J Telemed Telecare OnlineFirst, published on June 6, 2016 as doi:10.

1177/1357633X15626855

RESEARCH/Original Article

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Remote home management for chronic ! The Author(s) 2016
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DOI: 10.1177/1357633X15626855
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Ting He1,*, Xing Liu1,*, Ying Li2, Qiaoyu Wu1, Meilin Liu3
and Hong Yuan1,2

Abstract
Background: Remote home management is a new healthcare model that uses information technology to enhance patients’
self-management of disease in a home setting. This study is designed to identify the effects of remote home management on
patients with chronic kidney disease (CKD).
Methods: A comprehensive search of PubMed, MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials
was performed in January 2015. The reference listings of the included articles in this review were also manually examined.
Randomized controlled trials (RCTs) designed to evaluate the effects of remote home management on patients with CKD were
included.
Results: Eight trials were identified. The results of this study suggest that the quality of life (QOL) enabled by remote home
management was higher than typical care in certain dimensions. However, the effects of remote home management on blood
pressure (BP) remain inconclusive. The studies that assessed health service utilization demonstrated a significant decrease in
hospital readmission, emergency room visits, and number of days in the hospital. Another favorable result of this study is that
regardless of their gender, age or nationality, patients tend to comply with remote home management programs and the use of
related technologies.
Conclusions: The available data indicate that remote home management may be a novel and effective disease management
strategy for improving CKD patients’ QOL and influencing their attitudes and behaviors. And, relatively little is known about BP
and cost-effectiveness, so future research should focus on these two aspects for the entire population of patients with CKD.
Keywords
Chronic kidney disease, remote home management, quality of life, blood pressure

Date received: 12 October 2015; Date accepted: 17 December 2015

patients with CKD to understand their conditions and

Backgrounds
Chronic kidney disease (CKD) is a common long-term
condition that is frequently associated with a high preva-
lence and very high health costs.1 There are more than 70
million patients with CKD worldwide and, according to
estimates, the prevalence of CKD will increase as the
aging population increases dramatically. However,
although numerous advances have been made in the diag-
nosis and medical care of patients with CKD, significant
improvements in patients’ clinical conditions and long-
term survival have not been achieved. In addition, the
burden of treating and managing such patients is exacer-
bated by limited healthcare resources.2 A serious shortage
of healthcare personnel exists in many areas, especially in
developing countries, and there is no realistic prospect
that this situation will be resolved in the short term.3
Therefore, the management of patients with CKD
requires a fundamental change. Remote home manage-
ment, using information technology to enhance patients’
self-management of disease in a home setting, may help
improve their health status. Although previous reviews
have suggested that this new healthcare delivery model
is effective in treating hypertension, heart failure, diabetes,
and other chronic illnesses,4–6 studies of remote home
management in patients with CKD have been limited
and are controversial. Therefore, the objective of the pre-
sent paper was to perform a systematic review of pub-
lished evidence on the value of remote home
management for patients with CKD and provide a solid
1
Department of Cardiology, The Third Hospital of Xiangya, China
2
Center of Clinical Pharmacology, Central South University, China
3
Department of Gerontology, The First Hospital of Beijing University, China
*
These authors contributed equally to this work.
Corresponding author:
Hong Yuan, Center of Clinical Pharmacology (Department of Cardiology,
Hunan Research Center of Hypertension), The Third XiangYa Hospital
Central South University, 138 Tong-Zi-Po Road Changsha, Hunan410013,
People’s Republic of China.
Email: yuanhongxy3@163.com

