This document discusses reducing the environmental impact of caring for patients with kidney disease. It presents a position statement from the Italian Society of Nephrology with 10 initial actions focused on dialysis management: 1) reducing the need for dialysis through conservative strategies; 2) limiting drugs and favoring lifestyle/diet approaches; 3) encouraging reuse of hospital materials; 4) recycling paper and glass; 5) recycling non-contaminated plastic; 6) reducing water usage; 7) reducing energy usage; 8) including environmental criteria when evaluating dialysis machines; 9) properly sorting contaminated and non-contaminated waste; 10) considering environmental impacts in facility construction. The statement aims to increase awareness and coordinate industry/social interactions to
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sorella terra
1. Green Nephrology, Ecodialisi: parole o proposte?
Laudato si’, mi’ Signore, per sora nostra matre Terra, la quale ne sustenta et governa, et
produce diversi fructi con coloriti flori et herba
2. “La sfida urgente di proteggere la nostra casa
comune comprende la preoccupazione di unire tu5a
la famiglia umana nella ricerca di uno sviluppo
sostenibile e integrale, poiché sappiamo che le cose
possono cambiare.”
.”
3. Ques% problemi sono in%mamente lega% alla cultura dello scarto, che colpisce tanto
gli esseri umani esclusi quanto le cose che si trasformano velocemente in spazzatura.
Rendiamoci conto, per esempio, che la maggior parte della carta che si produce
viene ge<ata e non riciclata.
Sten%amo a riconoscere che il funzionamento degli
ecosistemi naturali è esemplare: le piante sinte%zzano
sostanze nutri%ve che alimentano gli erbivori; ques% a loro
volta alimentano i carnivori, che forniscono importan%
quan%tà di rifiu% organici, i quali danno luogo a una nuova
generazione di vegetali.
4. Then there is another viewpoint, not
just a question of ethics but a
question of our own survival. The
environment is very important not
only for this generation but also for
future generations. If we exploit the
environment in extreme ways, even
though we may get some money or
other benefit from it now, in the long
run we ourselves will suffer and
future generations will suffer. (…)
When they change dramatically, the
economy and many other things
change as well. So this is not merely
a moral question but also a question
of our own survival.
5. … The free-rider problem is well-known to
generate the “tragedy of commons”, as
illustrated by a myriad of case studies in
other realms. When herders share a common
parcel of land on which their herds graze,
overgrazing is a standard outcome, because
each herder wants to reap the private benefit
of an additional cow without taking account
of the fact that what he gains is matched by
someone else’s loss. Similarly, hunters and
fishers do not internalize the social cost of
their catches; overhunting and overfishing
led to the extinction of species, from the
Dodo of the island of Mauritius to the bears
of the Pyrenees and of the buffalos of the
Great Plains.
6. rsta.royalsocietypublishing.org
Research
Cite this article: Stahel WR. 2013 Policy for
material efficiency—sustainable taxation as a
departure from the throwaway society. Phil
Trans R Soc A 371: 20110567.
http://dx.doi.org/10.1098/rsta.2011.0567
One contribution of 15 to a Discussion Meeting
Issue ‘Material efficiency: providing material
services with less material production’.
Subject Areas:
materials science
Keywords:
sustainable taxation, circular economy,
regional job creation, caring, reuse,
service-life extension
Author for correspondence:
Walter R. Stahel
e-mail: walter_stahel@genevaassociation.org
Policy for material
efficiency—sustainable
taxation as a departure from
the throwaway society
Walter R. Stahel
7 chemin des Vignettes, Conches 1231, Switzerland
The present economy is not sustainable with
regard to its per capita material consumption. A
dematerialization of the economy of industrialized
countries can be achieved by a change in course,
from an industrial economy built on throughput
to a circular economy built on stock optimization,
decoupling wealth and welfare from resource
consumption while creating more work. The business
models of a circular economy have been known since
the mid-1970s and are now applied in a number of
industrial sectors. This paper argues that a simple
and convincing lever could accelerate the shift to a
circular economy, and that this lever is the shift to a
tax system based on the principles of sustainability:
not taxing renewable resources including human
labour—work—but taxing non-renewable resources
instead is a powerful lever. Taxing materials and
energies will promote low-carbon and low-resource
solutions and a move towards a ‘circular’ regional
economy as opposed to the ‘linear’ global economy
requiring fuel-based transport for goods throughput.
