LAUSR

Remote patient management (RPM) involves the collection of clinical, treatment-related and subjective patient data outside clinical settings to be used by healthcare professionals to monitor and adapt treatments remotely. In the area of kidney replacement therapy (KRT), various applications are being used, with different features such as remote monitoring (continuous and automatic data collection), data analysis software (detecting deviating values and providing alerts) and communication tools (e.g. shared patient records, messaging service) [1]. RPM may give patients more confidence to perform home dialysis and could reduce patients’ administrative burden [1–3]. Moreover, the use of RPM was associated with better clinical parameters [4], better treatment adherence [5], fewer hospital visits [4–6], less travel time [6] and lower costs [5, 6]. As with other forms of telemedicine, several barriers may limit the implementation and diffusion of RPM. Broens et al. [7] distinguished five categories of barriers: technical (e.g. users’ skills, data accessibility, presence of infrastructure such as Internet), acceptance (e.g. users’ motivation and beliefs, evidence about efficacy), financial (e.g. implementation and maintenance costs), organizational (e.g. changing work practices, team roles and responsibility) and policy and legislation (e.g. patients’ physical security and information security). It is yet unknown how often RPM is used by European nephrologists and the barriers they experience to use this technology. Some qualitative studies [8] describe experiences of RPM users, but studies on barriers for non-users do not report about nephrologists’ experiences [1]. Moreover, results from non-European countries cannot be generalized to Europe due to differences in geography, healthcare systems, digital skills and technical infrastructure. Therefore we studied the use of, attitude towards and added value of RPM and barriers for nonusers among European nephrologists treating adults with KRT. Between March and May 2019 we surveyed nephrologists with the Effect of Differing Kidney Disease Treatment Modalities and Organ Donation and Transplantation Practices on Health Expenditure and Patient Outcomes (EDITH) nephrologist survey [9]. The Medical Ethics Committee of Amsterdam UMC, location AMC in Amsterdam, The Netherlands waived the need for ethical approval and individual participants provided informed consent. In this study we included nephrologists who provided information on sex, age and centre characteristics. We reported quantitative results as proportions and performed thematic content analysis of responses from open questions using Broens’ model [7] to categorize barriers of non-users. In total, 519 nephrologists, 54% male, 29% 40 years of age, 55% between 41 and 60 years of age and 16% 61 years of age, from 33 European countries were included. The majority were employed in academic (57%) and public centres (78%) in urban areas (93%). Three-quarters (77%) worked in a centre that treats 100 patients per year with end-stage kidney disease. Thirty-three percent lived in a country with low gross domestic product (GDP), 38% in a middle-GDP country and 30% in a high-GDP country [9]. Twenty-six percent already used RPM in their clinical practice, mostly for peritoneal dialysis (PD) (71%) (Figure 1A). Most nephrologists had a positive attitude towards RPM, with no significant difference between users and non-users (Figure 1B). Respondents believed that RPM could result in improved quality of care (64%), better patient management (61%), reduced resource use (50%) or fewer complications (47%) (Figure 1C). The most frequently selected reason for not using RPM was a lack of resources (85%); other reasons were a lack of awareness (27%), safety concerns (22%) and perceiving no advantages (9%) (Figure 1D). We compared opinions from nephrologists living in low-, middleand high-GDP countries in Europe and found no differences in the use of, attitude towards or barriers to the use of RPM. Remarkably, respondents from both lowand high-GDP countries more frequently saw resource reduction as a potential value (low 53%, middle 41%, high 57%; P< 0.05), while those from middle-GDP countries more frequently reported reducing the risk of complications