Telehealth for Goals of Care Conversations in Advanced CKD: A Mixed-Methods Pilot Study of US Veterans and Their Clinicians.

As chronic kidney disease (CKD) progresses into advanced stages, health care use, comorbid conditions, and the risk of poor outcomes increases substantially. 1 This is particularly relevant in older patients with advanced CKD, who face a disproportionately high risk of illness, disability, and death. 2 Proactive GOC conversations in this patient population offer important opportunities to align medical care with patient goals. 3 , 4 The Veterans Affairs (VA) Life Sustaining Treatment Decisions Initiative aims to proactively engage seriously ill Veterans, including those with advanced CKD, in GOC conversations. Any subsequent decisions about life-sustaining treatments, such as Veterans’ preferences for cardiopulmonary resuscitation, mechanical ventilation, and dialysis, are then documented in the VA electronic health record via a Life-Sustaining Treatment progress note to ensure goal-concordant care. Despite support for GOC conversations among both nephrology communities and patients with CKD, 3 , 5 such conversations occur infrequently both within VA 6 and the community 7 , 8 and are often elicited reactively during acute hospitalizations. 9

Telehealth may be one promising strategy to facilitate early GOC conversations for patients with CKD. Although GOC conversations have historically been completed in-person, they may also be completed by telephone or telehealth as part of a seamless, accessible, and Veteran-centered care experience. Optimizing the use of VA telehealth, also known as Veteran Video Connect (VVC) or Clinical Video Telehealth (CVT), remains a top VA priority. Telehealth is generally perceived by older patients with CKD as an acceptable and effective approach to outpatient disease management, and studies have found no perceived difference in the overall quality of care received via telehealth versus an in-person visit. 10 , 11 , 12 However, discomfort with technology, technical issues, patient sensory deficits, and the inability to conduct physical examinations may impede some older patients and their clinicians from engaging in telehealth. 11 , 13 , 14 Furthermore, telehealth access may be more difficult for lower income and rural older adults without stable internet access, as well as those individuals who have never participated in telehealth. 15

While the coronavirus disease 2019 (COVID-19) pandemic increased the use of telehealth for GOC conversations, 16 little is known about the use of tele-palliative consultation for GOC conversations in older Veterans with CKD. Filling this knowledge gap is important to ensure that efforts to conduct and ultimately expand telehealth GOC conversations align with the needs of older Veterans with CKD as well as the clinicians who care for them. To this end, in this mixed-method pilot study, we describe the feasibility of engaging older Veterans with advanced CKD in GOC conversations via telehealth by (1) comparing Veteran characteristics, including life-sustaining treatment note completion rates and preferences, by visit modality; and (2) exploring Veteran and clinician perspectives surrounding GOC conversations via telehealth.

Methods

Study Design

We used a mixed-method convergent design in which both quantitative and qualitative data were collected, analyzed, and compared to identify areas of converge or divergence. 17 Data sources included a prospective observational cohort analysis (quantitative) and semi-structured interviews with clinicians and Veterans (qualitative). We categorized the types of visits into 2 categories: in-person/phone and telehealth. This categorization best reflected the division between what we considered non-novel technologies (in-person/phone) versus a novel technology (VVC/CVT) because novel technologies require more technical consideration on behalf of the user. This was a single-center VA hospital.

Setting and Population

Study participants in the observational cohort analysis were patients from a VA Hospital in Chicagoland who were aged ≥70 years with advanced CKD stage 4 or 5 and who followed-up with nephrology for ≥1 outpatient visit. Exclusion criteria included Veterans with life-sustaining treatment notes written within the last 90 days, those enrolled in hospice, or those already receiving dialysis.

Participants for the observational cohort analysis (n = 40) were recruited between February 1, 2022, and November 22, 2022, and were identified by the nephrologist on the research team. The palliative care coordinator contacted eligible Veterans and offered a palliative care clinic visit for GOC conversations, and agreeable Veterans were included in the cohort analysis. Visits were offered in person, via a telehealth visit at home (VVC), a telehealth visit at a VA outpatient clinic (CVT), or by phone, and visit modality preference was captured. Because palliative care visits for GOC conversations are considered standard of care for this population, no consent was obtained from Veterans for enrollment in the observational cohort analysis.

