Patient perspectives and experiences of remote consultations in people receiving kidney care: A scoping review

Abstract Background The coronavirus disease 2019 (COVID‐19) pandemic resulted in a rapid and sometimes chaotic change in how clinical care was delivered for people living with kidney disease, with increased reliance on digital technologies and the introduction of remote services. Objectives To conduct a scoping review of studies about patients' experiences and perspectives in receipt of remote consultations for kidney care. Design Using Arksey and O'Malley's framework, three databases were searched on EBSCO (CINAHL, MEDLINE and Psych INFO). The search included studies published in English from August 2010 to August 2021. Results Eight studies met the scoping review criteria (two cross‐sectional, two mixed‐method and four qualitative). Five themes were identified: overall satisfaction with remote services, benefits to patients (convenience, involvement in care and patient safety), barriers to remote consultations (technical difficulties, digital literacy and loss of interpersonal communication), patient concerns (need for physical examination, privacy and confidentiality) and prerequisites for successful remote care (existing patient–practitioner relationship, stable illness phase and access to technology). Conclusion Remote consultations confer multiple advantages to patients; therefore, remote consultations should be offered as an option to patients living with kidney disease beyond the COVID‐19 pandemic. However, there are several barriers to remote consultation that need to be addressed and understood before implementing remote care long‐term. Future research should examine the impact of remote consultations on people living with kidney disease from under‐served groups to identify barriers and ensure their suitability and accessibility to the wider population for a more patient‐centred approach to kidney care.


INTRODUCTION
The coronavirus disease 2019  pandemic resulted in a rapid and sometimes chaotic change in how clinical care was delivered to people living with kidney disease, with the introduction of digital technologies and increased reliance on telehealth. Telehealth or remote care is a clinical practice, usually conducted by video call or telephone, to provide a clinical consultation (Sikka et al., 2019). Before COVID-19, telehealth was initially implemented to maximise health-care access to people living in rural and remote areas (Bashshur & Shannon, 2009;Fisk et al., 2020;Rohatgi et al., 2017). However, over the past decade, new technologies have widened the scope of telehealth practices, making these tools more accessible and effective in caring for patients regardless of geographic proximity (Kvedar et al., 2014).
Given the current coronavirus pandemic, remote consultations are being widely adopted so that people living with kidney disease can access care while maintaining social distancing without risking exposure to and spread COVID-19. These changes are often heralded as being responsive, innovative, and person-centred.
However, there is a growing concern that such changes may adversely affect existing health inequalities in under-served communities (Bonner et al., 2018;Stauss et al., 2021;Walker et al., 2019).
Examples of under-served groups include individuals with poor health literacy, who are not fluent in English, have a learning disability or cognitive or mental health issues (Stauss et al., 2021;Walker et al., 2019).
A systematic review of patients' experiences of real-time online consultations at patients' homes for people living with chronic diseases (Almathami et al., 2020) (n = 45) reported benefits, including the reduced burden of travel and increased convenience. However, there were concerns about losing interpersonal contact and technical difficulties. None of the studies in this review included patients with kidney disease, and none included participants from under-served groups. However, under-served groups have specific characteristics such as high health-care burden and significant differences in how they respond to or engage with health-care interventions. Therefore, it is essential to better understand experiences of people living with kidney disease in receipt of remote care.
Currently, only two systematic review studies explore the factors influencing patients experience of remote consultations in kidney care (Blinkhorn, 2012;Lunney et al., 2018). However, these reviews focus primarily on the uptake of remote consultations to improve clinical health outcomes for those living with kidney disease. Despite the existing, albeit limited, evidence demonstrating the feasibility of remote consultations maintaining and even improving clinical health outcomes for patients living with kidney disease, there is little evidence to understand how patients experience and perceive remote consultations. Indeed, narrative reviews have discussed the potential applications of remote consultations for people living with kidney disease (Stauss et al., 2021). However, the impact of remote consultations and experiences of people living with kidney disease has not been systematically reviewed. Given this gap in the literature, a scoping review of the literature was undertaken to examine the available evidence. This scoping review aimed to explore the experiences and perspectives of people living with kidney disease toward remote consultations. Additionally, this scoping review aimed to map the range of literature on the topic to identify gaps that may inform future health-care practices and research.

