Introduction
Telehealth technologies offer advantages of accessibility, convenience, and time-effectiveness and are thus being increasingly adopted to aid the management of long-term conditions worldwide. Increasing evidence has demonstrated promising results for telecare or telehealth medicine in the management of diabetes, heart failure, asthma, chronic obstructive pulmonary disease, and cancer [1]; however, data on its use in patients on maintenance hemodialysis (MHD) are still sparse.
Recent Quality and Outcomes Framework Disease Register data comparing data from 2006-2007 to 2010-2011 showed a 45% increase in the prevalence of chronic kidney disease, second only to the increase in cancer (79%) [2]. The management of this long-term condition is increasingly challenging when it develops into end-stage renal disease (ESRD) or requires MHD. Renal anemia is extremely common among patients on MHD and often underlies symptoms including fatigue, depression, reduced exercise tolerance, and dyspnea; increased morbidity and mortality related to cardiovascular disease; an increased risk of hospitalization; and an increased length of hospital stay. Patient mortality and hospitalization risks were shown to decrease by 10%-12% for every 1 g/dL increase in mean facility-level hemoglobin [3]. MHD patients should thus be monitored for anemia in a timely manner and managed carefully; according to the Kidney Disease Improving Global Outcomes (KDIGO) guidelines, hemoglobin levels should be monitored at least monthly [4]. However, the actual management is still not satisfactory. Data from the Dialysis Outcomes and Practice Patterns Study (DOPPS) showed that more frequent hemoglobin monitoring was associated with lower facility-level variations in the hemoglobin levels [5]. Data from Chinese DOPPS facilities also showed that a large proportion of patients on MHD did not meet the expressed hemoglobin target and that less frequent and substantial increases in the doses of erythropoiesis-stimulating agents (ESAs) were associated with hemoglobin levels <9 g/dL [6]. Another cohort study enrolled a total of 2388 patients with ESRD (1775 patients on MHD) from nine centers in the largest dialysis facilities in six cities around China and found that about 60% of the patients did not reach the hemoglobin target of 11 g/dL, even though 85.0% of them were treated with erythropoietin [7].
Several renal dialysis registration data systems exist worldwide, including the United States Renal Data System (USRDS), the European Renal-European Dialysis and Transplantation Association Registry, the Australia and New Zealand Dialysis and Transplant Registry, the State of Chronic Dialysis Therapy in Japan, the Hong Kong Renal registration, and the China National Renal Data System. However, these registration systems collect data from dialysis units and issue a dialysis report every year only for quality measures. In China, a registration system that can reflect the dynamic, real-time anemia status of patients on hemodialysis is still lacking, thus preventing their timely treatment.
We therefore established the Red China project using telehealth technology in June 2015 with the aim of improving renal anemia in patients on MHD, allowing timely reporting to nephrologists, facilitating the early recognition and resolution of anemia, and benefiting the long-term prognosis of patients on MHD.
Discussion
Recently, there has been mounting evidence of the feasibility of smartphone apps in remote monitoring and flexible follow-up of patients in western countries [8-10]. However, the experience of using a smartphone app in the management of chronic diseases in China is limited. This study is the first in China to use telehealth technology to promote the management of renal anemia, assess user acceptability, and collect data on patients with ESRD on MHD.
The prevalence of ESRD is increasing worldwide. According to Nanjing Urban Employee Basic Medical Insurance data, the prevalence of ESRD is expected to increase by approximately 1.95% annually from 2015 to 2025, with a predictive value of 1505 per million population in 2025 [2], representing high financial and public health burdens. Furthermore, the increasing number of patients with ESRD accessing hemodialysis is associated with increasing challenges in terms of managing the accompanying renal anemia. Anemia is extremely common among dialysis patients and underlies a range of symptoms including fatigue, depression, reduced exercise tolerance, and dyspnea; increased morbidity and mortality related to cardiovascular disease; an increased risk of hospitalization; and a longer hospital stay. According to a 2017 USRDS report, the mean hemoglobin level in ESRD patients was 9.5 g/dL [11], while the KDIGO guidelines, European Best Practices Guideline, and The National Kidney Foundation Kidney Disease Outcome Quality Initiative guidelines recommend a target hemoglobin level of 11-12 g/dL in patients on MHD [4,12,13].
