Problem

One in 10 people in England live with chronic kidney disease (CKD),1 and around 32 000 people have a functioning kidney transplant in the UK.2 Patients who have had kidney transplants need regular specialist monitoring commissioned by National Health Service (NHS) England.3 This is routinely done at face-to-face appointments at approximately 3–4 monthly intervals in 52 regional renal centres across England. Each centre serves patients from a large geographical footprint and so patients routinely travel long distances to attend, having an impact on their lifestyle, income and environment.

The number of people with a functioning kidney transplant is increasing, placing heavier demands on renal services and particularly on outpatient capacity. This will require increased funding at a time when the NHS is working under unprecedented financial constraints. Furthermore, healthcare organisations have a duty to deliver improvements in quality, convenience and environmentally sustainable service (eg, reduction in CO₂ emissions). For these reasons, there is an increasing focus on delivering care closer to home.4

North Bristol NHS Trust (NBT) Renal Unit covers an area extending to a radius of up to 80 miles for kidney transplant patients. Therefore, some patients have to travel large distances to attend appointments with associated costs both in terms of travel and productivity losses, such as time off work or leisure activities as well as environmental impacts. A significant proportion of these patients have stable kidney function but need continued specialist monitoring and could potentially be managed through telephone consultations (referred to as ‘tele-clinics’).

The project aimed to establish a tele-clinic service for routine monitoring of kidney transplant recipients over a 12-month period. This was based on patient experience reports to the renal unit commenting about difficulties with travel and parking for follow-up appointments. A survey of 96 renal transplant patients suggested that 59% of patients would consider taking up the option of a tele-clinic appointment. A detailed semistructured interview of each of the 11 patients from a pilot tele-clinic in December 2014 was undertaken by an evaluator independent of the quality improvement team to get patient feedback. The interviews were recorded, transcribed and analysed under broad themes to inform us of the tele-clinic service model and the patients’ perception of the benefits and risks of tele-clinics (unpublished). The general consensus was that the telephone consultations were a good idea as an addition to regular face-to-face appointments. Most of the patients suggested that they would be happy to have every other appointment as a tele-clinic but would not want all their appointments replaced in this way. It was felt that they liked the reassurance of being physically ‘seen’ by a specialist.

Background

Before proceeding with tele-clinics, we conducted systematic searches to identify potentially relevant studies that supported the safety and acceptability of tele-clinics for renal transplant patients and found two non-comparative evaluations. A report of 3 years’ experience from one UK centre that uses a tele-clinic for kidney transplant recipients concluded that if implemented appropriately, the use of tele-clinics for the follow-up of renal transplant recipients is safe and confers environmental benefits.5 However, no formal evaluation of this service has been conducted. A systematic review of the use of tele-health in nephrology concluded that although tele-health applications (not restricted to tele-clinics) are currently being used successfully in the management of patients with CKD, compared with other chronic disease areas, the development of tele-health applications appears underused and under-researched.6

Baseline measurement

As we had not used a tele-clinic model before, we agreed that our first PDSA cycle would form our improvement baseline and a range of comparative measures such as attendance and time taken could be used to compare performance with the standard delivery model.

We agreed to collect several process measures, outcome measures and balancing measures after each tele-clinic (table 1). It was recognised that undertaking blood tests in the community prior to the tele-clinic appointment would improve the effectiveness of the consultation and also reduce the need for any further follow-up telephone consultations to discuss blood test results. We constructed a driver diagram to highlight our working model of the key drivers for change and to organise the improvement ideas. Our aim was to understand the different processes that need to be put in place in the primary–secondary care interface to set up the service and also to ensure that the blood test results are available to the clinician at the time of tele-clinic consultation. The process of undertaking blood tests prior to the tele-clinic was a significant departure from face-to-face appointments where blood tests are performed in the clinic, and the results were reviewed by the specialist after the clinic. Therefore, we collected information from four face-to-face clinics to ascertain the baseline percentage of blood test results that are available and that correct (appropriate) tests have been ordered (96.5%). In part, the project aimed to reduce the number of patients not attending their face-to-face clinics by offering a tele-clinic option. Therefore, in the period August–October 2016, we analysed the number of patients who did not attend face-to-face clinic (6.9%).

The allocated time for face-to-face clinic appointment currently is 15 min. We anticipated that although tele-clinic consultation may require less time due to lack of need for physical examination, this could be balanced out by the lack of visual cues necessitating more in-depth questioning and prolonged consultation time during a tele-clinic. Therefore, we collected the average length of consultation time for tele-clinics but included only time spent on the phone for two reasons. First, patients suitable for tele-clinics and those who opt to do tele-clinics are less likely to be complex clinically compared with face-to-face clinic patients and so may require less time for additional tasks in clinic such as case notes review or following up investigations. Second, additional time may be required to chase blood test results for tele-clinic patients if they are not accessible on the renal IT system on the day and so may not truly reflect the time spent undertaking telephone consultations.

