurred the lowest costs compared to those undergoing other dialysis modalities.
The Family Sicked Bed model represents a viable strategy for low- and middle-income countries facing significant burdens of ESRD and limited healthcare resources. Its feasibility largely depends on two key factors: the presence of a robust insurance infrastructure and sufficient primary care capacity. In regions with established health coverage, the model can be integrated into as a reimbursable form of home-based care, thereby reducing reliance on expensive inpatient services. In regions with underdeveloped insurance systems, pilot programs supported by public health funding may serve as a viable pathway for implementation. Importantly, the model requires only basic telemedicine support and a functional community health workforce. By significantly lowering out-of-pocket expenses and overall treatment costs, this approach not only improves patient affordability but also alleviates financial burdens on healthcare systems, positioning it as a promising, sustainable option for expanding dialysis access and managing chronic disease across diverse resource settings.
The limitations of this study were as follows: First, when calculating the annual medical expenses of Medicare patients, several potential confounding factors—such as clinical severity (e.g., varying complications and comorbidities), education level, occupation, and socioeconomic status—may have introduced certain biases. Second, the observation time of this study was relatively short, lasting only six months; a longer follow-up period is necessary to evaluate the long-term efficacy and sustained benefit of the intervention. Third, the study was conducted in a single center (The Second Affiliated Hospital of Shenzhen University) with a sample size of 150 patients, which may limit the external validity and generalizability of the results to other regions or healthcare systems. Fourth, this study did not include patient-reported outcome measures (e.g., quality of life scores, treatment satisfaction), which may underestimate the comprehensive impact of the management models on patients. Fifth, we did not analyze differences in management effectiveness between continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD) patients, which may obscure potential heterogeneity in intervention effects across dialysis modalities.
Future prospects
Remote management based on internet hospital and family-sicked bed management under the Four-Party Linkage model were effective ways for improving the quality of life and treatment services for home PD patients, making them worthy of widespread implementation. Bao ‘an People’s Hospital (Group) is currently exploring the integration of real-time patient vital sign data into the management platform through intelligent wearable devices utilizing Artificial Intelligence and Internet of Things (AIoT) technologies [19], enabling physicians to monitor patient conditions more accurately and in real time.
Conclusions
Within the 6-month follow-up period of this study, remote management based on internet hospitals and Family Sicked Bed models are essential components of community medical services in Shenzhen, and have demonstrated effectiveness in improving the quality of life and treatment services for home PD patients; their long-term sustainability requires further verification with extended follow-up. Based on Shenzhen’s medical insurance system and community health resource conditions, these approaches help address the relative shortage of hospital beds in professional medical institutions, reduce medical costs, avoid cross-infection associated with inpatient hospitalization, support better psychological well-being and accelerate the recovery of PD patients. Our data highlight that the Family Sicked Bed model offers a clear cost advantage over other home therapies in the context of Shenzhen’s healthcare system. Expanding access to Family Sicked Beds in regions with similar insurance and community health resources can help mitigate the substantial budgetary impact of PD care [20]. Moreover, remote management based on internet hospitals and Family Sicked Bed management under the Four-Party Linkage model have proven to be effective in the short term, and their long-term sustainability will require continuous monitoring and adjustment in combination with regional healthcare development.
Author contributions
JHC Conceptualization, Data curation, Formal analysis, Writing - review and editing, Project administration. BLF Conceptualization, Data curation, Formal analysis, Writing - original draft. CYL AND QCZ Conceptualization, Data curation.
Funding
This work received no external funding.
Data availability
Data available on request from the authors. The data that support the findings of this study are available from the corresponding author upon reasonable request.
Declarations
Ethical approval
This study was conducted in accordance with the Declaration of Helsinki and approved by The Second Affiliated Hospital of Shenzhen University Ethics Committee. All participants provided written informed consent prior to enrollment.
Consent for publication
Not applicable.
Informed consent statement for PD study
All maintenance PD patients participating in this study provided written informed consent prior to enrollment. The study protocol was approved by the second Affiliated Hospital of Shenzhen University Ethics Committee.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data available on request from the authors. The data that support the findings of this study are available from the corresponding author upon reasonable request.