METHODS
The current scoping review aimed to explore the experiences and perspectives of people living with kidney disease toward remote consultations in kidney care. The scoping review followed the five-stage methodological framework developed by Arksey and O'Malley (2005) and included (1) identifying the research question; (2) identifying the studies relevant to the research question; (3) study selection; (4) charting the data; (5) collating, summarising, and reporting of the result. This framework allowed the inclusion of various study designs and broader topics, such as telephone and video consultations, to be thoroughly investigated.

Search strategy
The inclusion of studies was limited to those about synchronous (i.e., video and telephone) remote consultations. specific key works were searched for the required data. The search strategy included a wide range of key works to increase the sensitivity and inclusiveness of the search (Table 2).

Study selection
The initial screening process identified 112 studies of which six were duplicates. Figure 1 illustrates the search collection and screening process using preferred reporting items for systematic reviews and meta-analyses (PRISMA) extension for the scoping reviews checklist (Tricco et al., 2018). After screening of titles, abstracts, and introductions, 44 were selected for full-text review with only 8 meeting all the inclusion criteria.

Data extraction
Study characteristics and information, such as publication year, study location, aim, design, sample size, and major findings, were documented and tabulated for the included studies (Table S3).

RESULTS
A total of eight studies published between August 2010 and August 2021 were included in this scoping review. Two studies used a cross-sectional design (Alshaer et al., 2020;Campbell et al., 2012), two used a mixedmethods design Qiu et al., 2021), and four used a qualitative design (Huuskes et al., 2021, Lunney et al., 2020Trace et al., 2020;Varsi et al., 2021). The studies were conducted in the United Kingdom, Canada, Australia, and Norway. Five common themes identified across the studies were (1) overall satisfaction with remote consultations, (2) benefits to patients, (3) barriers to remote consultations, (4) patient concerns, and (5) prerequisites for successful remote consultation.

Overall satisfaction with remote consultations
Participants overall satisfaction with remote consultations was reported in seven of the studies included in this review. Across three studies, participants reported high satisfaction with video consultations, stating they wanted to continue with remote healthcare services, and would also recommend the service to others (Lunney et al., 2020Varsi et al., 2021). Alshaer et al. (2020) found only 9% of participants rated the video appointment poorer than a face-to-face visit. While most patients (91%) did not express a compromise in the overall experience, rating it no different, better, or significantly better. Campbell et al. (2012) found that participants were satisfied with the session (76% strongly agreed), were able to present the same information as they would have in person (72% strongly agreed) and felt as confident about the doctor's assessment as they would with an in-person assessment (77% strongly agreed).
However, some patients reported that while there was nothing wrong with remote consultations, they simply preferred an in-person visit with the doctor. Qiu et al. (2021)

Convenience
The benefits of remote consultations for patients were identified in seven studies included in this review. The most widely reported benefit was the convenience of remote consultations (Alshaer et al., F I G U R E 1 Search collection and screening process using PRISMA extension 2020; Huuskes et al., 2021;Lunney et al., 2020;Qiu et al., 2021;Varsi et al., 2021). Participants reported that video consultations reduced the burden of appointment waiting time and time spent travelling. Moreover, the reduced burden of travel was further found to decrease travel time and costs associated with attending in-person consultations, such as transportation, parking and childcare. Varsi et al. (2021) further revealed participants perceived conducting consultations from the comfort of their own home as an added convenience. Patients reported feeling less stressed when attending a consultation from home rather than going to the hospital which came with feelings of anxiety and stress. Additionally, participants appreciated the flexibility of remote consultations, particularly not needing to cancel if they did not feel well enough to travel (Varsi et al., 2021). Alshaer and colleagues (2020) found that remote consultations were more convenient, with participants not having to take time off work/school or arrange childcare and reduced patients' reliance on caregivers. Huuskes and colleagues (2021) found that remote consultations interfered less with participants work as they no longer had to travel to or wait for clinic appointments. As such, participants reported feeling less guilt about disappointing their employer and felt they could better commit to their work.

Involvement in care
Two studies reported that participants perceived increased involvement with their healthcare as an added benefit of remote consultations. Trace and colleagues (2020) found that younger children enjoyed the novelty of using the computer and older children enjoyed the familiarity of screen-based conversations.
Furthermore, Trace et al. (2020) identified that the ability to screen-share during video consultations increased understanding of medical information and family engagement. Parents noted that there is no time to process the information in a face-to-face clinic.
However, screen-sharing enabled understanding of their child's healthcare, giving parents some relief and encouragement to continue dietary interventions. Moreover, screen-sharing allowed children to convene directly with the dietician rather than through a parent proxy by telephone. Huuskes et al. (2021) found that the increased responsibility for self-management required for remote consultations such as taking blood pressure, weight, and temperature, participants reported a sense of empowerment and readiness in their health care.

