Dr. Rajeev Rohatgi

Dr. Rajeev Rohatgi (RR) from the James J. Peters VA Medical Center discusses his abstract for the National Kidney Foundation’s 2014 Spring Clinical Meetings (SCM14), Telenephrology: A Model of Patient Centered Care, with Dr. Kenar Jhaveri (eAJKD), eAJKD Editor.

eAJKD: Why don’t you tell us a little about your research and abstract being presented at NKF 2014 Spring Meetings?

RR: The focus of our clinical interests has been on the early identification of chronic kidney disease and on developing systems or processes to deliver care to these patients.  To this end, we identified a population of patients who frequently missed or cancelled appointments with our nephrology group and developed this telenephrology program to improve compliance with visits.

The James J. Peters VAMC in Bronx, New York acts as the nephrology referral service for patients with kidney disease located at the Hudson Valley VAMC.   Due to (1) distance (at least 60 miles) and (2) patient complexity (medical and psychiatric illnesses), patients referred to the James J. Peters VAMC renal clinic from Hudson Valley VAMC often cancel or “no show” which increases the long term risk of rapidly progressive kidney disease and end stage kidney disease.  To address this issue we developed the telenephrology clinic, where patients visit their local Hudson Valley VA and then are evaluated remotely (through HIPAA compliant Skype-like system) by a James J. Peters VA nephrologist.  We hypothesized this would reduce patient travel, enhance compliance with visits, and improve surrogate markers of clinical outcomes.  The clinic has evaluated 93 unique patients who visited the clinic 494 times over 29 months. The no-show rate was 11.1% in telenephrology, while 53.1% of Hudson Valley patients who were scheduled to visit the Bronx VAMC renal clinic missed appointments (includes cancellations and no-shows) during the year prior to the start of the telenephrology clinic. During the first year, the clinic saved patients $8.90±0.45, 70.3±3.6 miles, and 85.2±4.1 minutes in travel per visit.  NKF blood pressure goal of MAP≤101.667 mm Hg (135/85) was achieved in 67.7% (5.4% no initial BP recorded) at the first visit and persisted in 61.3% (12.9% no follow up BP) during subsequent visits.  In patients that visited the telenephrology clinic at least 4 times, the average change in serum creatinine from the first to most recent visit was +0.3±0.1 mg/dL with an average loss of eGFR of -1.2±1.9ml/min. These data suggest that the telenephrology clinic improves compliance with nephrology visits, and saves patients’ time and money; however, a direct comparison to in-person care is necessary to confirm the non-inferiority of telenephrology/virtual medicine-based care.

eAJKD: Can you discuss the “skype” like system?

RR: The visit occurs via a HIPAA compliant “Skype” like system which permits direct visualization of the patient and real-time interaction. Our system includes a “digital” stethoscope so when technician at Hudson Valley places the stethoscope’s diaphragm on the chest, back or abdomen the physician can hear listen to heart, lung and abdominal sounds.

eAJKD: Where do you and your group go from here?

RR: Our next step is to develop a comparable traditional in-person care group to test the non-inferiority of telenephrology program.  The possibilities include take a historical control of Hudson Valley CKD patient referred to the James J. Peters VAMC prior to the development of this telenephrology program or compare our outcomes to CKD patients that live local to the James. J. Peters VAMC.

In the future, we would like to develop an in-patient telenephrology service with our Hudson Valley VAMC partners.  Thus, for patients with CKD and acute kidney injury not requiring dialysis, they will be managed at the local Hudson Valley VAMC without needing to be transferred to the in-patient service at the James J. Peters VAMC.  The benefit to the patient is that they remain close to their family members while they are hospitalized.

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