Can RPM move the needle on post-discharge care for AKI?

Setting up an RPM program for AKI

According to Erin F. Barreto, Pharm.D., clinical pharmacist, researcher and associate professor of medicine and pharmacy at Mayo Clinic, the health system decided to launch an RPM program for AKI survivors to fill gaps in follow-up care post-discharge.

"We need[ed] to help them find ways to stay in their homes so they can keep working and living while still getting adequate care," she said in an interview. "And so, we developed the AKI remote patient monitoring program, which is one of several remote patient monitoring programs that exists and is supported by the Mayo Clinic Center for Digital Health."

The data has demonstrated the potential for acute kidney injury survivors' care to be affected through interventions like diuretic management, potassium supplementation, increased monitoring, emergency department referral -- all of those are sufficiently promising to continue to propel forward with AKI RPM.

The AKI RPM program involves identifying potential AKI patients during hospitalization who would benefit from continued monitoring after discharge. The enrolled patients receive a blood pressure cuff, scale and tablet. They measure their blood pressure and weight daily and transmit the readings to their care team in the Center for Digital Health, who monitors the data.

"If there are indications that the vital signs or the symptoms that they're having are out of normal, then there are escalation pathways that allow that [data] to get to the care providers to make sure that [the patients] have the resources they need," Barreto said. "So, for example, if all of a sudden they have gained five pounds and they are newly short of breath, then we might call an advanced practice provider and see if they want to do anything different with their medications or talk to a nephrologist about whether they need even more monitoring."

The patients are also scheduled for routine maintenance lab tests at the clinic about once a week to monitor their kidney health. Patients remain in the program for at least four weeks and a maximum of three months. Depending on their clinical needs, they either move into Mayo Clinic's chronic kidney disease care clinic or return to their primary care provider.

"[We try] to make sure that that transition is seamless, and then they're aware of how best to care for them[selves] from a kidney perspective moving forward," Barreto said.

The AKI RPM program aims to improve post-discharge care for AKI survivors in numerous ways.

For one, AKI patients experience electrolyte changes, including changes to potassium levels, which can be life-threatening, Barreto explained. RPM helps care teams track these changes and intervene before they result in severe illness or death.

Another significant issue facing AKI patients is that they might have a buildup of fluid if they haven't fully recovered when they leave the hospital.

"That fluid can cause weight gain and shortness of breath," Barreto noted. "It can cause heart problems, and you need medications to try and remove that fluid from your body. In the same way, as your kidneys are healing, they're trying to relearn how to remove that fluid from their body, and sometimes they put too much urine out while they're still getting reorganized after being injured. And so, you can end up dry in the sense that you can have too little fluid circulating, and that can increase your risk of having AKI again in the future."

Thus, it is vital to effectively manage the utilization of diuretics -- medications that help rid the body of excess fluid -- following AKI hospitalization. RPM offers a convenient, real-time view of diuretic use and its effects, enabling clinicians to adjust the medications as needed to prevent recurrent episodes of AKI or the progression to chronic kidney disease.

Though the RPM program has the potential to enhance post-discharge care for AKI survivors, Baretto noted several key considerations that organizations must be aware of to ensure its success, including having a process in place to help identify suitable patients for the program.

"Many patients who have acute kidney injury also have heart disease and lung disease and are admitted to the hospital for infections and brain problems and all of these other things," she said. "And so acute kidney injury is kind of a diffuse problem that affects a whole host of patients across the practice. Trying to figure out exactly how to choose patients for the program [in a way] that is thoughtful and equitable and doesn't add complexity to already complex care for people, I think, can be a challenge."

Initially, the health system tasked their inpatient kidney specialists with identifying viable candidates for the program, she added. However, not every patient with AKI is cared for by a kidney specialist. So, the Mayo Clinic developed screening lists that can be used across service lines to identify patients for the program equitably.

Another consideration was digital health literacy, which is the level of access and comfort a person has with digital health tools. Mayo Clinic's Center for Digital Health has created a team to address this issue. The team sends new candidate packages to newly enrolled participants in the various technology-supported programs the health system offers. They also contact patients directly to train them on digital health tools and answer questions.