Design

This project was codesigned with patients throughout, using surveys, semistructured interviews and overarching programme governance structures. In addition, two patient representatives were active members of the codesign team and contributed to the improvement ideas and development of the improvement measures and helped to operationalise the service through development of patient information leaflets and questionnaires. In collaboration with West of England Academic Health Sciences Network (WEAHSN), we held a multidisciplinary workshop in December 2015 with patient representatives, renal consultant colleagues, renal administrative team, central outpatients booking team, general practitioners (GP), transplant nurse specialists, quality improvement experts from WEAHSN to process map the potential new care pathway for tele-clinics and capture improvement ideas (figure 1).

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Figure 1

Process map for tele-clinics. GP, general practitioner; NBT, North Bristol NHS Trust.

We negotiated a local tariff of £188 compared with face-to-face clinic tariff of £218 with NHS England for an initial pilot project between August 2016 and July 2017. Blood tests were required to be undertaken ahead of the tele-clinic at the local GP surgery, but we were unable to negotiate a payment to GP surgery with local Clinical Commissioning Groups (CCGs) for this additional activity due to lack of engagement from CCGs. However, we anticipated that the patient eligibility and demand for the tele-clinic service will mean that only 1–2 patients per month per GP surgery will require this service and therefore should not unduly burden the local phlebotomy services at the GP surgery. The project lead, through close liaison and through newsletters to GP groups and medical committees was able to raise awareness and secure buy-in to undertake blood tests for the project.

The tele-clinic intervention was designed to have the following main features:

• Patients judged suitable for tele-clinics by their specialist would be offered a telephone clinic appointment during which their progress, symptoms, blood test results and blood pressure (BP) measurements would be discussed and advice given. Patient eligibility criteria were developed by renal consultants at NBT based on the consensus that stable patients were unlikely to require physical examination or close monitoring in secondary care more frequently than every 3–4 months. For this pilot, we selected stable kidney transplant recipients who had a functioning kidney transplant for at least a year; had not had any transplant rejection episodes; had not started any new immunosuppression medications in the preceding 6 months; had a rate of decline in glomerular filtration rate that was <5 mL/min/1.73 m²/year; had agreed to alternate tele-clinics and face-to-face clinics; and did not have hearing or learning difficulties that could affect telephone consultation.

• Patients were invited to opt-in during routine face-to-face clinic appointments. We created an electronic flag on our renal IT system to identify those who refused the offer and the reasons for not taking up the offer. Those who chose to do tele-clinics were booked in to a tele-clinic as the next follow-up appointment.

• The tele-clinic would be offered to patients on an alternating basis with their face-to-face appointment based on feedback received from the qualitative interview from a pilot clinic as described above.

• These patients would be sent an appointment invitation letter with instructions to get blood tests done ahead of the tele-clinic and encouraged to measure BP either at home (self- monitoring through automated BP devices) or at their GP surgery. After several deliberations with the laboratory teams and GPs, it was agreed that a blood test form with instructions on what blood samples and what tubes the blood samples needed to be sent in would be incorporated in the clinic appointment letter. Some of these blood tests were standard for all patients, and they were preselected on the form. As different patients were on different immunosuppression medications for their kidney transplant, measurements of immunosuppression drug level were not preselected but required patients or the phlebotomists at GP surgery to select them at the time of sampling. We also created a unique location code ‘NBTRT’ to inform the laboratories that the samples originated in primary care in relation to tele-clinics undertaken by NBT.

• We agreed a standard operating procedure with all seven pathology labs in the region (NBT; University Hospital, Bristol [UHB]; Royal United Hospitals, Bath [RUH]; Musgrove Park Hospital, Taunton; Yeovil District Hospital, Yeovil; Weston General Hospital, Weston; and Gloucestershire Royal Hospital, Gloucester) so that results from samples with this location code were forwarded to NBT renal team rather than to GPs to ensure that these results were adequately acted on and to reduce additional workload for GPs in dealing with any abnormal results. The clinical laboratory systems in NBT, UHB, RUH and Weston are electronically linked to the renal IT system and results were automatically downloaded. Those in Yeovil, Taunton and Gloucester were not electronically linked and therefore relied on paper copies of results to be forwarded to renal unit to be manually entered by the renal administration team.

• Initially, the telephone clinics were delivered by one consultant, but this was rolled out to six consultants delivering tele-clinics by the end of the project.

Strategy

This project had two parallel PDSA improvement ramps, with multiple PDSAs contained within each.

Results

Blood test quality

During the pilot, overall 74.8% of blood tests were ordered correctly. Table 3 shows the proportion of blood tests undertaken correctly in the different time periods. The blood test quality in the final PDSA cycle was 90.9% (figure 2). This is slightly lower than the figure for face-to-face clinics (96.5%). Unlike the face-to-face clinic, where blood tests are done by few trained renal phlebotomists, blood tests are undertaken by multiple staff members within several GP practices. We acknowledged the inherent limitations in this model and accepted that the blood test quality for tele-clinics is unlikely to match that for face- to-face clinic results. The results that were often missed or incorrectly done were the immunosuppression drug levels. A missing single immunosuppression drug level does not adversely affect clinical decision making as we mostly rely on trends in immunosuppression drug levels to adjust dosing. Follow-up of these patients with missing results in subsequent face-to-face clinics did not identify any adverse events relating to incorrect results.