Patient safety
Three studies reported the element of safety for patients as benefit to remote consultations. According to Huuskes and colleagues (2021), patients felt that remote consultations enabled them to stay home and avoid the risk of being exposed to infections in the clinic. Qiu et al. (2021) revealed that all participants felt that remote consultation was a safe way to communicate with their physicians. Alshaer et al. (2020)

Privacy and confidentiality
Four of the reviewed studies identified privacy and confidentiality of remote consultations as a concern to patients. Huuskes et al. (2021) reported that the confidential nature of information sharing during consultations meant that some participants were not comfortable sharing sensitive information in their own homes or workplace and

Need for physical examination
Four of the studies reported the need for physical examination was perceived as concern for remote consultations. Qiu et al. (2021) reported that adolescents were more comfortable describing and showing their physician symptoms in-person, rather than trying to explain symptoms via a screen. In the study by Lunney et al. (2020) (Thiyagarajan et al., 2020) and people living with chronic diseases (Almathami et al., 2020). Almathami et al. (2020) also found that remote consultations were well received and accepted by patients, with the benefit of reduced time spent and money spent travelling being highly valued. In line with previous findings, it was found that remote consultations increase patients' involvement in their kidney care and engagement with medical information, but also patients described feeling safe (Leonardsen et al., 2020;Rahimpour et al., 2008;Rygh et al., 2012).
Although previous studies have found withdrawal from remote care due to nonadherence and technical difficulties with remote care in some disease settings (Cruz et al., 2014;Gorst et al., 2014), remote consultations have been widely welcomed by high-risk patients in the context of the COVID-19 pandemic (Boehm et al., 2020).
Based on our results, patients described technology as a significant barrier to remote consultations. Our findings described the challenges and disruptions from technology that frequently occurred, consistent with many previous findings (Donaghy et al., 2019;Greenhalgh et al., 2018;Sturesson & Groth, 2018). Despite technical challenges, patients continued to persevere with technology and remained enthusiastic about remote consultations.
Previous research has identified socioeconomic factors, education level and age are barriers to using technology for remote care (Kontos et al., 2014;Rosner et al., 2017). Therefore, it is possible that many of the participants within these studies were digitally literate and experienced technology users. Alternatively, previous research suggests that the perceived seriousness of patients' conditions can be an important factor influencing patients' willingness to use remote consultations, where lower use of remote consultations is associated with poorer health conditions (Mold & de Lusignan, 2015).
It was further found that patients experienced a loss of interpersonal interaction with remote consultations, which raised challenges in building a rapport with clinicians, communicating nonverbal cues and navigating sensitive conversations. The results from the current review underlined the perceived prerequisites for successful remote consultation. In line with previous research (Rubeis et al., 2018), we found that an established, trusting relationship between patient and physician was important for success. During the COVID-19 pandemic, it was reported that physicians preferred to conduct remote consultations via video rather than over the phone, as this helped establish a rapport with people living with diabetes (Quinn et al., 2020). Moreover, this study acknowledges that physicians require remote consultation training was required for physicians.
Despite the manifold potential benefits of remote consultations for patients, the long-term implementation of such practices demands careful consideration and evaluation of appropriateness and effectiveness for future kidney care.  Table 3. 3. Where possible, provide face-to-face consultations for first initial visit to build patient-practitioner rapport.

Strengths and limitations
4. Provide training for practitioners on how to conduct a remote consultation and communicate health information virtually.
5. Incorporate training on remote consultation into undergraduate medical and nursing curricula, and in junior doctor education programmes.
6. Prepare and provide an information sheet/resource for patients to prepare for remote consultations.
7. Ensure technical support/training is available to both clinicians and patients.
between desired and available digital health services (Chang et al., 2004). Remote care is an essential tool that could be leveraged to provide equitable access to kidney care worldwide. Patient involvement in development, implementation and utilisation of such solutions should be considered an integral part in health-care initiatives. Therefore, we suggest that remote care interventions for managing kidney disease should be codesigned with patients living with kidney disease from under-served groups to identify specific barriers and address individual needs for a more patient-centred approach to care.