"As a team, we have had to be a little bit more adaptable, which is expected when you open a program; you have to keep it kind of restrained until you figure out how it's going and where your gaps are and what you need to shore up," Barreto said.

Assessing the impact of RPM

After launching the AKI RPM program nearly three years ago, Mayo Clinic researchers set out to study its feasibility and efficacy in improving post-discharge AKI support, publishing their findings in the journal Kidney Medicine.

According to Barreto, one of the study authors, the study's goals were twofold: one, to share the health system and participants' experience with AKI RPM, including program recruitment and the types of alerts and interventions it prompted, and two, to examine whether the program could reduce readmissions. The researchers performed a cohort study with matched historical controls that included adults hospitalized at the Mayo Clinic for AKI and then discharged to their homes.

They included 49 patients enrolled in the AKI RPM program between October 2021 and November 2022. The historical control group included AKI survivors hospitalized from October 2018 to September 2021.

Of the 49 patients enrolled in AKI RPM, 82% participated in the program after hospital discharge. The median duration of participation in the program was 32 days.

"What we showed was that No. 1, patients were able to be recruited into the program," Barreto said. "They participated, they got their vital signs, they took their weights, they went to the lab to get their blood drawn and get their laboratory monitoring completed. In general, that's a pretty good sign that the program, at least among this subset of 40 or so odd people, was successful."

The study also shows that among the 40 patients who actively participated in the program, 73% had at least one alert. The alerts were primarily for abnormal symptoms, specifically weight gain or edema. The leading intervention recommendation by RPM providers was diuretic adjustments.

"So that highlights the potential role that this remote monitoring has for these patients because there were certainly interventions that needed to be made during that timeframe," she said.

Another common intervention was the management of electrolyte abnormalities, like potassium changes.

These study results give program leaders a sense of which areas in post-discharge AKI care need to be improved, Barreto noted.

Still, RPM failed in one significant measure. The study showed that the AKI RPM program did not reduce unplanned hospital readmissions or emergency visits within six months of discharge compared to the historical control group. Further, the risk for new worsening kidney dysfunction in the 90 days to six months after discharge did not differ between AKI RPM program participants and controls.

However, Barreto noted that there might be several reasons for these outcomes that are not connected to AKI.

"When you look at reasons for rehospitalization, they might have very little to do with kidney health," she said. "You fall on the ice, and you break your arm, you go back to the ER for that, and it might have nothing to do with kidney health. [The study was] also a very small comparison -- better than anything else that's out there in the field, but that might have contributed to an inability to see a signal."

Barreto further underscored the challenges inherent in an epidemiologic study like this, where researchers compare study participants to historical controls, because provider behavior is outsized in patient discharge and post-discharge monitoring.

Thus, Barreto and her fellow researchers concluded that though advocating for integrating RPM into routine post-discharge care for AKI survivors would be premature, continued research is needed to more fully understand the effect of digital health tools on patient outcomes within AKI subgroups.

Barreto went a step further, noting that the data has "demonstrated the potential for acute kidney injury survivors' care to be affected through interventions like diuretic management, potassium supplementation, increased monitoring, emergency department referral -- all of those are sufficiently promising to continue to propel forward with AKI RPM. And we certainly [will] continue to do that, and we're refining aspects of the program to better meet these needs."

The Mayo Clinic team also plans to continue diversifying and expanding the participant pool for the AKI RPM program. Ultimately, the benefits of RPM might outweigh its limits.

"We'll continue to mature as we do more studies and build more programs, but I think that what we have shown is that there is a way to connect with patients that is acceptable to them and also resource-conscious in the healthcare environment," Barreto said. "And I think it will probably enable us to reach more patients and minimize the gaps in care that we currently are observing."

Anuja Vaidya has covered the healthcare industry since 2012. She currently covers the virtual healthcare landscape, including telehealth, remote patient monitoring and digital therapeutics.