Perceptions of Telehealth vs In-Person Visits Among Older Adults With Advanced Kidney Disease, Care Partners, and Clinicians

This qualitative study identifies patient, care partner, and clinicians’ perceptions of the patient-centeredness, benefits, and drawbacks of telehealth compared with in-person visits.


Introduction
Telehealth use increased dramatically during the COVID-19 pandemic among older adults with chronic conditions, including chronic kidney disease (CKD). 1 Approximately 38% of US adults over 65 years have CKD, corresponding to 20% of traditional Medicare payments (ie, $114 billion annually). 2 Telehealth is likely to remain significant to CKD care, bolstered by the Advancing American Kidney Health Initiative and the 2018 Bipartisan Budget Act. 3,4 Even before the COVID-19 pandemic, telehealth was seen as a cost-effective strategy to improve access to care for patients with chronic illnesses. [5][6][7] Yet little is known about whether and how telehealth promotes patient-centered care among older adults with complex conditions, such as CKD.
Telehealth may improve access to patient-centered care, particularly for populations facing challenges with transportation or caregiving, and those seeking to distance during the pandemic. [8][9][10] Some patients with CKD appear willing to use telehealth, 11,12 and outcomes appear similar between those receiving telehealth vs in-person care in small, observational reports. 13,14 Surveys suggest that many patients with chronic conditions are satisfied with telehealth care, [14][15][16] and telehealth has been successfully used for CKD disease management. 9,17 Telehealth may have drawbacks, particularly among older adults with chronic conditions. Older adults commonly have less access to and less comfort with technology than younger adults. 18 Moreover, telehealth may compromise care quality because of inadequate physical examinations and laboratory tests, key care components. [19][20][21] Some studies demonstrate lower telehealth willingness and satisfaction among persons who are older, identify as Black, or have less education. 22 The impact of telehealth on engagement and experience of older, chronically ill adults remain insufficiently understood.
Most studies involving patients have relied on surveys or claims data, which, although instructive, are insufficient for understanding telehealth experiences of older persons with chronic conditions. 11,19,[23][24][25] This qualitative study conducted at 4 sites uniquely addresses these gaps by identifying factors affecting telehealth experiences of older adults with CKD, their care partners, and kidney clinicians to improve patient-centered telehealth.

Methods
This qualitative study was approved by the institutional review board at Tufts University School of Medicine. Phone interviews were conducted and recorded, and notes were taken by trained researchers (T.P., K.G.) from August to December 2020 following verbal informed consent, where study goals and rationale was explained. This study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guideline. 26 This qualitative study is part of the Decision Aid for Renal Therapy (DART) Trial (ClinicalTrials.gov NCT03522740), which examines the effectiveness of a decision aid to support older patients facing dialysis decisions (eAppendix 1 in the Supplement). The DART Trial recruited 400 English-fluent patients age 70 years or older with nondialysis CKD and an estimated glomerular filtration rate less than 30mL/min/1.73 m 2 receiving care at nephrology clinics in Greater Boston, Massachusetts; Portland, Maine; San Diego, California; and Chicago, Illinois. This subsample was selected from participants who were followed up with for 12 months, following purposive sampling criteria, including age, gender, race, ethnicity, treatment preference, and site.
Patients self-identified race and ethnicity using US census categories. Race was included because prior literature suggests that there may be disparities in access to and experiences with telehealth by race and ethnicity, and we felt it was important to more deeply understand this.
Additionally, our stakeholder advisory board, which is comprised of individuals of diverse expertise (eg, patients, caregivers, policy makers, patient organizations, clinicians, etc.) and racial and ethnic diversity, strongly recommended that we examine this.

Data Collection
A social scientist with expertise in qualitative methods and kidney disease (K.L.) 27,28 designed 3   semistructured interview guides based on literature review and clinical experience (ie, patients, care partners, clinicians). The guides were refined by the research team and the DART Stakeholder Advisory Board (eAppendix 1 in the Supplement). We recruited a subset of DART participants following purposive sampling criteria: gender, age, race and ethnicity, region, and education (patients), and years in practice (clinicians). Care partners, nominated by patients as the people with whom they discuss health care decisions, were approached and consented independently. Clinicians were recruited via email. Open-ended questions explored patients', care partners', and clinicians' perceptions of telehealth and patient-centered care implications (eAppendix 2 in the Supplement).