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2 Journal of Telemedicine and Telecare 0(0)
foundation for medical decision-making and healthcare
reform.
Materials and methods
Literature search
We conducted a systematic review of the available litera-
ture adhering to the QUORUM guidelines and performed
meta-analyses of intervention studies.7 PubMed,
MEDLINE, Embase, and the Cochrane Central Register
of Controlled Trials (CENTRAL) were searched in
January 2015 by professional document retrieval person-
nel from the Xiang-Ya Medical Library of Central South
University using the following search terms: ‘telemedi-
cine,’ ‘telehealth,’ ‘telemonitoring,’ ‘ehealth,’ ‘mobile
health,’ ‘home health care,’ ‘home care services,’ ‘home-
base,’ ‘blood pressure measurement,’ ‘self measurement,’
‘renal insufficiency,’ ‘chronic,’ ‘hypertension,’ ‘high blood
pressure,’ ‘renal,’ ‘kidney,’ and ‘controlled clinical trial.’
Reference listings of relevant meta-analyses and reviews
were manually examined. There were neither language nor
data restrictions. All of the potentially relevant studies
were examined in full.
Selection criteria
Randomized controlled trials (RCTs) that investigated the
effect of remote home management on patients with CKD
were included in the study. The duration of the interven-
tion had to be at least four weeks to achieve clinically
meaningful outcomes. Only adult patients (518 years of
age) who satisfied the diagnosis criteria of CKD were eli-
gible to participate in the study. Additionally, we used the
latest report from repeat studies of the same or similar
content. We operationally defined remote home manage-
ment as any strategy of telemedicine application in CKD
patients in which there was a direct or indirect persona-
lized feedback information from a healthcare practitioner
to the patient about the forwarded clinical data, with a
traditional care group not using remote home manage-
ment. The strategies of telemedicine application included
in this review were computerized systems for information
exchange, video conferencing, and exchange of informa-
tion via telephone or other mobile devices, short message
service, or through the Internet.8
Quality assessment
The methodological quality and risk of bias were evalu-
ated by two reviewers in accordance with the standards of
the Cochrane Collaboration.9 The items were as follows:
random sequence generation, allocation concealment,
blinding of participants and personnel, blinding of out-
come assessment, incomplete outcome data, selective
reporting, and other biases, such as funding sources. All
of the items were assigned a value of ‘low risk,’ ‘high risk,’
or ‘unclear.’ Moreover, the intention-to-treat analysis
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(ITT) principle was used to evaluate the integrity of the
outcome data. The GRADE10 system was used to grade
the quality of evidence and the strength of the recommen-
dations. This system evaluates five primary domains for
each outcome: limitations of the study design and execu-
tion, inconsistency, indirectness, imprecision of results,
and publication bias.
Data extraction
Two reviewers who focused on CKD research extracted
data from the included studies based on methods (alloca-
tion, blinding, and follow-up duration), participants
(diagnosis, country, randomized number, age, gender, eth-
nicity, inclusion criteria, and exclusion criteria), interven-
tions (intervention duration and process of intervention)
and outcomes (quality of life; change from baseline in
mean BP and interdialytic weight; patient’s attitude; cost
and healthcare service utilization including readmission,
emergency room visits, and number of days in the hos-
pital). Correspondence with the authors of the included
studies was initiated as necessary. To determine the
change in BP and quality of life (QOL) for remote home
management compared to typical care, the difference in
the mean values, with 95% confidence intervals (CIs), was
calculated. Data from studies that expressed outcomes in
terms of p and F values, rather than mean and standard
deviation values, were transformed to estimates of mean
and standard deviation values according to the Cochrane
handbook.9 If there were discrepancies, all of the authors
reached a consensus by discussion. All of the obtained
data were carefully examined for accuracy.
Statistical analysis
The data from each included trial were analyzed using
Review Manager (RevMan, Version 5.3, Copenhagen:
The Nordic Cochrane Centre, The Cochrane Collaboration,
2014). The quantitative analysis was based on ITT prin-
ciples as much as possible. BP reductions and the score
of QOL were calculated before data pooling and were
subsequently combined. Mild, moderate, and severe het-
erogeneity were defined using I2 values of 25%, 50%, and
75%, respectively. If there was significant heterogeneity,
the random effects model was used. An evaluation of pub-
lication bias was planned if we had more than 10 studies,
but it was not assessed because of the small number of
studies.11 Values of p 4 0.05 were considered to be statis-
tically significant.
Results
Flow of included studies
A total of 2734 studies were identified by searching
PubMed, MEDLINE, Embase, and the Cochrane
Central Register of Controlled Trials. After removing
duplicate studies, 2334 abstracts were screened. A total
He et al.
Figure 1. Flow chart for eligible studies.
of 17 relevant full-text articles were assessed for eligibility,
of which eight trials fulfilled the inclusion criteria12–19
(Figure 1).
Study characteristics
Eight trials, which provided data on 648 patients,
were included in the systematic review. The numbers of
participants were 99, 120, 160, 47, 21, 57, 44, and 100.
The average age of the patients ranged from 46–68
years. Males tended to be more highly represented than
females. No trials reported ethnicity. One study was con-
ducted in Germany,17 one in Spain12 two in China,13,19
and the remainder of the studies were conducted in
the USA.14–16,18 In all except one study,18 the patients
were receiving replacement therapy including hemodialy-
sis, peritoneal dialysis and renal transplantation.
Five13,15,17–19 of the eight studies provided intervention
via telephone, either in the form of a call or a text mes-
sage; three studies12,14,16 provided intervention via tele-
vision or video-conferencing. The design, duration and
set-up of the trials were different, representing substantial
heterogeneity. Three trials15,17,18 reported BP changes
from baseline to endpoint, three trials4 reported changes
in QOL. Four trials12,14,16,19 reported that the healthcare
service utilization included emergency department visits,
readmission, and the number of days in the hospital;
among them, two trials12,14 reported the cost of interven-
tion. Two trials15,18 reported the patients’ attitude. The
data for QOL, BP, and their standard error were obtained
from tables; however, one study did not provide the mean
SD values for BP (Table 1).
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3
Ten trials20–29 examining the effect of remote home
management for patients with CKD were excluded. The
reasons for exclusion are reported in Table 2.
Risk of bias in the included studies
All of the trials were randomized; however, only two
trials13,19 described the generation of random sequencing.
Only one trial18 described the concealment of allocation.
None of the trials were double blinded, as determined by
the nature of the intervention. Five trials13–15,18,19 had
incomplete outcome data, which might have influenced
the results for QOL and BP. In addition, none of the
studies were affected by selective reporting or other
biases. Figures 2 and 3 illustrate the overall risks of bias
detected in the 8 included trials.
Quality of life and utilization of healthcare services
Two of three trials,13,19 according to the Kidney Disease
Quality of Life Short Form (KDQL-SF) scale, confirmed
a significant difference in certain dimensions of QOL.
Indeed, patients in the remote home management group
believed that they were receiving more staff encourage-
ment at six weeks (p ¼ 0.03) (Mean Difference (MD),
4.94; 95% CI, 0.42–9.46), and their pain was significantly
improved at six and 12 weeks (p ¼ 0.0009, 0.02).
However, the other aspects of QOL did not show a sig-
nificant difference. Sexual function and sleep exhibited sig-
nificant heterogeneity at six weeks (I2 ¼ 90%, 59%);
sexual function, quality of social interaction, sleep and
patient satisfaction demonstrated significant heterogeneity
 4

