During the COVID-19 pandemic, there was an increase in peritoneal dialysis infection rates (referred to as peritonitis) among kidney patients living in rural and First Nations communities in Northern BC. Now, a study suggests an underlying reason: an abrupt, pandemic-forced shift from Northern BC’s long-standing hybrid care model to virtual-only care eroded the trust and relational continuity that are foundational to safe peritoneal dialysis (PD) practice. A key message from the study is that virtual care itself is not the problem — it is the loss of in-person connection, community support, and the relationships with the care team that underpin safe home dialysis.
PD is a home-based therapy in which patients perform dialysis themselves by infusing and draining a cleansing fluid through a catheter in the abdomen, typically several times a day or overnight. Notably, the Northern Health region has one of the highest prevalence rates of PD in Canada, reflecting both the region's geography and the critical role this therapy plays in keeping patients connected to their home communities.
Dr. Anurag Singh is a nephrologist with Northern Health who helped lead the study. He notes that PD is a valuable form of therapy for people living with kidney failure in rural and remote areas. Without this option, many would have to relocate to urban areas to receive in-centre hemodialysis on a regular basis.
“For our patients across Northern Health, staying home means staying employed, connected to family, community, and land, and for Indigenous patients especially, that connection is central to well-being," explains Singh.
However, patients need training on how to self-administer PD at home safely, to avoid infection. Between 2021 and 2023, Singh and his colleagues noted increasing rates of peritonitis – an abdominal infection that can result from bacterial growth in patients on PD – just as the pandemic had forced them to shift much of their in-person care to virtual care, in the form of phone calls. Compounding this was the loss of community-based primary care supports and the near-complete suspension of PD team home visits and community outreach over these three years.
To investigate, Singh and his colleagues analyzed health records of patients with peritonitis, which numbered 78 infections over the course of the three-year study period. The analysis identified three factors associated with an increased risk of peritonitis: challenges with sterile technique, receiving 85% or more of their care virtually by phone, and residence in communities with reduced access to in-person services—conditions that disproportionately affect some Indigenous communities.
Notably, people from Indigenous communities made up about a third of the people who had peritonitis, but these individuals experienced more than 70% of all cases of infection.
To gain a better understanding of the underlying issues, the researchers interviewed 12 patients, which revealed how virtual care was impairing patients' ability to learn safe PD techniques and eroding trust with their care teams.
“People described feeling disconnected from their care teams, unsure whether they were performing their exchanges correctly, and reluctant to ask for help," says Singh. “Some felt judged or blamed for their infections rather than supported."
He notes that some patients reported feeling abandoned even if they had regular check-in calls with their care team, underscoring the importance of in-person meetings for building trust. “In-person visits allow clinicians to assess technique, inspect catheter sites, and read nonverbal cues, but just as importantly, they create space for the kind of relational connection that makes patients feel comfortable being honest about their challenges," Singh explains.
“For Indigenous patients whose experiences with healthcare may already be shaped by mistrust and intergenerational trauma, that relational safety is not optional — it's foundational," he says, adding, “Virtual care is a valuable tool, but it's not a substitute for relationship-based care."
Importantly, peritonitis rates in the Northern Health region have since improved. Following the study period, the PD program returned to a hybrid care model — reintegrating regular in-person visits, PD team home visits, and community outreach. These structural changes, combined with a renewed focus on cultural safety and relationship-based care, are believed to have contributed to better outcomes. According to Singh, the experience reinforces that hybrid care, when built on a foundation of trust and continuity, remains the most effective model for supporting patients on home dialysis in rural and Indigenous communities.
Study: Virtual Care Utilization and Peritonitis Risk in Rural and Indigenous Peritoneal Dialysis Patients
