Clin-STAR Journey Story

What's Lost with Telehealth: Patient Care and Research in Nephrology During the COVID Crisis

As a geriatric nephrologist, Rasheeda Hall, MD, MBA, MHS, cares for one of the most vulnerable populations of older adults—people with chronic kidney disease. Along with a limited life expectancy, these patients often also have high blood pressure and diabetes, as well as difficulty moving around. On average, they take between five and 14 medications per day, and are hospitalized more than once a year.

With COVID-19, "the aspect of patient care that has primarily changed is that the general clinic has transitioned from being all face-to-face, to being telehealth, and mostly phone visits," says Dr. Hall. Several months into the pandemic, the shortcomings of telehealth and the wider impacts of the crisis on people with chronic kidney disease are becoming apparent.

Dr. Hall leads a geriatric nephrology clinic at the at the Veterans Administration Medical Center in Durham, NC. She is an assistant professor of medicine at Duke University, where she arrived in 2006 for her internal medicine residency, and continued for a nephrology fellowship and master's in health sciences. She also completed an advanced fellowship in geriatrics in 2015.

Like many clinicians, Dr. Hall had begun doing some telehealth visits before the pandemic, and remote care has had many benefits during the COVID-19 crisis. But the changeover to mostly phone visits has also revealed how visiting the clinic serves a broader purpose than medical management of her patients' kidney disease. "Especially for some older patients, the clinic is part of their routine of how they do things. For example, it's when they get their prescriptions filled," she says, "and now—as for everyone—their routine is off. What we're starting to see is some patients are not doing as well with self-management—their diabetes is a bit worse, their blood pressure isn't that well controlled."

"If it's not their routine, it's something different about their social support," that's affecting self-management, says Dr. Hall. "For our patients, there are a lot of ways social determinants of health can go wrong, and threaten their health in general." For example, an older patient may depend on a spouse or a child to help with medications, paying bills, and reminding them to get their routine care. If that person becomes ill, or can't visit, "you can picture a cascade of effects," she says. "From the perspective of the nephrologist, we could see their kidney function isn't as stable in 2020 as it was in 2018 or 2019."

Even in the best of times, social support is an important unmet need, one conclusion of research Dr. Hall carried out with an R03 Grants for Early Medical/Surgical Specialists' Transition to Aging Research (GEMSSTAR) award. Hall and her team conducted semi-structured interviews with older adults on dialysis to investigate what quality of life means for them, and found that social support was just as important as physical well-being. “If we can understand how to measure quality of life, we can pursue interventions and know we’re on target to address things that matter most to patients,” says Dr. Hall.

Supported by a Paul B. Beeson Emerging Leaders Career Development Award in Aging, Dr. Hall is now tackling another aspect of geriatric assessment—the prevalence of prescribing potentially inappropriate medications, and the risk of harmful side effects, including falls and confusion. Already, she has analyzed data from the Chronic Renal Insufficiency Cohort Study and found that use of such medications, which include proton pump inhibitors, alpha blockers, and NSAIDS, increases with age. Next Dr. Hall is interviewing older patients on dialysis and their health care providers to understand how to design a deprescribing program that would be accepted by all, and ultimately help people with kidney failure maintain independence.

With the pandemic, she converted her research protocol to complete most interviews by phone. But going forward, she says, COVID-19 has made it harder to recruit new study participants. "I haven't asked others, but I wonder how much the pandemic is affecting interest and participation in research broadly." Her next step will be a pilot study of a de-prescribing intervention with the goal of reducing hospitalizations, and she anticipates that it will need to be conducted remotely.

Despite current challenges, Dr. Hall urges early-career clinician-scientists to consider focusing on older adults. "If you have even an inkling of interest, you should dig deeper into what geriatrics means, and why the specialty was created. And then compare that to how care is delivered in your specialty."

"For me, as a nephrologist, that's a way to acknowledge the differences, but also see the opportunity to integrate geriatrics into how we care for patients with kidney disease," she says. "There's so much more we could be doing."