Table 1. Baseline characteristics of included studies (by first author and year).
Gallar, 200712 Chow, 201013 Berman, 201114 McGillicuddy, 201315 Minatodani, 201316 Neumann, 201317 Rifkin, 201318 Zhai, 201419

Country USA China, Hong Kong USA USA USA Germany USA China
Design Randomized Non- Randomized Non- Randomized Non- Randomized Non- Randomized Non- Randomized Non- Randomized Non- Randomized Non-
blinded blinded blinded blinded blinded blinded blinded blinded
Duration 8 months 6 weeks 21 months 3 months 3 years 3 months 6 months 3 months
Description of study Patients undergoing Chronic kidney dis- High-risk dialysis Renal transplant End-stage renal failure End-stage renal failure Veterans with stage 3 Chronic kidney dis-
population peritoneal dialysis ease undergoing patients recipients requiring requiring or greater chronic ease undergoing
peritoneal dialysis hemodialysis hemodialysis kidney disease and peritoneal dialysis
uncontrolled
hypertension
No. of patients 57 100 44 21 99 120 47 160
Men, n (%) 15 (60%) NR 26 (59%) NR NR 61 (51%) NR 79 (58%)
Age (years) 46.3 57 NR NR 60 560 450 55
Interventions Patients received A standardized 6- Remote technology A smart phone that Received home moni- Standard care sup- Physicians or pharma- A standardized 6-
alternately a week nurse- (video-conferen- received and trans- toring via remote plied with telemet- cist called to discuss week post-dis-
monthly teleconsul- initiated telephone cing) with RCN mitted encrypted technology (video ric weight the readings, pro- charge nurse-led
tation through tele- follow-up regi men physiological data conferencing) with monitoring which vide counseling, or telephone support
vision set. and delivered RCN oversight can sent the par- adjust medications intervention
reminders to meas- ameters to mobile as indicated by
ure BP using text phone. telephone
messaging
Outcomes Hospitalization rate, QOL (KDQL-SF) Health outcome Acceptability, adher- Health resource out- IWG, the average Data exchange, device QOL (KDQL-SF),