In addition to substantial improvements in material
and energy efficiency, regional job creation and
national greenhouse gas emission reductions, such a
change will foster all activities based on ‘caring’, such
as maintaining cultural heritage and natural wealth,
health services, knowledge and know-how.
1. Introduction
Previous patterns of growth have brought
increased prosperity, but through intensive
and often inefficient use of resources. The
role of biodiversity, ecosystems and their
services is largely undervalued, the costs of
waste are often not reflected in prices, current
c
⃝ 2013 The Author(s) Published by the Royal Society. All rights reserved.
on March 27, 2016
http://rsta.royalsocietypublishing.org/
Downloaded from
10. Posi%on statement: outline: clinics
Towards personalised, non only pharmacologic approaches.
• Nutritional management in all CKD stages (healthy
eating habits, retarding dialysis, maintaining
nutritional status).
• Physical activity (idem plus reducing the pill
burden, improving quality of life).
• Choice of RRT; development of home dialysis;
implementation of incremental and tailored
schedules; optimisation of the access to kidney
transplantation (reducing the burden of dialysis,
reducing costs).
13. ridurre i bisogni, senza ridurre i risultati…
“Globalization was purported to be the rising tide that
would lift all boats. However, the reality has been that it
lifted the big boats but tended to sink or swamp many
smaller ones”, Margaret Chan, World Conference on
Social Determinants of Health, 2011 (REF.1
).
Healthy people, living healthy lives on a healthy and
peaceful planet — these are the ultimate objectives of the
17 Sustainable Development Goals (SDGs), which were
formally adopted by all United Nations member states
in 2015, to be achieved by 2030 (REF.2
). The SDGs high-
light that achieving health and well-being for all requires
a robust, multisectoral approach.
Kidney disease is often a consequence of, or is exacer-
bated by, the lack of access to primary health care, early
diagnosis and essential medications. Consequently,
kidney disease disproportionately affects vulnerable
populations and exacerbates poverty. Kidney dysfunc-
tion is also associated with a high cost of care and is a
major contributor to morbidity and mortality, although
this effect is often obscured by its comorbid diseases3
.
Approximately 850 million people worldwide are esti-
mated to have kidney disease, including chronic kidney
disease (CKD), acute kidney injury (AKI) and kidney
failure, for which patients require kidney replacement
therapy (KRT) — dialysis or kidney transplantation —
for survival4
. Lack of access to dialysis has long been a
reality in low-income countries (LICs), but its impact has
now been dramatically highlighted even in high-income
countries (HICs), owing to critical shortages of dialysis
equipment and staff during the coronavirus disease 2019
(COVID-19) pandemic5
. CKD is the leading cause of
catastrophic health expenditure (that is, out-of-pocket
expenditure on health above 40% of household income
that further impoverishes the household) worldwide6
.
Global mortality from kidney disease might be as high
as 5 million annually, given the widespread lack or
limited access to life-saving KRT3,7,8
. CKD is projected
to become the world’s fifth leading cause of death by
2040 (REF.9
).
The recognition that health is key to maximizing our
individual capabilities underscores the importance of
ensuring that the SDGs do not become perpetual tar-
gets but instead become realized goals, leaving no one
behind10
(BOX 1). In this Review, we outline the relevance
Sustainable Development Goals
relevant to kidney health: an update
on progress
Valerie A. Luyckx 1,2,3 ✉, Ziyad Al-Aly 4,5
, Aminu K. Bello6
, Ezequiel Bellorin-Font7
,
Raul G. Carlini8
, June Fabian 9
, Guillermo Garcia-Garcia 10
, Arpana Iyengar11
,
Mohammed Sekkarie12
, Wim van Biesen 13
, Ifeoma Ulasi14
, Karen Yeates15
and
John Stanifer16
Abstract | Globally, more than 5 million people die annually from lack of access to critical
treatments for kidney disease — by 2040, chronic kidney disease is projected to be the fifth
leading cause of death worldwide. Kidney diseases are particularly challenging to tackle because
they are pathologically diverse and are often asymptomatic. As such, kidney disease is often
diagnosed late, and the global burden of kidney disease continues to be underappreciated. When
kidney disease is not detected and treated early, patient care requires specialized resources that
drive up cost, place many people at risk of catastrophic health expenditure and pose high
opportunity costs for health systems. Prevention of kidney disease is highly cost-effective but
requires a multisectoral holistic approach. Each Sustainable Development Goal (SDG) has the
potential to impact kidney disease risk or improve early diagnosis and treatment, and thus reduce
the need for high-cost care. All countries have agreed to strive to achieve the SDGs, but progress
is disjointed and uneven among and within countries. The six SDG Transformations framework
can be used to examine SDGs with relevance to kidney health that require attention and reveal
inter-linkages among the SDGs that should accelerate progress.
