Communication and Remote Care Delivery for an Aging Population With Kidney Disease

Approximately 37 million adults live with chronic kidney disease in the United States, and adults older than 65 years account for the fastest growing subpopulation within this group.¹ For this reason, both clinicians and the health systems in which they operate must be equipped to assess and address the unique needs of a rapidly aging population with kidney disease.

Age-related inequities in health outcomes in kidney disease persist; age is a known negative prognostic marker for adverse health outcomes in kidney disease, including risk of progression to kidney failure.² Given the multimorbidity, polypharmacy, symptom burden, cognitive decline, and frailty that accompany kidney disease in older adults, eliminating age-related inequities in this group requires a shift away from a disease-focused approach to research and care to one that is person centered.³ As outlined by a recent American Geriatrics Society Expert Panel, person-centered care for older adults not only requires sincerely incorporating patients’ values into treatment plans, but it also requires transforming organizational culture and systems-level care processes to ensure high-quality communication between patients and clinicians.⁴

Elsewhere in JAMA Network Open, Ladin et al⁵ describe multilevel stakeholder perspectives on a timely, health systems–level determinant of patient-clinician communication quality: the telehealth encounter.⁵ The study, conducted as part of the larger Decision Aid for Renal Therapy (DART) trial to test the effectiveness of a video-based dialysis decision-making tool on reducing decisional conflict, deeply explored nephrology clinician, patient, and care partner perceptions of the quality and utility of telehealth encounters during the COVID-19 pandemic. While general perspectives of patients with kidney disease on virtual visits and remote data monitoring have previously been described, perspectives from older stakeholders within this group and their care partners have remained underinvestigated.

The investigation by Ladin et al⁵ responds directly to a recent call to build the evidence base for person-centered strategies to eliminate age-related inequities in health outcomes.⁶ In choosing a qualitative study design, the authors applied the most rigorous method to amplify the opinions and experiences of their stakeholders. In purposefully including care partners, a stakeholder advisory board, and patients who identify as Black, the authors filled existing gaps in equitable kidney disease research. Importantly, in deconstructing the telehealth encounter, the authors addressed an underinvestigated yet timely aspect of person-centered kidney disease care: developing systems-level solutions to improving patient-clinician communication and remote care delivery.

Despite the known power differential between patients and clinicians and the disparate experiences of care that can often ensue, some universal themes emerged across diverse stakeholder groups in Ladin et al.⁵ Patients and clinicians lauded the utility of telehealth in improving access to care by eliminating transportation needs and reducing associated costs. However, both groups expressed concern over an inability to conduct accurate blood pressure and volume status examinations. Groups also described technology-related challenges, some of which were perceived to widen existing disparities in equitable access to care for those with limited health literacy or hearing loss.

Qualitative research moves beyond reporting frequencies of themes expressed by stakeholders and allows investigators to identify themes that were particularly emphasized as meaningful to participants. It also allows investigators to uncover themes that were unexpected or surprising. In the analysis by Ladin et al,⁵ stakeholders expressed significant worries about a fractured patient-clinician relationship that would be exacerbated by remote medical care. Stakeholders also voiced concerns related to the quality of serious illness communication and advance care planning, still nascent areas of person-centered kidney disease research. Novel themes arose, including exploring the benefits of video platforms to provide previously unseen views of patient homes and investigating telehealth-associated disruptions to the patient-clinician therapeutic alliance among individuals who belong to minority racial and ethnic groups. Each of these areas is worthy of future investigation and will likely require conducting additional qualitative and mixed-methods analyses.

Using lessons learned from the investigation by Ladin et al,⁵ it appears that achieving high-quality communication and remote care delivery for older adults will require systems-based solutions that dismantle existing inequities. Multimodal platforms that allow for dual audio and video capabilities to address technology-related issues disproportionately affecting those with limited economic resources must be developed. Services that incorporate visual cues for those with cognitive impairment and medical translation services for those with limited English proficiency should be expanded. Programs that allow special training in virtual serious illness communication should be offered to and incentivized for clinicians. Partnerships with community health centers and organizations that allow for initial in-person visits to build the patient-clinician therapeutic alliance should be nurtured. Importantly, the efficacy of these health systems–level changes should be rigorously tested, iteratively refined, and durably implemented.

Remote medical care for both kidney disease and non–kidney disease populations will continue to exist for the foreseeable future. Under its annual proposed rule for payments within the Medicare Physician Fee Schedule, the Centers for Medicare & Medicaid Services may extend telehealth services approved during the COVID-19 pandemic through December 2023.⁷ Actualizing person-centered care for the rapidly aging population with kidney disease will require health systems to transform and expand on existing remote models of care delivery to acknowledge the unique symptom- and service-related needs of older adults.