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cost (hospitalizations, ER ence to the proto- come measures ultra-filtration; BP acceptability, BP blood chemistry,
visits, number of cols medication (hospitalizations, ER complication con-
days hospitalized), adherence, BP visits, number of trol, readmission,
cost, QOL days hospitalized), clinic visit rates
Economic analysis,
Remote care
nurse–patient
contact

BP: blood pressure; ER: emergency room; IWG: inter-dialytic weight gain; KDQL-SF: Kidney Disease Quality of Life Short Form; NR: not reported; QOL: quality of life; RCN: remote care nurse.
Journal of Telemedicine and Telecare 0(0)
He et al. 5

Blood pressure (BP) and interdialytic weight

at 12 weeks (I2 ¼ 64%, 85%, 71%, and 66%, respectively)
(Tables 3 and 4). The other trial,14 which used the Short The analysis of the mean difference in BP from the trials
Form 36-Item Health Survey (SF-36) scale, a standard showed that the remote home management group had an
QOL instrument, were not included in the analysis increased systolic blood pressure (SBP) by 4.89 mm Hg
because they did not report the actual QOL score (95% CI, 2.13–11.91; p ¼ 0.14) and a reduced diastolic
values; thus, the result could not be pooled.
Additionally, the effect of remote home management
on the healthcare service utilization was reported in four
studies, which demonstrated a significant decrease in hos-
pital readmission, emergency room (ER) visits, and the
number of days in the hospital. The two articles that per-
formed cost analyses showed conflicting results, One
study16 showed that the cost of remote home management
was lower than traditional care management, whereas the
other study12 showed the opposite result.

Table 2. Characteristics of excluded studies.

Study, first author, year Reason for exclusion

Daelemans, 201420 Self-control design

Aberger, 201421 Self-control design
Scherpiber-de Haan, Intervention (family physician vs
201322 nephrologist) did not meet
inclusion criteria
Bernstein, 201023 Intervention (remote full-care
hemodialysis units and without
onsite nephrologist vs with on
site nephrologists) did not
meet inclusion criteria
Becker, 201024 Self-control design
Michael, 200925 This study is not a controlled
trial
Schulz, 200726 The data of this study is repeat
analysis by ‘‘Neumann 2013’’
Nakamoto, 200727 Self-control design
Nakamoto, 200428 Self-control design
Cargill, 200329 The patients of this study
included children Figure 3. Risk of bias summary according to recommendations
from the Cochrane Collaboration.

Figure 2. Risk of bias graph according to recommendations from the Cochrane Collaboration.

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6 Journal of Telemedicine and Telecare 0(0)

Table 3. Forest plot of comparison: Remote home management vs usual care: quality of life (six weeks).
Outcome measures MD Relative (95% CI) p Value I2

Symptom/problem 0.52 3.53–4.58 0.8 0

Effect of kidney disease 2.69 1.46–6.85 0.2 0
Burden of kidney disease 0 3.51–3.51 1 0
Work status 0.46 3.85–2.92 0.79 0
Cognitive function 1.87 2.89–6.63 0.44 0
Quality of social interaction 1.46 5.76–2.83 0.5 20%
Sexual function 2.8 8.47–2.87 0.33 90%
Sleep 1.19 6.23–3.84 0.64 59%
Social support 0.08 4.66–4.50 0.97 0%
Staff encouragement 1.26 5.79–3.28 0.59 0%
Patient satisfaction 0.58 3.14–4.30 0.76 0%
Physical functioning 1.04 5.36–3.29 0.64 0%
Role–physical 2.92 1.65–7.49 0.21 42%
Pain 8.59 3.52,13.66 0.0009a 0%
General health perception 2.03 2.18–6.25 0.34 0%
Emotional wellbeing 0.46 4.42–5.34 0.85 0%
Role-emotional 0.63 5.86–4.59 0.81 0%
Social function 3.22 2.08–8.52 0.23 0%
Energy/fatigue 2.6 2.40–7.60 0.31 0%
Overall health 1.59 3.08–6.26 0.5 0%

CI: confidence interval; MD: mean difference.