✉e-mail: Valerie.luyckx@
uzh.ch
https://doi.org/10.1038/
s41581-020-00363-6
REVIEWS
NATURE REVIEWS | NEPHROLOGY VOLUME 17 | JANUARY 2021 | 15
SUSTAINABLE DEVELOPMENT GOALS AND KIDNEY DISEASE
of the population has routine access to diagnostic tests
for kidney disease, including routine blood and urine
tests67
(FIG.2).
In 2017, a global survey reported that haemodialysis
was available in over 90% of countries68
. However, access
to and distribution of KRT across nations remains highly
inequitable and is often dependent on out-of-pocket
expenditure and access to private facilities in LICs.
Chronic peritoneal dialysis was available in over 90% of
upper-middle-income countries and HICs, in contrast
to 64% of LMICs and 35% of LICs68
. Acute peritoneal
dialysis had the lowest availability globally. Over 90% of
upper-middle-income countries and HICs offered kid-
ney transplantation, with over 85% of these countries
reporting both living and deceased donor programmes.
tion of risk factors and disease burdens, achievement of
universal health coverage (UHC) and delivery of quality
health care.
Poverty. Poverty (SDG 1) impacts how and where indi-
viduals live, their food choices, access to education,
employment opportunities, access to technology and
innovations, and their knowledge and exercise of their
rights70
. The proportion of people living in extreme pov-
erty(thatis,livingon<US$1.90aday)declinedfrom36%
in 1990 to 8.6% in 2018; however, the rate of decline has
slowed2
. Importantly, 8% of employed people live below
the poverty line, which reflects unjust working condi-
tions. More women than men live in poverty, and pov-
erty rates are higher in rural and conflict-affected areas.
Kidney health
in children
• Child rights
• Child advocacy
• Paediatric bioethics
• Regulations and policies
• Antenatal screening
• Genetic counselling
• Safe pregnancy
• Safe delivery
• Optimal maternal nutrition
• Maternal health
• Nutrition
• Education
• Equity
• Safety
• Low birthweight
• Prematurity
• Intrauterine
growth retardation
• Neonatal acute
kidney injury
• Adolescent health
• Self-care
• Sexual and
reproductive
education
• Distance to health centre
• Resources, infrastructure and supplies
• Referral system and continuity of care
• Lack of universal health coverage
• Out-of-pocket expenditure
• Catastrophic expenditure
• Safe homes
• Climate
• Sanitation
• Safe water
• Vulnerability to
infections and toxins
• Stunting
• Wasting
• Failure to thrive
• Obesity and overweight
• Nutritional deficiencies
• Family structure
• Socioeconomic status
• Racism
• Education
• Cultural factors
• Social habits
• Child education
• Health awareness
• Safety measures
Fig. 1 | Multiple structural factors influence kidney health in children.Conditionsexperiencedduringfetallifeandearly
childhoodaffectthephysicalandpsychosocialdevelopmentofchildren.Theeffectsoftheseconditionspersistthroughout
the life course and influence an individual’s future health and that of their children. Achievement of the Sustainable
Development Goals (SDGs) is urgent to enable each child to maximize their own capabilities and to improve the health
of future generations. Poverty has an overarching impact on child health and well-being. Children require a safe home
and school environment, access to healthy food, good education, freedom from forced labour and access to recreational
time and space to thrive and grow up healthy. Moreover, healthy and educated mothers have healthier children.
NATURE REVIEWS | NEPHROLOGY VOLUME 17 | JANUARY 2021 | 21
16. Journal of
Clinical Medicine
Concept Paper
Dialysis Reimbursement: What Impact Do Different
Models Have on Clinical Choices?