Semi-structured interview Veteran participants (n = 11) were selected from the observational cohort participants and included Veterans who had palliative care visits either in-person/phone (n = 7) or via telehealth (n = 4). Participants were recruited between March 18, 2022, and January 27, 2023. Observational cohort participants were excluded from interviews if they were non-English speaking, had moderately severe to severe dementia, were unable to provide verbal consent, or did not complete a GOC conversation. All 4 palliative care clinicians were recruited for semi-structured interviews between July 15, 2022, and October 15, 2022. Veterans and clinicians provided verbal consent to participate in interviews.

Exposure and Predictors

The primary variable of interest was Veterans’ visit modality preference, classified as (1) in-person or telephone or (2) VVC/CVT. Patient, clinician, and health-systems-level factors that are potentially associated with visit modality preference were also examined.

Outcomes

Primary outcomes of interest included life-sustaining treatment note completion rates and preferences by actual (rather than initially preferred) visit modality. Additional outcomes included patient and clinician perspectives regarding the impact and acceptability of engaging older Veterans with advanced CKD in GOC conversations.

Data Sources

Data sources for the observational cohort analysis included the electronic health record and Veterans Health Administration administrative databases, including the Corporate Data Warehouse and the Care Assessment Need score database. Care Assessment Need scores are percentiles of the predicted probability of death, hospitalization, or either event occurring within 90 days or 1 year based on Veterans’ comorbid conditions and health care utilization. 18 , 19 The score is primarily used in VA primary care settings to identify high-risk Veterans. We extracted data for all study participants from February 1, 2022, to April 19, 2023. Details regarding data source and time period of each variable are shown in Table S1 .

Notes taken by the palliative care coordinator during initial contact with the Veteran were examined and analyzed separately as an additional data source using a qualitative, descriptive approach.

The implementation outcomes framework guided the design of the Veteran and provider semi-structured interviews. 20 Questions focused mostly on the acceptability (satisfaction with aspects of the intervention), appropriateness (perceived usefulness and practicability), and feasibility (suitability for everyday use and practicability) aspects of implementation outcomes. More specifically, Veteran semi-structured interview guides asked about their experiences with the palliative care visit; their rationale for choosing a particular visit modality; and perceived benefits and disadvantages, as well as barriers and facilitators to GOC conversations (in general and by modality). Clinicians were asked about their experiences conducting GOC conversations with older CKD Veterans, perceived support, benefits, and disadvantages of each visit modality.

Analytical Approach

Statistical Analysis of Quantitative Data

Bivariate analyses were used to compare Veteran sociodemographic and clinical characteristics by visit modality preference and by study enrollment status (enrolled vs declined, Table S2 ). Veterans’ visit modality preferences were graphed. Life-sustaining treatment note completion rate and corresponding preferences were compared by actual modality of palliative care visit. The χ 2 test was used for categorical variables, including the Fisher exact test when the expected cell value was <5. The Mann–Whitney 2-samples test for the equality of medians was used for nonnormally distributed continuous variables and the t test for normally distributed variables. All analyses were conducted using Stata/MP 17.0.

Qualitative Analysis

Semi-structured Veteran and clinician interviews were audio recorded, professionally transcribed verbatim, and prepared by the research team for analysis. We used an inductive, rapid analytic approach and the constant comparison method to analyze and interpret qualitative data. 21 As described in recent literature, rapid qualitative analysis approaches represent an emerging methodology to accelerate identification of prominent themes while maintaining scientific rigor. 22 , 23

Analysis was conducted by 3 study team members trained in qualitative data analysis (CR, TM, and SB) to identify emerging themes around key barriers and facilitators for acceptability, appropriateness, and feasibility, as well as the perceived impact of engaging Veterans in GOC conversations. In our analysis, we also identified themes around practical suggestions for future work in the area of improving access and patient-centricity of GOC conversations via telehealth for older Veterans with CKD 4-5. A template summary table of key domains for each interview, including perceived barriers and facilitators by visit modality, as well as potential benefits and disadvantages of engaging Veterans with CKD in GOC conversations across visit modalities were generated. Veteran and palliative care clinician data were analyzed concurrently to triangulate data. As in prior studies, we reasoned that using this summary table would allow us to quickly derive discrete, relevant qualitative data without losing key information. 24

The table was finalized after testing with the first 3 interviews. Remaining interviews were assigned to 2 analysis team members. For each interview, one member was responsible for reviewing the transcript and populating the template table and another team member reviewed the summary to add missing information or clarification. Discrepancies were reconciled through consensus 25 : if team members were unable to agree on the contents of a summary table, the team met to discuss the discrepancy, seek input if needed from clinician co-authors (AV, SL, and JS), and achieve consensus. Transcripts were reviewed in a final round to refine summary tables. Through this iterative process, emerging themes were categorized as a barrier/facilitator or benefit/disadvantage of using GOC conversations across modality. Representative quotes presented by Veteran or clinician groups were drawn from these steps.