Data Analysis
Interviews were transcribed verbatim and continued until thematic, and sampling saturation was achieved and confirmed through deliberation. 29 The team developed a preliminary codebook for patient and care partners and another for clinicians, following interview guides. At least 4 researchers (T.P., K.G., K.A., J.P.) independently coded 10 interviews line by line, allowing for new codes to emerge inductively using NVivo version 11 (QSR International). Iterative deliberation produced a consensus about coding discrepancies and emergent codes. 30 The team refined the codebook and independently recoded the original 10 interviews and 6 additional transcripts. Codes were clarified and organized into categories through a consensus process to encompass the range and variability of subthemes and to characterize confirmatory and contradictory narratives. 31 Emerging themes were discussed and refined by the research team. Following thematic analysis, researchers further analyzed commonalities and differences in opinions and experiences of telehealth by patient selfreported race and ethnicity.

Results
We conducted 60 interviews (

Variable Quality of Care
Most clinicians viewed telehealth as compromising quality care due to an inability to conduct physical examinations and laboratory tests, including inaccurate edema and blood pressure measurement ( Patients worried about quality care and home diagnostics. Patient 33 shared: "I don't think it's a good idea to try to diagnose people over the telephone…Your machine may not be as good as the ones at the doctor's office, and you may be getting a wrong result." Patient 7 said: "I'm not good at doing the blood pressure at home"

Patient Engagement With Clinicians
Patients, care partners, and clinicians described telehealth as more convenient, less costly, and more efficient for patients than clinic visits (

Loss of Interpersonal Connection and Mistrust
Patients and clinicians bemoaned loss of social connection (

Difficulty of Breaking Bad News
Clinicians struggled understanding patient emotions and being sufficiently empathic virtually. For example, clinician 1 stated: "You need to be in the room with someone to see how they're reacting. I never felt at all comfortable with these types of heavy decisions being made remotely" Clinician 13  Clinicians reported disparities in quality of telehealth encounters among elders with hearing impairment. Clinician 6 said: "People whose elderly fingers shake too much to use these devices, or who have hearing [or] vision problems…[telehealth] magnifies disparities." Clinician 13 explained that telehealth worsened quality of care, "especially with patients who are elderly and are hard of hearing.
Over the phone, having a serious discussion…about dialysis is very challenging, and in some cases, Patients of color were less satisfied with telehealth. They were more concerned about losing access to in-person visits, skeptical that clinicians could understand their chief complaints. Patient 26, who identified as Black, explained: "I need to see the doctor…her facial expressions. She should be able to see me and tell whether I'm okay with whatever she's saying or not. [You cannot] really do that over the telephone." Patient 33, who also identified as Black, stated: "I certainly hope they don't  16,23,37,38 In CKD, people of color face greater barriers to accessing home-centric care, such as home dialysis and virtual health care visits. [39][40][41] Structural inequalities further exacerbate the digital divide in access to stable internet connection, smartphones, and digital and health literacy.
Our findings reinforce this but suggest that further examining the impact of perceived and experienced discrimination is important, as patients of color in our sample consistently expressed dissatisfaction and mistrust associated with telehealth encounters. 42 To overcome these gaps, investment is needed, including distribution of technology and internet (eg, smartphones and tablets) within underserved communities, as suggested by some participants, and additional telehealth training for populations who need it most, including the elderly.

JAMA Network Open | Geriatrics
Our findings also offer insights into remedies to improve telehealth and suggest that telehealth may best supplement rather than supplant in-person visits for patients who are older and chronically ill. Clinicians suggested sharing detailed EMR summaries with patients and care partners and having advance practice providers follow-up after difficult conversations. Clinicians also suggested leaving patients time during the visit to process information and explicitly asking about emotions where nonverbal cues were unavailable. Implementing these strategies requires training clinicians and support staff in optimizing telehealth encounters while offering incentives and oversight tailored to improve patient satisfaction. Our findings clarify that care partner participation can improve care quality, especially for patients with limited health literacy, and was more easily achieved with telehealth than in-person. 3,43,44 Limitations Limitations include recall bias and underrepresentation of Hispanic patients and non-English speakers, populations highly vulnerable and disproportionately affected by COVID-19 and CKD.
Modest participation from 1 site may limit full appreciation of differences in telehealth delivery by site. Study strengths include a large geographically and racially diverse older sample that represents a spectrum of stakeholders.

Conclusions
The findings of this study suggest a spectrum of telehealth satisfaction among older patients with CKD and care partners and found nephrologists tended to be less satisfied with telehealth. Training clinicians in virtual physical examinations, interspersing in-person visits, and interventions to mitigate disparities is needed.