Giorgina Barbara Piccoli 1,2,* , Gianfranca Cabiddu 3 , Conrad Breuer 4, Christelle Jadeau 5,
Angelo Testa 6 and Giuliano Brunori 7
1 Department of Clinical and Biological Sciences, University of Torino Italy, 10100 Torino, Italy
2 Nephrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France
3 Nephrology, Brotzu Hospital, 09100 Cagliari, Italy; gianfranca.cabiddu@tin.it
4 Direction, Centre Hospitalier Le Mans, 72000 Le Mans, France; cbreuer@ch-lemans.fr
5 Centre de Recherche Clinique, Centre Hospitalier Le Mans, 72000 Le Mans, France; cjadeau@ch-lemans.fr
6 Association ECHO, 44000 Nantes, France; atesta@echo-sante.com
7 Nefrologia, Ospedale di Trento, 38100 Trento, Italy; gcbrunori@hotmail.com
* Correspondence: gbpiccoli@yahoo.it; Tel.: +33-669-733-371
Received: 12 January 2019; Accepted: 21 February 2019; Published: 25 February 2019
!"#!$%&'(!
!"#$%&'
Abstract: Allowing patients to live for decades without the function of a vital organ is a medical
miracle, but one that is not without cost both in terms of morbidity and quality of life and in economic
terms. Renal replacement therapy (RRT) consumes between 2% and 5% of the overall health care
expenditure in countries where dialysis is available without restrictions. While transplantation is
the preferred treatment in patients without contraindications, old age and comorbidity limit its
indications, and low organ availability may result in long waiting times. As a consequence, 30–70%
of the patients depend on dialysis, which remains the main determinant of the cost of RRT. Costs
of dialysis are differently defined, and its reimbursement follows different rules. There are three
main ways of establishing dialysis reimbursement. The first involves dividing dialysis into a series of
elements and reimbursing each one separately (dialysis itself, medications, drugs, transportation,
hospitalisation, etc.). The second, known as the capitation system, consists of merging these elements
in a per capita reimbursement, while the third, usually called the bundle system, entails identifying a
core of procedures intrinsically linked to treatment (e.g., dialysis sessions, tests, intradialyitc drugs).
Each one has advantages and drawbacks, and impacts differently on the organization and delivery
of care: payment per session may favour fragmentation and make a global appraisal difficult; a
correct capitation system needs a careful correction for comorbidity, and may exacerbate competition
between public and private settings, the latter aiming at selecting the least complex cases; a bundle
system, in which the main elements linked to the dialysis sessions are considered together, may
be a good compromise but risks penalising complex patients, and requires a rapid adaptation to
treatment changes. Retarding dialysis is a clinical and economical goal, but the incentives for
predialysis care are not established and its development may be unfavourable for the provider.
A closer cooperation between policymakers, economists and nephrologists is needed to ensure a high
quality of dialysis care.
Keywords: dialysis reimbursement; costs; renal replacement therapy; incremental dialysis;
predialysis care
1. Introduction
Renal replacement therapy (RRT) is a life-saving, long-lasting, expensive treatment. In Europe,
Japan, the United States and Canada, about one person in 1000 is presently alive thanks to dialysis or
J. Clin. Med. 2019, 8, 276; doi:10.3390/jcm8020276 www.mdpi.com/journal/jcm
ridurre i bisogni, senza ridurre i risultati…
22. la medicina di precisione si adatta bene alla dialisi
incrementale... che può anche essere “decrementale”
CURRENT
OPINION Precision medicine approach to dialysis including
incremental and decremental dialysis regimens
Mariana Murea
Purpose of review
Conventional standardization of haemodialysis for treatment of end-stage kidney disease (ESKD) is
predicated upon the fixed construct of one disease stage and one patient category. Increasingly
recognized are subgroups of patients for whom less-intensive haemodialysis, such as incremental or
decremental haemodialysis, could be employed.
Recent findings
Almost 30% of patients with incident ESKD have clinical and residual kidney function (RFK) parameters that
could accommodate less-intensive haemodialysis. In one study, patients with incident ESKD and substantial
RKF treated with low-dose haemodialysis had similar mortality rate as those treated with standard-dose
haemodialysis, adding to the evidence that endogenous kidney function – when present – can complement
less-intensive haemodialysis schedules. Hazards related to incremental haemodialysis include insidious
development of fluid overload and higher rates of fluid removal. Finally, deintensification of haemodialysis
treatment could be employed in patients with ESKD who seek conservative care.
