7. PROJECT SUMMARY The 60 million rural dwellers across the United States are older, more likely to live in poverty, and more likely to be either underinsured or uninsured compared to their urban counterparts. Moreover, the 240,000 rural patients with end stage kidney disease (ESKD) have less access to nephrology care, are less likely to finish pre-kidney transplant evaluation, and are less likely to undergo kidney transplantation. Telehealth is uniquely positioned to overcome geographic barriers of rural America by capitalizing on electronic information and telecommunication technologies. Yet telehealth is underutilized among rural patients in general, and little is known about how geography, resources, and distance to healthcare facilities contribute to access to care, outcomes, and quality of life for rural patients with ESKD. A comprehensive study of utilization, cost-effectiveness, and patient and provider preferences would be an important step in expanding telehealth policies specifically aimed to care for the rural ESKD population. We propose the following specific aims: (1) to assess the costs, utilization, and outcomes associated with telehealth for rural patients with ESKD; (2) to compare telehealth provision of ESKD care to standard in-office care in the rural ESKD population using model-based cost-effectiveness analysis; and (3) to understand facilitators and barriers of using telehealth from the perspective of patients and providers. A detailed training plan for Joel T. Adler, MD, MPH, is outlined in this proposal. In brief, it includes in-depth coursework to extend and expand Dr. Adler’s research skills, a practicum experience with the RURAL (Risk Underlying Rural Areas Longitudinal) Cohort study in the southern rural United States, and a mentorship plan jointly prepared by the principal investigator and a team with expertise in kidney disease, health services research, qualitative research, cost-effectiveness analysis, and the mentorship of junior clinician-scientists. This will help the candidate meet the following career goals: (1) gain state of the art expertise in large claims database, geographic information systems, cost-effectiveness, and qualitative research, (2) apply for and obtain R01 grant funding, and (3) transition to academic independence. When completed, Dr. Adler will have learned the perspectives of rural patients with EKSD and providers on telehealth that will be methodically crucial in designing pilot studies that inform R01 proposals to increase accessibility and utilization of telehealth on a population-health level for rural patents with ESKD. These efforts will culminate in a comprehensive understanding of the role of telehealth in caring for rural patients with ESKD by economic assessment of its utilization, a cost-effectiveness analysis for implementation on a wider scale, and learning how these align with patient and provider preferences to inform future policy regarding telehealth utilization and reimbursement.

8. PROJECT NARRATIVE Rural patients with end stage kidney disease (ESKD) suffer from disparities and limited access to home dialysis and kidney transplantation. Telehealth, recently brought to the forefront by the COVID-19 pandemic, represents a strategy to improve access to quality nephrology care and transplantation for rural patients with ESKD. The goal of this project is to understand the costs, benefits, and utilization of telehealth in the rural population with ESKD and to use this information to improve patient quality of life and access to care.