Table 4. Forest plot of comparison: Remote home management vs usual care: quality of life (12 weeks).
Outcome measures MD Relative (95% CI) p Value I2

Symptom/problem 0.61 4.53–3.31 0.76 0

Effect of kidney disease 2.8 1.21–6.81 0.17 0
Burden of kidney disease 1.35 2.26–4.95 0.46 0
Work status 0.01 3.37–3.36 1 0
Cognitive function 1.23 5.98–3.53 0.61 0
Quality of social interaction 2.42 6.71–1.88 0.27 64%
Sexual function 2 2.79–6.79 0.41 85%
Sleep 2.68 2.40–7.77 0.3 71%
Social support 2.64 7.04–2.12 0.29 0%
Staff encouragement 4.94 0.42–9.46 0.03a 0%
Patient satisfaction 0.72 2.99–4.22 0.7 66%
Physical functioning 3.1 6.90–0.69 0.11 0%
Role-physical 0.07 4.13–4.27 0.97 0%
Pain 0.28 1.17–11.39 0.02a 0%
General health perception 1.03 3.59–5.66 0.66 0%
Emotional wellbeing 0.24 4.99–4.51 0.92 0%
Role-emotional 0.75 6.04–4.55 0.78 0%
Social function 3.22 2.08–8.52 0.23 0%
Energy/fatigue 2.12 2.98–7.22 0.41 0%
Overall health 0.26 5.19–4.67 0.92 0%

CI: confidence interval; MD: mean difference.

a
p < 0.05, for differences between groups.

blood pressure (DBP) by 0.17 mm Hg (95% CI, 2.64– limited to small samples, studies involving patients requir-
2.30; p ¼ 0.41). However, neither result reached statistical ing dialysis demonstrated the ability of remote home man-
significance. Heterogeneity was observed among the trials agement to optimize interdialytic weight gain and reduce
(I2 ¼ 0%, 49%) (Figures 4 and 5). Moreover, although the ultra-filtration rate.