Summary
A shift in approach to ESKD from a dichotomous frame – disease presence versus absence – to stages of
dialysis-dependent kidney disease, each stage associated with attuned haemodialysis intensity, has been
proposed. Haemodialysis standardization and personalization – often considered mutually exclusive – can
be combined in incremental haemodialysis. Data from ongoing and future randomized clinical trials,
comparing less-intensive with standard haemodialysis schedules, are required to change practice.
Keywords
clinical trials, decremental, end-stage kidney disease, haemodialysis, incremental
INTRODUCTION
End-stage kidney disease (ESKD) is marked by initi-
ation of kidney replacement therapy of which
chronic haemodialysis is the most common form
of dialysis therapy in the USA and other developed
countries. In its fundamental approach, the treat-
ment of patients with ESKD with chronic haemo-
dialysis has five main components: dialysis
frequency, treatment time per dialysis session, con-
trol of uremic symptoms, control of volume status
and management of metabolic imbalances. Among
these components and boxed by clinical practice
guidelines and reimbursement policies, providers
have little room to edit the haemodialysis pro-
gramme, in spite of the fact that many elements
of haemodialysis prescription (e.g. lower treatment
frequency, ultrafiltration rate, treatment time, dial-
ysate electrolyte concentrations) have not been val-
programme, equally prescribed to patients who
transition from chronic kidney disease to ESKD
(incident dialysis) and those with long-term ESKD
(prevalent dialysis). This ‘one-size-fits-all’ approach
to treating patients with ESKD is the norm in many
developed countries, even though some patients,
due to disease heterogeneity or by choice, might
fare better with different haemodialysis treatment
programs. Exemplary haemodialysis treatment
doses [i.e. minimum delivered single pool Kt/Vurea
(spKt/Vurea) !1.2 and urea reduction ratio (URR)
!65%] are the benchmark in all dialysis
Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
Correspondence to Mariana Murea, MD, Department of Internal Medi-
cine – Section on Nephrology,Wake Forest School of Medicine, Medical
Center Boulevard, Winston-Salem, NC 27157-1053, USA.
Tel: +1 336 716 4650; fax: +1 336 716 4318;
REVIEW
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KEY POINTS
! There is significant heterogeneity among patients with
ESKD; a shift from ‘one-size-fits-all’ approach to
haemodialysis therapy to ‘stage-based’ approach has
been proposed to tailor haemodialysis by
patient subgroups.
! At least one-third of patients with incident ESKD have
substantial RKF; these patients might not derive
additional benefit from being treated with standard
haemodialysis as opposed to less-
intensive haemodialysis.
! Patients treated with reduced-frequency haemodialysis
can develop insidious volume overload and be exposed
to high rates of fluid removal; adjuvant pharmacologic
therapy and timely adjustment in haemodialysis
prescription are of paramount importance.
! Combining standardized and personalized care in well
selected subgroups of patients with ESKD might
surmount some of the challenges of incremental HD.
! Multicentre clinical trials on comparative effectiveness
between less-intensive and standard haemodialysis
schedules are required to change current practice.
Novel therapeutic approaches in nephrology and hypertension
ridurre i bisogni, senza ridurre i risulta9…
23. Esiste probabilmente spazio per aumentare la dialisi
incrementale: l’esperienza di Le Mans è riassunta
così : periodo 2017-2021
DP : 18.6% dei nuovi pazienti
Tutti hanno iniziato in dialisi peritoneale
incrementale;
Tutti i pazienti che hanno iniziato la DP erano seguiti
in precedenza; 80% erano seguiti nell’unità di follow-
up “intensivo” UIRAV
ridurre i bisogni, senza ridurre i risultati…
24. Le Mans, emodialisi: periodo 2017-2021
105 pazienti iniziano
l’emodialisi in maniera
“non standard” :
incrementale (90) e
decrementale (15).
Solo 53 su 158 iniziano
e continuano in dialisi
trisettimanale.
ridurre i bisogni, senza ridurre i risultaG…
25. “i giochi sono fatti” nel periodo pre-dialisi:
All patients who started on PD started with incremental schedles; all
were followed previously, 80% in UIRAV
PD prevalence: 18.6% of new cases
ridurre i bisogni, senza ridurre i risultati…
28. la “riscoperta” dell’a0vità fisica ada4ata al paziente.
