Virtual kidney transplant evaluation allows patients to be evaluated for transplantation from home instead of visiting a hospital for testing during COVID-19 restrictions

CHICAGO: A virtual telehealth platform is allowing the surgery program at the Medical University of South Carolina (MUSC) to evaluate and wait-list patients for kidney transplantation despite reductions in direct, in-person health care visits brought about by the Coronavirus Disease 2019 (COVID-19) pandemic. Between April and September, surgical teams have been able to perform more transplant evaluations and add the same number of patients to the wait list as they did in the same period last year, according to researchers whose study was selected for the 2020 Southern Surgical Association Program and published online as an "article in press" by the Journal of the American College of Surgeons in advance of print.

"Because of the platform, we can give continuous access to patients in the kidney transplantation program even in the midst of a pandemic that has restricted access to the hospital. We can provide access to kidney transplantation even for patients who have difficulty getting to the transplant center because of where they live or who have difficulties due to their socioeconomic status," said Vinayak S. Rohan, MD, FACS, an assistant professor of surgery and lead study author. Patients in the virtual telehealth program lived, on average, 130 miles from the transplant center, and 65 percent were African American.

Before being considered for kidney transplantation, patients with end-stage renal disease must undergo a comprehensive evaluation that includes a medical and surgical history, physical and psychosocial exam, and blood testing for compatibility with an eventual donated organ.

Depending on a patient's condition, other testing may be ordered, including blood testing for the overall function of the heart, kidneys, liver, thyroid, and immune system, as well as targeted studies of the lungs and heart, cancer screening, colonoscopy, gynecologic or prostate examination, and dental workup to be sure there is no sign of infection or gum disease that could affect the immune system.¹

This evaluation is routinely done in one or more in-person visits to the transplantation center or to primary or other physicians' offices. However, the onset of COVID-19 severely limited patient access to non-urgent care and closed ambulatory clinics that conduct kidney transplant evaluation.

An operational team from MUSC's division of transplant surgery quickly moved to reduce the need for in-person visits by implementing a virtual kidney transplant evaluation. The team included transplant surgeons, nephrologists, advanced practice practitioners, social workers, and other members of the surgical quality improvement program.

The research team stratified patients who had recently been referred by their doctors or dialysis units for possible transplantation and were in the process of pre-transplant review by providers and insurance carriers. After an initial review of their medical records, patients were stratified into one of three groups.

The first, or "red," group included patients whose age or medical condition made it unlikely they would end up being candidates for transplantation and therefore require a full presurgical evaluation. Patients in this group were over age 70 and had a history of stroke, significant cardiac or peripheral vascular disease, or poor functional status.

The second, or "green," group included patients who were likely to be candidates for transplantation and placed on the wait list for a donated organ. Patients in this group were under 45 years of age and had no history of diabetes.

The third group, or "yellow," group included "fast track" patients as well as all other patients. "Fast track" patients were on the wait list at another transplantation center and required minimum further workup.

Patients were scheduled and evaluated by the virtual platform based on this stratification. "Fast-track" patients were expedited through the virtual evaluation. These patients were followed by individuals in the red and green groups.

After an initial call to determine if a patient or a family member could use a smart phone or tablet and verify insurance, the patient was scheduled for check-in, a link to the doxy.me virtual platform was sent, and the telehealth visit was completed. The doxy.me virtual platform was chosen because it is easy to use, complies with HIPAA privacy, and does not require additional software to complete the visit.

Between April and September, 176 transplantations were performed. Of the 1,148 patients who were referred for transplantation, 930 underwent virtual evaluation and 282 were placed on the wait list. In the same period in 2019, 177 transplantations were performed. Of 1,639 patients referred, 880 were evaluated and 308 were wait-listed.

Dr. Rohan believes this type of platform can be used by any medical specialty even after the pandemic. "However, we need new regulations to achieve this goal," he pointed out.

Provisions in the national COVID-19 aid and relief legislation, the CARES Act, made the shift to the virtual evaluation platform possible by expanding Medicare coverage for telehealth during the pandemic.^2,3

"We need to continue this practice in the future, even after the CARES Act expires, and expand care across state lines so that patients can continue having access to medical care across all specialties," he said.

Dr. Rohan's study coauthors are Nicole Pilch, PharmD; Deborah Cassidy, MS; John McGillicuddy, MD, FACS; Jared White, MD, FACS; Angello Lin, MD; Satish N. Nadig, MD, FACS; David J. Taber, PharmD; Derek Dubay, MD, FACS; and Prabhakar K. Baliga, MD, FACS.

"FACS" designates that a surgeon is a Fellow of the American College of Surgeons.

Authors have no disclosures related to this study.

Citation: Maintaining equity and access: Successful implementation of a virtual kidney transplant evaluation. Journal of American College of Surgeons. DOI: https://doi.org/10.1016/j.jamcollsurg.2020.12.003.

1. Evaluation for Kidney Transplant. National Kidney Foundation. Available at: https://www.kidney.org/atoz/content/kidney-transplant-evaluation. Accessed November 8, 2020.
2. Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020. Congress.gov. Available at: https://www.congress.gov/bill/116th-congress/house-bill/6074. Accessed November 8, 2020.
3. CARES Act. Congress.gov. Available at: https://www.congress.gov/bill/116th-congress/senate-bill/3548. Accessed November 8, 2020.

About the American College of Surgeons

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has approximately 90,000 members and is the largest organization of surgeons in the world. "FACS" designates that a surgeon is a Fellow of the American College of Surgeons.

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