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He et al.
Figure 4. Forest plot of comparison: remote home management vs usual care: systolic blood pressure (SBP). CI: confidence interval; SD:
standard deviation.
Figure 5. Forest plot of comparison: remote home management vs usual care: diastolic blood pressure (DBP). CI: confidence interval; SD:
standard deviation.
Patients’ attitude
The impact of remote home management on patients’ atti-
tude was consistent across the trials included in this
review. In general, patients were willing to accept remote
home management as a self-management approach and
showed a positive attitude toward it. McGillcuddy
et al.15 demonstrated that the acceptability of patients’
participation was high (75%), and the intervention
group reported high overall satisfaction with mobile
phone-based programs (average score, 4.8/5 points;
Likert scale: one means strongly disagree and five means
strongly agree). Rifkin et al.18 showed a high-level satis-
faction with wireless blood pressure monitoring, and 96%
of the participants reported that they would like to con-
tinue using the device. Similarly, clinical physicians con-
sidered the device to be a highly acceptable intervention.
Publication bias
Our strategy employed a comprehensive search that
included conference papers. Our reviews included eight
RCTs, only five articles made a quantitative analysis.
According to the Cochrane Handbook for Systematic
Reviews9 and previous literature,30 the test for a funnel
plot only can be done when there are at least 10 studies
included in a meta-analysis. So we were unable to employ
a funnel plot to assess publication bias because of the
small number of eligible studies. However, the results
reported in the included RCTs were equivocal in favoring
remote home management and typical care. Hence, there
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7
does not appear to be a publication bias in this field of
interest.
Discussion
CKD is a worldwide public health problem that affects
millions of people in developed and developing countries.
In China alone, there are more than 119.5 million individ-
uals with CKD.31 The increasing number of patients with
CKD not only threatens public health but also substan-
tially increases the nation’s financial burden. Studies have
demonstrated that CKD is associated with increased hos-
pitalization, cardiovascular disease and mortality.
Moreover, CKD affects patients’ psychological health,
daily functioning, general well-being and social function-
ing, which are determinants of the patients’ QOL.32 Lower
scores of QOL are often associated with a higher risk of
developing end-stage kidney disease and all-cause mortal-
ity.33 Thus, there is great demand for patient-centered
comprehensive management to improve clinical outcomes
and maintain a desirable QOL. Recent studies have indi-
cated that the appropriate comprehensive management of
patients with CKD should not only provide proper medi-
cations, lifestyle instructions and relevant information
regarding CKD treatment but also motivate the patients
to accept the care.34 Some evidence demonstrates20,21
the beneficial effects of patient monitoring and timely
feedback, focused on a prominent role of patients’ self-
management with the supervision and support of health-
care professionals, bringing into focus the advances in
8 Journal of Telemedicine and Telecare 0(0)
wearable device and information technology, which can
be exploited to improve CKD management. Remote
home management can be a strategy for closer monitor-
ing, timely feedback and appropriate intervention to not
only achieve better clinical outcomes but also to increase
participation and improve QOL.
Quality of life and healthcare service utilization
The results showed that the QOL with remote home man-
agement was higher than the QOL with traditional care in
certain dimensions of the KDQL-SF which is the specific
instrument that focuses on problems associated with
CKD.35 Indeed, the study group patients were experien-
cing less physical pain and receiving more staff encourage-
ment than the traditional care group at six weeks or
12 weeks. In a previous review, researchers showed that
severe pain is prevalent among patients with CKD and
that more than 58% of CKD patients experience
pain and 49% of the patients rate their pain as moderate
or severe.36 Early detection of and intervention for pain
among patients with CKD can help substantially reduce
the financial burden associated with pain-related hospital
readmission and promote better QOL8 In remote
home management, the health data from the patient’s
feedback can assist healthcare professionals to treat pain
in a timely manner. In addition, such a patient-centered
and physician-supervised approach can reinforce self-
management and promote medication adherence for
pain reduction. Because of the unexpected adverse effects
and lack of desire to increase an already large pill burden,
patients with CKD showed poor compliance in taking
analgesic agents.37 Overall, the remote home management
approach can provide support and referral when patients
suffer from pain and can increase patients’ self-efficacy in
pain control.
The characteristics of interventions varied in each
study, including the duration, type and intensity of the
intervention; however, all showed positive effects on
health service utilization. Remote home management
results in a significant decrease in hospital readmissions,
ER visits, and number of days in the hospital, which is
consistent with the finding that the frequency of hospital
readmission has a negative correlation with QOL.38 In
addition to these factors, the type and duration of treat-
ment given can greatly influence the QOL in patients with
CKD. However, little is known concerning the QOL in
CKD patients before renal replacement therapy, and the
present analysis primarily included hemodialysis and peri-
toneal dialysis patients.
Blood pressure and weight
The significance of the effects of remote home manage-
ment on BP, which is important in lowering CKD mor-
bidity and mortality, remains inconclusive. In fact, remote
home management holds the potential to greatly enhance
CKD patients’ BP and self-management of disease. The
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results of this study, however, only revealed a declining
effect on DBP, and even an increasing trend on SBP, when
home remote management was compared to traditional
care. This finding is inconsistent for those with pre-
hypertension or hypertension alone, for whom remote
home management interventions significantly reduce BP
and improve adherence to medical therapy.39,40
Moreover, some self-control studies confirmed that home
blood pressure management combined with web-enabled
collaborative care results in better and faster BP con-
trol.20,21 There are a few potential reasons for why this
review failed to find any major effect of BP as a result of
this new healthcare delivery model. On the one hand, the
studies that focused on BP were not conducted using a
double-blind design. Although it was not possible to
blind participants to the intervention because of the
nature of the intervention involving patient self-manage-
ment, the research staff during study visits could be blinded
to treatment allocation. On the other hand, some of the
studies included in the review were not evaluated using
ITT analysis. The introduction of these potential biases
might affect the results of BP in the individual studies or
in the overall systematic review. Therefore, despite this
review’s failure to illustrate a robust response to interven-
tion by patients with CKD, we still believe that remote
home management holds promise for controlling BP. In
the future, more high-quality studies should be performed
to the effects of evaluate home management on BP.
It is worth noting that the interdialytic weight and ultra-
filtration rate, which are closely related to BP, were signifi-
cantly reduced. A likely reason is that the remote home
management patients received more dialysis staff encour-
agement. It has been well documented that patient-received
encouragement from the dialysis staff is an important
factor in improving fluid control adherence.41
Patients’ attitude
Favorable effects were observed in the patient’s attitude;
however, these effects were difficult to quantify given the
disparate methodologies employed. In general, regardless
of their gender, age or nationality, the patients complied
with remote home management programs and the use of
technologies, which means that patients were receptive to
remote home management as a self-management approach
and they demonstrated a positive attitude toward it. This
result is also reflected in the questionnaire, which is the
easiest way to measure patients’ attitudes, although both
the validity and reliability of this method are weak.42
Indeed, active patient participation plays an important
role in the effective management of CKD, which is a
long-lasting, frustrating and often progressive disease.
The GRADE analysis of the quality of included studies
showed that the strength of evidence for quality of life, BP
and interdialytic weight was ‘low’ due to the presence of
publication bias and/or the lack of ITT analysis.
Moreover, because of the presence of potential bias and
publication bias, the strength of evidence for healthcare
He et al. 9