Original Investigation
Exercise Training in Adults With CKD: A Systematic Review and
Meta-analysis
Susanne Heiwe, RPT, PhD,1,2,3
and Stefan H. Jacobson, MD, PhD1,4
Background: Whether exercise can affect health outcomes in people with chronic kidney disease (CKD)
and what the optimal exercise strategies are for patients with CKD remain uncertain.
Study Design: Systematic review and meta-analysis of randomized controlled trials.
Setting & Population: Adults with CKD stages 2-5, dialysis therapy, or a kidney transplant.
Selection Criteria for Studies: Trials evaluating regular exercise training outcomes identified by searches
in Cochrane CENTRAL, MEDLINE, EMBASE, CINAHL, Web of Science, BIOSIS, PEDro, AMED, AgeLine,
PsycINFO, and KoreaMed, without language restriction.
Intervention: Regular exercise training for at least 8 weeks.
Outcomes: Vary by study but could include aerobic capacity, muscular functioning, cardiovascular function,
walking capacity, and health-related quality of life. Treatment effects were summarized as standardized
difference with 95% CIs using random-effects meta-analysis.
Results: 41 trials (928 participants) comparing exercise training with sham exercise or no exercise were
included; overall, improved aerobic capacity, muscular functioning, cardiovascular function, walking capacity,
and health-related quality of life were associated with various exercise interventions, although the
preponderance of data were for dialysis patients and used aerobic exercise programs.
Limitations: Unclear or high risk of bias in 32% of the trials, few trial data concerning resistance training,
and limited data for several important outcomes.
Conclusions: Regular exercise training generally is associated with improved health outcomes in in-
dividuals with CKD. Correctly designed exercise rehabilitation may be an effective part of care for adults with
CKD. Future studies should examine longer term outcomes and strategies to translate exercise done in a
supervised setting to the home setting for broader applicability.
Am J Kidney Dis. 64(3):383-393. ª 2014 by the National Kidney Foundation, Inc.
INDEX WORDS: Kidney disease, chronic; exercise; physical fitness; exercise training; systematic reviews;
meta-analysis.
ridurre i bisogni, senza ridurre i risultati…
32. Ridurre gli spostamenti: una COVID-lesson?
la medicina a distanza: ecologica o spersonalizzante?
Carbon Footprint of Telemedicine Solutions -
Unexplored Opportunity for Reducing Carbon Emissions
in the Health Sector
Åsa Holmner1
*, Kristie L. Ebi2,4
, Lutfan Lazuardi3
, Maria Nilsson4
1 Department of Radiation Sciences, Umeå University, Umeå, Sweden, 2 ClimAdapt, LLC, Seattle, Washington, United States of America, 3 Department of Public Health,
Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia, 4 Department of public health and clinical medicine, epidemiology and global health, Umeå
University, Umeå, Sweden
Abstract
Background: The healthcare sector is a significant contributor to global carbon emissions, in part due to extensive travelling
by patients and health workers.
Objectives: To evaluate the potential of telemedicine services based on videoconferencing technology to reduce travelling
and thus carbon emissions in the healthcare sector.
Methods: A life cycle inventory was performed to evaluate the carbon reduction potential of telemedicine activities beyond
a reduction in travel related emissions. The study included two rehabilitation units at Umeå University Hospital in Sweden.
Carbon emissions generated during telemedicine appointments were compared with care-as-usual scenarios. Upper and
lower bound emissions scenarios were created based on different teleconferencing solutions and thresholds for when
telemedicine becomes favorable were estimated. Sensitivity analyses were performed to pinpoint the most important
contributors to emissions for different set-ups and use cases.
Results: Replacing physical visits with telemedicine appointments resulted in a significant 40–70 times decrease in carbon
emissions. Factors such as meeting duration, bandwidth and use rates influence emissions to various extents. According to
the lower bound scenario, telemedicine becomes a greener choice at a distance of a few kilometers when the alternative is
transport by car.
Conclusions: Telemedicine is a potent carbon reduction strategy in the health sector. But to contribute significantly to
climate change mitigation, a paradigm shift might be required where telemedicine is regarded as an essential component
of ordinary health care activities and not only considered to be a service to the few who lack access to care due to
geography, isolation or other constraints.