Telehealth technologies offer advantages of accessibility, convenience, and time effectiveness and are thus being increasingly adopted to aid the management of long-term conditions worldwide. Increasing evidence has indicated promising results for telecare and telehealth medicine in the management of diabetes, heart failure, asthma, chronic obstructive pulmonary disease, and cancer [1] and even chronic kidney disease and peritoneal dialysis [14-16]. Sobrinho et al reported that a mobile health app that aimed at assisting in the early diagnosis and self-monitoring of disease progression in patients with chronic kidney disease was associated with quality attributes such as safety, effectiveness, and usability [14]. Telemedicine is also a promising new tool for the remote management of automated peritoneal dialysis, allowing timely intervention prior to the development of more significant problems, reducing the frequency of in-person visits for emergency problems, and reducing health care resource utilization and associated costs [17-19]. However, data on its use in patients on MHD, especially for management of renal anemia, are still sparse.
We therefore developed the Red China project using telehealth technology in June 2015 with the aim of allowing timely reporting to nephrologists, to facilitate the early recognition and resolution of anemia and thus improve the long-term prognosis in patients on dialysis. Similar to the American practice, the Red China project collects and reports the patient hemoglobin test data on a regular basis, prompting the clinician to personally adjust the anemia management medication for patients on MHD, which can reduce the workload of medical staff. In addition to individualized management of patients, the project monitors the compliance status of the patient population in the dialysis center, assists clinicians in overall analysis, and improves MHD patients’ hemoglobin level.
Our results showed that achieved rate of target hemoglobin levels in patients on MHD increased significantly from 47.55% to 56.07% during the 28 months following the introduction of the project, compared with another cohort study in China that showed a target rate of 40% [7]. Our results also showed that the proportion of patients with a hemoglobin level <8 g/dL decreased from 4.96% to 4.08% following the start of the project, compared with 12% in China’s DOPPS research [6], 31.7% in Japan’s DOPPS study [20], and 8.7% in North America’s DOPPS study [20,21]. The mean hemoglobin level in this study increased from 10.83 (SD 1.60) g/dL to 11.07 (SD 1.60) g/dL, compared with the mean hemoglobin levels of 10.5 (SD 2.0) g/dL, 10.4 (SD 1.2) g/dL, and 11.5 (SD 1.2) g/dL in China, Japan, and North America, respectively. Although the Red China project has the potential to help clinicians improve anemia in patients on hemodialysis, there is a gap in performance between Shanghai and developed countries such as Japan and North America. Notably, we did not observe a consistent improvement in the hemoglobin levels over baseline for several months. This could be because many other factors played an important role in modulation of the hemoglobin levels, including dialysis adequacy, nutrient status, infection, and chronic gastrointestinal bleeding, which were not recorded in this project. In addition, management of renal anemia via the app took time to yield benefits.
In terms of privacy and security, the Red China project follows the “National Standard of the People's Republic of China: GB/T 35273-2017 Personal Information Security Specification of Information Security Technology.” When collecting information, full informed consent was obtained from all patients on MHD and data entry was conducted by full-time personnel with research qualifications. Only researchers have access to the patient data in the center. The data are deidentified, and security measures such as encryption are used for data transmission and storage. The Red China project uses the largest social app in China—WeChat—for patient management. The WeChat platform uses information security technologies such as encryption and anonymization to ensure information security. WeChat has passed the assessment and filing of national network security–level protection and has met the requirements of international authoritative certification standards. The Red China project uses the Alibaba Cloud server to transmit normal and secure traffic back to the server by conducting recognition of malicious features and protecting the service traffic of the app; through the website HTTPS encryption, it can prevent hijacking and tampering, avoid malicious invasion of the website server, and ensure the security of core data.
This study had several limitations. We did not include information on serum iron levels, total iron-binding capacity, transferrin saturation, ferritin levels, or use of drugs such as iron and ESA. However, we aim to improve this platform and include other laboratory parameters such as iron metabolism indicators as well as iron and ESA use in the future. In addition, this telemedicine system has been limited to the physicians, and we believe it would be useful to send the information to patients as well and provide patient education to improve clinical outcomes in the future.
Telehealth technology offers a tool for improved monitoring and calibration of anemia to meet the recommended targets. This telemedicine system could be also used to analyze the reason why some patients could not meet the target and to help develop strategies to improve patient outcomes for anemia management as well as other clinical parameters such as dietary intervention for control of phosphate levels and blood pressure. Further studies in emerging dialysis practices serving large numbers of patients are needed to determine the effects of this technology on improving the achievement of anemia targets as well as the associations with patient outcomes.
In conclusion, telehealth technology offers a promising, feasible, and accessible tool for improving the management of renal anemia in patients on MHD.