our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the
Overall quality

GRADE Working Group grades of evidence. High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on
The basis for the assumed risk: aall of studies were non-blinded; bfailure to adhere to the intention to treat principle; cpublication of evidence is limited to one trial; dpublication of evidence is limited to two trials;
service utilization and patients’ attitude was ‘very low’

of evidence
(Table 5).

Very low

Very low
The present analysis has several limitations. Only one
Low

Low

Low
study used power calculations to determine sample sizes.13
Thus, the results should be interpreted with caution.
Dose response

Furthermore, most of the studies included in this review

focused on patients with end-stage renal failure and those
gradient

receiving dialysis but included only a limited number of

early-stage CKD patients; thus, the results cannot be gen-
No

No

No

No

No
eralized for the entire population of patients with CKD.
confounding would

Conclusion
change effect

The available data indicate that remote home manage-

Plausible

ment may be a novel and effective disease management

No

No

No

No

No

strategy for improving the QOL of patients with CKD

and influencing their attitudes and behaviors. However,
effect
Large

the present studies are all small sample research and

No

No

No

No

No

have some potential bias, so the large-scale multi-site

effectiveness RCTs are needed to improve the persuasive-
Strongly suspectedd

Strongly suspectede
Strongly suspectedc
Table 5. GRADE analysis: Remote home management vs usual care, outcome for chronic kidney disease (CKD) patients.

ness of the evidence and provide support for implementa-

tion of the research. And, relatively little is known about
Publication

blood pressure and cost-effectiveness, so future research

should focus on these two aspects for the entire popula-
bias

No

No

tion of patients with CKD. Additionally, using different

mobile technologies as well as different aesthetic design
may provide important insights into the scope of remote
Imprecision

home management’s potential benefits.

No

No

No

No

No

Declaration of conflicting interests

The authors of this manuscript state that they do not have any
Indirectness

conflict of interests and nothing to disclose.

No

No

No

No

No

Funding
The author(s) disclosed receipt of the following financial support
Inconsistency

for the research, authorship, and/or publication of this article:

the study was supported by the National Natural Science
Foundation of China (no. 81273594), the National Science and
No

No

No

No

No

Technology Major Projects (no. 2012ZX0903014001), the

estimate. Very low quality: We are very uncertain about the estimate.

National Key Technology R&D Program (no. 2012BAI37B05),

and the Project of Technology Department of Hunan Province
Very seriousa,b

Very seriousa,b

Very seriousa,b
Very seriousa

(no. 2013TZ2014).
Risk of bias

Seriousa,b

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