In a separate and complementary qualitative analysis, responses to questions by the palliative care coordinator during initial contact with the Veteran, including the question of modality preference, were extracted from the corresponding notes. Two investigators on the team [TM and AV (coordinator)] coded the notes and summarized the codes into themes around patient perspectives, facilitators, and barriers regarding the palliative care visit and visit modality ( Table S3 ).

Mixed-Methods Integration

Quantitative and qualitative findings were integrated to describe key themes regarding acceptability of engaging older Veterans with advanced CKD in GOC conversations via telehealth (see Fig S1 ). A matrix approach was used to triangulate data from both sources. 26 Specifically, findings from each method were reviewed side-by-side with a focus on identifying findings from each method that agreed with, complemented, added to, or conflicted with one another. 25

Ethics Approval

This study was deemed exempt from Institutional Review Board review by the author’s institution due to only involving interview procedures and secondary use of identifiable private information for purposes of health care research.

Results

Quantitative Results

Sixty-two Veterans were identified, and 40 Veterans (64.5%) were enrolled in the study. Nineteen (30.1%) declined palliative care visits, and 3 (4.5%) had discontinued palliative care consults due to non-response or scheduling issues ( Fig 1 ). Veteran demographic and clinical characteristics did not differ significantly among Veterans who declined a palliative care visit versus Veterans who were enrolled in the study ( Table S2 ).

The majority of enrolled Veterans were White (67.5%), non-Hispanic (92.5%) men (97.5%). Veterans’ mean age was 80.8 years (standard deviation, 7.1). Median distance from the health facility was 17.6 miles (interquartile range [IQR], 11.4-23.7). While there was no significant difference in distance between those who preferred in-person versus telehealth visits, those who preferred in-person visits lived further from the hospital (19.3 miles vs 12.8 miles). Enrolled Veterans had high 1-year (95; IQR, 85-98) and 90-day (95; IQR, 85-97.5) mortality Care Assessment Need percentiles and were considered high-risk. Half of the enrolled Veterans had an emergency department visit (50.0%), and 40% were hospitalized during the study follow-up period. Approximately 17.5% of enrolled Veterans died during the study follow-up.

Most Veterans preferred in-person palliative care visits (65%), followed by VVC (28%), telephone (5%), and CVT (2%) ( Fig S2 ). Demographic and clinical characteristics also did not differ significantly among Veterans who preferred an in-person or telephone palliative care visit versus VVC or CVT ( Table 1 ). Table 2 describes Veteran-related factors by modality of palliative care visit preference. There was a trend toward more family involvement in virtual visits (75.0% vs 46.4%). There were also no meaningful differences in life-sustaining treatment note completion rate and corresponding preferences by visit modality ( Table 3 ). Comments made to the palliative care coordinator about the palliative care visit and modality are described in Table S3 .

Qualitative Results

Of the 40 Veterans enrolled in the observation cohort study, 11 participated in interviews. The remaining participants were either poor interview candidates (eg, sensory impairments), did not respond to interview recruitment attempts, or declined to participate in interviews. All 4 palliative care clinicians (2 physicians and 2 nurse practitioners) also participated in interviews.

We identified 2 interrelated themes: (1) engaging Veterans with advanced CKD in GOC conversations was influenced by a number of factors (ie, key barriers and facilitators), and (2) engaging Veterans in GOC conversations affected their perception of their care. We describe these themes and corresponding subthemes with representative interview quotes by participant group(s) (Veterans or Clinicians) and applicable modalities (VVC, in-person, or any) in Table 4 .

Theme 1: Engaging Veterans in GOC conversations varies by key factors (barriers and facilitators).