Citation:Holmner Å, Ebi KL, Lazuardi L, Nilsson M (2014) Carbon Footprint of Telemedicine Solutions - Unexplored Opportunity for Reducing Carbon Emissions in
the Health Sector. PLoS ONE 9(9): e105040. doi:10.1371/journal.pone.0105040
Editor:Igor Linkov, US Army Engineer Research and Development Center, United States of America
33. la medicina a distanza: ecologica o spersonalizzante?
Future Healthcare Journal 2021 Vol 8, No 1: e85–91 REVIEW
PROCESS AND SYSTEMS Does telemedicine reduce the carbon
footprint of healthcare? A systematic review
Authors: Amy Purohit,A
James SmithB
and Arthur HibbleC
In the rapidly progressing field of telemedicine, there is
a multitude of evidence assessing the effectiveness and
financial costs of telemedicine projects; however, there is
very little assessing the environmental impact despite the
increasing threat of the climate emergency. This report
provides a systematic review of the evidence on the carbon
footprint of telemedicine. The identified papers unanimously
report that telemedicine does reduce the carbon footprint
of healthcare, primarily by reduction in transport-associated
emissions. The carbon footprint savings range between
0.70–372 kg CO2e per consultation. However, these values are
highly context specific. The carbon emissions produced from
the use of the telemedicine systems themselves were found
to be very low in comparison to emissions saved from travel
reductions. This could have wide implications in reducing
the carbon footprint of healthcare services globally. In order
for telemedicine services to be successfully implemented,
further research is necessary to determine context-specific
considerations and potential rebound effects.
KEYWORDS: telemedicine, sustainability, e-health, carbon footprint
synchronous is real-time data transmission. The data may be
transmitted via a variety of media, such as audio, video or text.
This paper will focus on all forms of telemedicine involving direct
patient care where the carbon footprint of the telemedicine
project is compared to a face-to-face (FTF) scenario.
Telemedicine is a recent development within healthcare.
In this decade, there has been an explosion in telemedicine
research, focusing on specific medical specialties. The reported
advantages include lower financial costs, high patient
satisfaction, better rural access, decreased waiting times and
fewer missed appointment.2–7
There is less available evidence
from primary care; however, there are positive findings in
primary care chronic disease management.8–10
The main
disadvantages are erosion of the clinician–patient relationship
and concerns around quality of care. In terms of clinician–
patient relationship, this concern arises particularly from
elderly patients and healthcare providers themselves; however,
acceptance has been shown to be increasing.6,11,12
There are
mixed reports on the quality of care provided by telemedicine;
some sources report improved or maintained standards of care,
whereas others found a reduction in quality of care compared to
FTF scenarios.9,13–19
ABSTRACT
Ridurre gli spostamenti: una COVID-lesson?
35. Posi%on statement:
Spun% per la ricerca
• Qualità della dieta: la dieta
vegana planet- friendly
non è ...
• Qualità della dialisi: esiste l’ “iper-dialisi”?
• Valutazione dell’attività fisica anche in
termini di “risparmio” di farmaci, etc ...
• l’e-medicine dovrebbe essere un “plus”...
36. La clinica: in breve...
• La terapia nutrizionale, la terapia fisica, un
approccio olistico e personalizzato, la scelta di una
dialisi su misura non hanno solo un significato
clinico ma anche “ecologico”.
• Attenzione ai luoghi comuni, alle dimostrazioni
pleonastiche e agli alibi per ridurre il contatto con
i pazienti...
• La green nephrology è un “punto di vista”
“I did not become a vegetarian for my health, I did it for the
health of the chickens.”
Isaac Bashevis Singer
38. Posi%on statement: outline: technology
• Water conserva%on (reducing consump%on of natural
resources; recycling and reusing water).
• Energy conserva%on (reducing consump%on of natural
resources; employing alterna%ve energy).
• Waste management (reducing waste; promo%ng a wise
triage of contaminated and non contaminated waste;
introducing reuse and recycle whenever possible).
• Industrial design (influence the industry by considering
environmental impact a quality item; demand informa%on
throughout hardware, soDware and disposable lifecycle;
promote cradle to cradle approaches).