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Table 3

Summary of PDSA cycles to improve blood test quality

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Figure 2

Run chart showing blood test quality. PDSA, Plan–Do–Study–Act.

Blood test availability

At the start of the project, results from all laboratories in NBT, UHB, RUH and Weston were accessible through renal IT system. Towards the end of the QIP (Quality Improvement Project) in July 2017, we were able to get the remaining laboratories in Taunton and Yeovil, electronically connected, and results were automatically downloaded onto the renal IT system. Gloucester was still not electronically linked, and we relied on paper copies of results to be sent to us. The main reasons for results not being visible were: blood test forms (with location code NBTRT) not accompanying the samples sent by GP surgery. Instead locally generated labels used by primary care staff on blood samples and therefore results forwarded back to GPs and not to renal unit. There was a lack of awareness of protocol for processing results accompanied by blood test form with NBTRT location code among some laboratory staff. On average, 84.4% of blood test results were available for the tele-clinics during the entire project but the final PDSA cycle showed an improvement to 90.9% (figure 3).

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Figure 3

Run chart showing blood test availability. PDSA, Plan–Do–Study–Act.

Length of tele-clinics

Across all tele-clinics, the average call length was 10.3 min (figure 4). The figures from January 2017 are an average for all consultants who have done the tele-clinic. There is a trend towards reduced length of consultation time over the course of the project. This could be due to the fact that clinicians became more familiar with the conduct of the tele-clinic. We also had developed a standard tele-clinic template, which was used by clinicians as an aide memoire during the consultation process. The spike observed in April 2017 was associated with another consultant colleague undertaking the tele-clinic for the first time.

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Figure 4

Run chart showing average length of call during each tele-clinic.

Lessons and limitations

PPI involvement was crucial to ensure that the new service being offered was fit for purpose as this was intended to improve patient experience. The semistructured interviews highlighted the importance of offering patients the choice to opt-in for tele-clinics and to maintain some of the appointments as face-to-face visits and hence the provision of alternating tele-clinics and face-to-face appointments. The patient members within the quality improvement team were kidney transplant recipients themselves attending face-to-face appointments at our centre and therefore provided valuable insight in codesigning the service, logistics of undertaking blood tests in primary care and the use of language that was understood by patients with kidney disease in the clinic appointment letter and patient information leaflet. In addition to the experienced patient members’ input in to the project, we found the feedback that we collected through our satisfaction survey informative and provided us a broader perspective of other patients’ experiences.

The success of the tele-clinics relied heavily on primary care’s willingness to conduct blood tests without a formal agreement for these costs to be reimbursed. Due to the small volume of patients per practice needing this service, it was possible to sustain this for the pilot. However, six GP practices decided not to support the pilot due to the lack of reimbursement. While efforts were made to explain the purpose and benefits of the pilot, we have not been able to engage with CCGs and GP surgery due to sustainability transformation plan reconfiguration and other competing priorities for the CCGs. Addressing this issue will be essential for the service to become embedded and sustainable long term as without consistent GP support, the service will inevitably lead to health inequalities.

We anticipated higher demand for tele-clinics (59%) based on patient survey than observed for this project (47.5%). This figure, gathered through this project, draws on a larger number of patients and can be used for more accurate planning of future tele-clinic services. We have also identified the reasons for patients declining tele-clinics. This gives a platform for future attempts to recruit suitable patients to tele-clinics.

While we have been able to identify several financial and efficiency benefits arising from the project, we have not been able to produce a definitive picture of the cost of tele-clinics versus face-to-face clinics. Collaboration with health economists might help to address this gap. In addition, while we failed to find any evidence that tele-clinics were associated with increased 30-day hospital admission or urgent follow-up visits in secondary care, this quality improvement project was never powered to detect such a difference. A much larger study, ideally a randomised controlled trial, would be required to provide far more definitive evidence of safety or equivalence between the two modes of delivery.

In addition, we were not able to collect data on additional GP consultations in-between the tele or face-to-face clinics. It is possible that a face-to-face clinic may detect early problems and deal with them thereby reducing future GP workload. However, it is also possible that face-to-face consultations generate more workload for GPs than tele-clinics. This requires further evaluation.

Conclusions

The project has shown that tele-clinics for kidney transplant patients are deliverable and well received by patients with a positive environmental impact. The project has also delivered modest financial savings for the NHS; however, the true financial picture for the wider health economy and the health economic benefits for patients and the environment has been hard to capture and would warrant further research. This model has the potential to be rolled out to other renal centres if a national tele-clinic tariff that is acceptable to all stakeholders can be negotiated, and an integrated and appropriately reimbursed phlebotomy service can be developed to facilitate remote monitoring of patients between primary and secondary care.