Uncertainty surrounding disease trajectory and lack of appreciation regarding the severity of illness. One sub-theme emerging across all modalities and participant groups was that the uncertainty of a Veteran’s disease trajectory was a barrier to GOC conversations. For example, it is difficult for Veterans to make life-sustaining treatment decisions when they are unclear as to when a health crisis may occur or how it would impact them (see Quotes 1.1.A and B). Clinicians also identified that it is difficult to engage in shared decision making when the Veteran does not appreciate the severity of their illness (Quotes 1.2.A).

Buy-in from referring providers and institutional support. Clinicians reported that limited buy-in from non-palliative care providers is a barrier to GOC conversations. For instance, GOC conversations can be difficult when the referring provider does not explain to the patient what palliative care is or the reason for referral, but this additional explanation and preparation would facilitate GOC conversations (Quote 1.3.A). Clinicians also cited leadership and systems support for GOC conversations as a facilitator (Quote 1.6.A).

Degree of comfort with technology. Both clinicians and Veterans spoke about Veterans’ comfort with telehealth technology as a facilitator to VVC visits (Quotes 1.8.A and B) and lack thereof as a barrier (Quotes 1.4.A and B).

Less emphasis on physical nearness to patients. Clinicians reported that physical examinations are not a crucial component of GOC conversations as a facilitator to VVC visits. Therefore, Veterans do not need to conduct GOC conversation visits in-person the way they might otherwise conduct visits requiring close physical examination or testing (Quote 1.9.A).

Scheduling logistics and proximity to clinic. Veterans and clinicians noted difficulties getting to the facility as a barrier to in-person visits (Quotes 1.5.A and B) but that tailoring the scheduling and modality of a GOC conversation visit—for instance, by scheduling visits on days when the Veteran already has in-person appointments—was a facilitator to GOC conversations (Quotes 1.6.A and B).

Theme 2: Engaging Veterans in GOC conversations impacts their perception of care.

The sense of feeling informed and reassured after GOC conversations. The benefits of GOC conversations (regardless of modality) reported by clinicians and Veterans included making a positive impact on Veterans’ lives by focusing on their goals, continuity, and coordination of care (Quotes 2.2.A and B). Veterans also expressed feeling informed and comforted after GOC conversations knowing that palliative care providers and documented life-sustaining treatment preferences are available when needed (Quotes 2.1.A and B).

Increased family and caregiver participation. Veterans and clinicians reported increased family and caregiver participation as a benefit of VVC because people who might have difficulties joining the Veteran for a visit in-person could attend virtually instead (Quote 2.3.A and B).

Greater insight into the patient’s unique context. Clinicians also reported that VVC visits provide insight into the Veteran’s unique context (eg, home milieu or another personal environment otherwise unavailable during an in-person visit; Quote 2.4.A.).

Smoother communication and the value of physical presence. The benefits of conducting GOC conversations in-person reported by Veterans and clinicians included smoother patient-clinician communication (for example, reading non-verbal cues and expressing thoughts are easier; Quotes 2.6.A and B) and in-person visits being more suitable to the serious and sometimes emotional nature of GOC conversations due to the physical presence of another individual (Quotes 2.5.A and B).

Mixed Methods

Suggestions for optimizing access and patient-centricity of GOC conversations via telehealth resulting from the triangulation approach are summarized in Table 5 .

Discussion

To our knowledge, this is the first study leveraging the strengths of both quantitative and qualitative research methods to describe the feasibility of engaging older Veterans with advanced CKD in GOC conversations via telehealth. The findings support that telehealth can feasibly bring high-value GOC conversations to certain older adults with kidney disease (eg, those with sufficient technological proficiency), as those who wished to conduct virtual visits were successfully able to do so.

While patient characteristics, GOC conversation quality, and content was similar between modalities, qualitative findings yielded in-depth perspectives among Veterans and clinicians regarding their experiences with each visit modality. The findings suggest that factors increasing the ease of GOC conversations may also increase their benefits. Specifically, the more Veterans and providers are empowered (eg, by institutional and leadership support, involvement from non-palliative care clinicians, etc) to make informed decisions regarding their health (understanding and appreciation of their illness), the easier it is to conduct GOC conversations and the more impactful these conversations are. The recommendations in Table 5 can maximize access to GOC conversations and their effectiveness in older Veterans with advanced CKD.

Individual patient-centric visit modality considerations are also important. Veterans selected the modality that was most convenient for them, and there were benefits and challenges associated with each. For example, in-person visits involved smoother patient-clinician communication without technical interruptions, an often cited barrier to telehealth. 11 This study also shows that while telehealth may be feasible for facilitating GOC conversations, there is no one-size-fits-all approach to visit modality selection. Rather, it requires careful consideration of the patient’s physical, cognitive, and environmental milieu.

