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Chronic kidney disease (CKD) constitutes a public health problem whose prevalence and incidence are increasing worldwide, aggravated by the shortage of specialists that reaches critical levels in developing countries. Telenephrology (TN) for people with chronic kidney disease (CKD) has been proposed as a strategy to address the growing demand for timely access to a nephrologist and reduce waiting lists for the specialty. The objective of this study is to evaluate the health impact of a public TN strategy in the national health network implemented in Chile since 2018.
Descriptive study of asynchronous kidney disease teleconsultations between November 1, 2018 and August 31, 2023, carried out on patients (pts.) referred from 1,106 National Primary Care centers (PHC) and evaluated by telematic modality by 39 nephrologists assigned to the Digital Health Department of the Ministry of Health (Chile). Patient data were anonymized for this study. The nephrologists response options were: 1) Counter-refer to APS with treatment recommendations or request more information; 2) Refer to in-person nephrology care for complex nephropathy. The evaluated variables were: age, sex, comorbidities, response time, CKD grade, georeferential registry, post online evaluation destination, KFRE equation (Kidney Failure Risk Equation) and screening of CKD in diabetic patients evaluated by teleophthalmology.
RESULTS:
32,102 people were evaluated; mean age 69.9 (SD: 13.7), 80% > 60 years; 57.1% women. CKD category: G1 (8.7%); G2 (16.5%); G3a (23.2%); G3b(33.8%); G4 (15.3%) and G5 (2.5%). Comorbidities: diabetes mellitus 59.0%, arterial hypertension 96.4%, dyslipidemia 86.4%, overweight 51.2% and obesity 33.8. Response time mean was 5.3 days (range 1-8). The resolution reported: 20,811 patients (65.3%) were referred to PHC and 11,065 patients (34.7%) to in-person nephrology (512 patients with CKD G5). Graph 1.
KFRE was evaluated in 23,265 patients: intermediate and high risk were at 2 years 3.5% and 3.9% and at 5 years 6.8% and 11.5% respectively. Men vs women had KFRE risk > at 2 and 5 years: median 0.31% vs 0.27% and median 1.18% vs 0.95%, respectively (p< 0.0001). The georeferential registry and KFRE made it possible to locate areas of the country with a higher prevalence of CKD ( Picture 1) . On the national tele-ophthalmology platform, 12,355 patients were diagnosed with complex diabetic retinopathy with high risk of concomitant undiagnosed diabetic nephropathy and they were promptly referred to telenephrology.
CONCLUSIONS
The implementation of TN as a public policy has allowed improvement and timely access to the nephrologist for PHC CKD patients with a higher risk of progression and reduced national waiting lists. The counter-referral to PHC evaluated by the online specialist without the need for face-to-face consult, free up outpatient appointments in the hospital nephrology unit for patients with more complex kidney diseases.
The incorporation of the KFRE equation, georeferenced records and tele-ophthalmology allowed the implementation of coordinated preventive interventions in populations with a higher risk of advanced CKD.