Our study showed that elderly patients with comorbidities who were on HHD accepted telemonitoring but would not give up receiving face-to-face medical care whenever possible. The nurses who performed HHD, despite initial resistance to remote medical supervision, also gave positive evaluations of telemonitoring.
Many studies have described the use of telemedicine as a form of intervention for patients with chronic kidney disease according to the systematic review by Shen et al.,15 but only three studies specifically referred to home dialysis.
Home dialysis combined with telemedicine was considered one of the main tools for supporting distancing and was considered a public health measure by some countries, as reflecting Truong et al.’s16 study regarding new policies for dialysis treatment in the United States. No randomized study on the use of telemedicine by patients undergoing HHD has been conducted to date.
This study evaluated the experience of patients and nurses enrolled in an HHD program with synchronous telemonitoring performed by a physician for 6 months.
In a pioneering way, our study addresses a population with several comorbidities and motor limitations that hinder their ability to travel to hemodialysis centers and receive help from nurses for home treatment. In contrast, previously published studies, such as that of Liu et al.,3 portray HHD as a form of self-care or a way of overcoming geographical barriers, making our study unique.
The HEMO study applied the ICED to a population of patients undergoing dialysis at a satellite clinic to evaluate their profile in terms of the risk of hospitalization and morbidity.17 The distribution of normal, mild, moderate and severe patients according to the ICED was 0.2%, 34.9%, 31.2% and 33.7%, respectively. In our study population, the high severity index of 82% stood out, indicating the frailty of our patients.
To evaluate patients’ experience with telemonitoring, we divided the analysis into three main points: ease of technology use, quality of synchronous telemonitoring and comparison of synchronous telemonitoring with face-to-face visits.
Although the population was elderly, they had no difficulty using the technology. Diamantidis et al.18 in 2015 used an application to assist with medication use in a patient population similar to that of our study and described that their population, although elderly, made regular use of the technology at home through laptops and had no difficulty with it.
At the beginning of telemonitoring, the nurses felt a lack of confidence and distrust, but they soon adjusted to the technology and began viewing it as an ally in their work. These professionals were instrumental in the implementation of telemonitoring as device facilitators and drivers of adherence. In 2021, during the period of the COVID-19 pandemic, the American Society of Nephrology COVID-19 Home Dialysis Subcommittee published incentive measures and guidelines for the use of telemedicine in which nurses are described as having a prominent role in the implementation of this technology.19
When we evaluated the quality of care provided by videoconferencing, there were reports of feelings of insecurity due to the distance from the doctor during the HHD procedure and the increased need to provide day-to-day care for a population with multiple comorbidities. The patients reported having a positive experience, a high degree of satisfaction and a sense that the intervention was favorable for their treatment based on the greater sense of confidence and accommodation that telemonitoring provided them. They were able to have their treatment-related questions answered and obtain more detailed information on diet and medication use. In addition, empathy and individual-focused care helped the patients overcome the anguish caused by social distancing without negatively affecting their privacy. The increased frequency of medical consultations can identify complications earlier, thereby preventing exacerbations, and can provide specific guidance for care, thus generating trust, which also increased the safety of the nurses’ work. These data are consistent with the available literature. Nadeau-Fredette et al.20 conducted a multicenter study in Canada in which several potential complications during home dialysis were identified through telemedicine, and patients were satisfied with the care they received.20 Review studies on telemedicine and patient satisfaction showed increased satisfaction with the use of technology for monitoring, which can have a positive impact on the entire treatment by improving patients’ engagement with their treatment, their health and their quality of life.3,21 Liu et al.3 evaluated the experience of patients and nurses in Australia with remote monitoring using safety alarms for clinical parameters, which were sent to nurses over a 128-day monitoring period. As in our study, both the patients and nurses had a positive experience, and the major positive points were the saving of time previously spent commuting, greater empathy and consequent adherence to treatment.
When comparing care provided via video calls with face-to-face visits with the doctor, we found that telemedicine was acceptable to both the patients and the nurses, especially during the pandemic, but was considered complementary to face-to-face visits. Its main limitation was the lack of physical examinations. Walker et al.22 conducted a systematic review of patients’ experiences with telemedicine for monitoring chronic diseases. For patients with chronic diseases, remote monitoring increased their disease-specific knowledge, triggered earlier clinical assessment and treatment and improved self-management and shared decision-making. However, these potential benefits were balanced against concerns about losing interpersonal contact and the additional personal responsibility associated with remote monitoring.22