Study participants suffered from relatively high morbidity and/or mortality, underscoring that older patients with advanced CKD should be engaging in GOC conversations. This requires the collaboration of non-palliative care and palliative care providers to ensure Veterans are proactively referred and appropriately prepared for such discussions. It is also encouraging that consultation acceptance rates were high across all visit modalities, affirming that patients are ready to have these important discussions.

An important limitation of our study was the small sample size. A larger sample size would have afforded a greater ability to detect statistically significant differences in patient characteristics and clinical outcomes between visit modalities (for example, descriptively, patients who preferred telehealth lived closer to the hospital and those who enrolled in the study had more emergency room visits and higher rates of mortality). Future studies may be needed to obtain sufficient statistical power to assess whether such differences are significant and examine potential reasons for such differences. Another important limitation is that most of our sample was non-Hispanic White males, a population that has historically had greater telehealth access and utilization than minorities. 27 , 28 While our sample appears to be fairly representative of the broader in-state older adult Veteran population, 29 future studies with larger and more diverse samples may be better equipped to identify differences by demographic characteristics and yield findings that are more broadly generalizable. Similarly, our findings may not be generalizable to patients using non-VA health systems. Our study also did not examine the outcomes of patients who declined a palliative care visit.

Our research underscores the growing movement to proactively incorporate palliative care into kidney care. 30 , 31 , 32 As the largest integrative health care system as well as the largest provider of kidney care in the country, 33 the VA is uniquely positioned to leverage its infrastructure and facilitate relationships between nephrologists and palliative care clinicians to study effective partnerships. There are well documented structural and clinical barriers to nephrologists engaging patients in advance care planning. 8 One suggestion could include elevating tele-palliative consultation and allowing VA sites with robust palliative care teams to offer their services virtually, with the goal of reaching rural or homebound patients or those patients without access to local palliative care. Additional research in this area could advance a more compressive approach to VA kidney care and offer a future model for partnerships.

Article Information

Authors’ Full Names and Academic Degrees

Alexi Vahlkamp, MA, Julia Schneider, MD, Talar Markossian, PhD, Salva Balbale, PhD, Cara Ray, PhD, Kevin Stroupe, PhD, and Seema Limaye, MD

Authors’ Contributions

Research idea and study design: AV, JS, TM, SB, CR, KS, SL; data acquisition: TM, SB, CR, KS; data analysis/interpretation: TM, SB, CR, AV, SL; statistical analysis: TM; supervision or mentorship: KS. Each author contributed important intellectual content during article drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved.

Support

This work was funded by the Hines VA Serwa Research Center grant, “Optimizing VA’s Veteran video connect capacity to engage high-risk Veterans with advanced kidney disease in goals of care conversations.” PI: Seema Limaye, MD. The funder did not have any role in the study design; or the collection, analysis, or interpretation of data; writing the report, and the decision to submit the report for publication. All views expressed are those of the authors and do not reflect the views of the Department of Veterans Affairs.

Financial Disclosure

The authors have no financial disclosures to report.

Acknowledgements

We acknowledge the Veterans who participated in this study, as well as the leadership of Dr Holly Kramer and the Serwa Research Center. We also acknowledge the work of Ms Zhiping Huo for her contributions to our data sets.

Peer Review

Received January 22, 2024. Evaluated by 2 external peer reviewers, with direct editorial input from the Editor-in-Chief. Accepted in revised form June 11, 2024.

Footnotes

Complete author and article information provided before references.

Supplementary File (PDF)

Figure S1: Description of convergent design.

Figure S2: Patient preferences∗ for palliative care visit modality (n = 40).

Table S1: Veteran Patient-Level Variables by Source and Time Period.

Table S2: Demographic and Clinical Characteristics, and Patient Outcomes by Study Enrollment Status (n = 62).

Table S3: Patient Perspectives, Facilitators, and Barriers About Palliative Care Visit and Visit Modality (n = 62), Identified During Initial Contact Call by Palliative Care Social Worker.

Supplementary Material

Supplementary File (PDF)

Figs S1, S2; Tables S1-S3.

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Associated Data

Supplementary Materials

Supplementary File (PDF)

Figs S1, S2; Tables S1-S3.