As the healthcare community takes action to contain COVID-19, patient care is being impacted in ways that would have been unimaginable just months ago. Once the dust settles, some aspects of care delivery will return to normal, and other aspects will be permanently reshaped.
We interviewed nephrologists from various parts of the U.S. about how they expect the status quo in kidney care to change as a result of the COVID-19 pandemic. Here are a few key themes from our discussions:
Disruption Will Create Opportunities for Positive Change
Constraints breed creativity, and the COVID-19 crisis is forcing healthcare providers to respond as innovators. Many of these innovations will result in lasting changes that allow nephrologists to embrace new ways of prioritizing patient outcomes.
Vandana Dua Niyyar, MD, a nephrologist with Emory University in Atlanta, GA, said the crisis will give nephrologists an opportunity to reevaluate past practices. “Necessity is the mother of invention,” she said. “This crisis has exposed our weakest links and going forward, we must distinguish between what we do because ‘it has always been done that way’ and what we do that actually improves outcomes.”
Anas Abou-Ismail, MD, a private practice nephrologist in Palm Springs, CA, offered a similar viewpoint by comparing COVID-19’s impact on healthcare to the impact of the 2008 financial crisis on certain industries.
“The financial crisis helped create an environment for innovative companies like Airbnb,” he said, referring to how foreclosures and underemployment were tailwinds for Airbnb’s disruption of a stagnant hospitality industry. “It’s similar right now for healthcare. Patients and nephrologists are much more receptive to trying new things out. People are willing to change the way they are used to doing things.”
Telemedicine Will Grow, as an Additional Avenue in Delivering High-Touch Care
With CKD patients urged to stay home to avoid transmission of COVID-19, nephrologists have seen a dramatic decrease in clinic visits. But many nephrologists are now offering telemedicine, bolstered by emerging technology and new Medicare waivers, to maintain contact with patients and preserve practice revenue during social distancing.
According to Eugene Galperin, MD, a nephrologist in the greater Seattle area, an increase in telemedicine visits in the near term will pave the way for broader adoption in the future. Galperin has been working to incorporate telemedicine into his practice for several years and has seen a dramatic uptake since the COVID-19 pandemic started.
When broad social distancing restrictions were implemented, he gave CKD patients the opportunity to either postpone their appointments or substitute them with telemedicine visits. Initially most chose to postpone, but after just a couple of weeks the number of patients accepting the telemedicine visits nearly doubled.
“The majority of [CKD] patients have a chronic disease which can be monitored, managed, and adjusted without physical exams. I expect to see a surge in patients embracing telemedicine,” he said. He also noted that telemedicine creates benefits for nephrologists, such as increased capacity, flexibility to self-manage schedules, and a lower cost structure for care delivery.
Alice Wei, MD, a private practice nephrologist in New York, NY, agreed that telemedicine can lead to positive outcomes. “I think we’ll find that care that is delivered remotely has a similar impact on patient outcomes as in-center care,” she said.
Niyyar also sees broader adoption for virtual care. “Remote access to our patients will become integral to their care,” she said. “Telemedicine by providers, ambulatory assessments of vitals/physical examination, and perhaps even remote monitoring of dialysis access will not only be possible but may soon become the norm.”
Brent Williams, MD, a private practice nephrologist in New York, NY, was optimistic about use of telemedicine but acknowledged some significant challenges to broad adoption. “Telemedicine will never completely replace face to face visits,” he said. “If people think telemedicine is going to make things a lot easier [than face-to-face visits], the jury is still out.”
Williams mentioned specific hurdles that need to be addressed before practice patterns change in a meaningful way, including onerous government regulations and relatively low reimbursements. “Right now, it’s not as financially feasible to build up a practice with the majority of your care provided through telemedicine,” he said.
But Wei sees the COVID-19 pandemic as a possible driver of regulatory and reimbursement change. “A lot of those barriers have been temporarily lifted during the COVID crisis,” she said. “It may create a massive push by physicians to have those same rules and regulations removed for good.”
Despite his excitement about telemedicine, Galperin also made sure to clarify that high-touch, in-person patient care will never entirely go away. Many of his telemedicine visits are supported by caregivers who help patients set up and monitor the technology during the visit. Under normal circumstances, he recommends a balance of virtual visits and physical visits. “For more vulnerable patients, you will still need to do in-person visits, but you may be able to alternate them with telemedicine to add flexibility.”
Wei agreed, saying, “People say telemedicine is the answer, but it’s not the answer to every question. It’s like being used to using a screwdriver and then being handed a hammer. You can’t just use it for the same purpose, but it is a new tool that can be added to your toolbox.”
Home Modalities Will Get Even More Attention
COVID-19 has wreaked havoc on dialysis facilities, and some dialysis patients are now looking for options that do not require them to leave home, go to an outpatient medical facility multiple times per week, and expose them to other people who may potentially have the virus.
“You can’t help but realize the benefits of home dialysis for infection control,” Wei said.
Abou-Ismail said, “Some patients are worried about being in a dialysis unit.” At the same time, patients recognize that they cannot avoid life-saving dialysis treatments altogether. “They are now trying to think of ways they can do home dialysis. This is unusual because some of these same people would have never considered it under normal circumstances.”
Widespread concern about exposure to COVID-19 may be temporary, but as more patients become educated on their modality options, it may lead to a significant increase in home dialysis adoption. According to Abou-Ismail, “Some of the progress may reverse in the short term, but in the long term, I think you’re going to see a lot more patients start to think ‘what if this happens again?’”
Williams mentioned that home dialysis facilities need to address gaps in remote care if they are going to see significant growth. “The patients that are feeling more vulnerable or isolated don’t want to do [dialysis] at home,” he said. “Home facilities must figure out how to address all patients’ needs at their home, not just dialysis treatments.”
Utilization Will Continue to Move to Non-Hospital Sites of Care
As hospitals think carefully about the bed capacity and resources that are available for treating COVID-19 cases, ED triage procedures are becoming much more deliberative. This often means that hospitals provide patients with options to treat in alternate sites of care and recommend outpatient versus inpatient care, when medically appropriate. Some nephrologists note that dialysis patients have historically had a relatively low threshold for inpatient admission when they show up to the ED, but this may change as a result of COVID-19.
Galperin mentioned he has seen the lowest nephrology census numbers in recent memory within the hospitals in which he rounds, since the COVID-19 crisis started. He says this could represent a positive trend. “We may see more attention paid to the kidney disease patients that need to be admitted to the hospital versus those that can be seen just as effectively in other sites of care.”
Often, providing site-of-care options to kidney disease patients in the ED involves rigorously coordinating outpatient dialysis treatments for patients who are not admitted. Galperin applauds the work of local hospital teams. “Emergency room case managers are doing a remarkable job contacting dialysis clinics and finding [patients] a place to dialyze instead of being admitted to the hospital,” he said. “As long as it’s medically appropriate, it makes sense to keep those hospital beds available for patients who can’t be treated anywhere else.”
We thank the nephrologists who took a brief window out of their schedules to contribute to this article. We will be publishing a follow-up post in several weeks – if you would like to be included in future publications, please email Ben Kuhn at firstname.lastname@example.org.