Characteristics of Veterans with CKD Using a Telenephrology Program in the Veterans Health Administration

Abstract

Key points: We examined clinical characteristics of Veterans receiving telenephrology care. Telenephrology was associated with higher prescription rates of guideline directed therapies and longer survival in Veterans with CKD. Adjusting for telenephrology visits and other clinical factors, rurality and heart disease were associated with an increased risk of mortality.

Background: Veterans with CKD residing near lower complexity Veterans Health Administration facilities are often managed by primary providers. To improve access to nephrology for rural Veterans, we established a hub-and-spoke network that used telemedicine to connect nephrologists to Veterans at Veterans Affairs facilities lacking nephrology services (spokes).

Methods: Veterans with CKD, refractory hypertension, and electrolyte disorders cared for at spoke sites were defined as eligible. Patients requiring dialysis or hospital management were excluded. We compared demographics, clinical characteristics, prescription rates, and mortality of the Veterans cared for by telenephrologists (Telenephrology+) with those cared for by primary providers (Telenephrology-).

Results: The Telenephrology+ group consisted of 2147 eligible Veterans who had telenephrology visit(s) during the study period (2021-2024). The Telenephrology- control group consisted of 9678 telenephrology eligible Veterans who were managed by primary providers. At baseline, Telenephrology+ Veterans were younger (69±12 versus 74±10 years; P < 0.001) but had more advanced CKD (eGFR 47±21 versus 55±16 ml/min per 1.73 m 2 , P < 0.001) than Telenephrology- Veterans. Hypertension, diabetes mellitus, and heart disease were common in both groups. During the course of the study, more of the patients in the Telenephrology+ group were started on guideline directed therapies ( P < 0.001). Survival analysis showed that the Telenephrology+ group had a significantly lower mortality compared to the Telenephrology- group (hazard ratio [HR], 0.62; confidence interval [CI], 0.55 to 0.71; P < 0.001). Mortality in the Telenephrology+ Veterans remained lower (HR, 0.85; CI, 0.74 to 0.98; P = 0.02) after adjustment for confounders and medication use. In addition to telenephrology visits, major factors influencing mortality were rurality (HR, 1.52; CI, 1.39 to 1.67; P < 0.001), heart disease (HR, 1.95; CI, 1.76 to 2.17; P < 0.001), and prescription of sodium glucose transporter 2 inhibitors during the study period (HR, 0.50; CI, 0.44 to 0.57; P < 0.001).

Conclusions: Telenephrology was associated with higher prescription rates of guideline directed therapies and longer survival in Veterans with CKD.

Keywords: CKD; clinical epidemiology; epidemiology and outcomes.