Mitigating Urological-Oncologic Outpatient Volume Reductions during COVID-19 in a Tertiary Referral Center

By: Editorial Staff | Posted on: 23 Feb 2021

Introduction

Beginning in March 2020 telehealth usage expanded across hospitals and clinics in the United States in response to the COVID-19 pandemic, ¹ with urologists rapidly integrating virtual outpatient visits into their practices. The differential impact of telehealth on frequently encountered urological–oncologic conditions has yet to be investigated. Here, we compare trends in urological–oncologic appointment rates over a matched period in 2019 and 2020. Additionally, we study individual trends for the most commonly encountered urological–oncologic conditions in terms of telehealth usage, new and established patient appointment distribution, and overall appointment volume to identify key differences in healthcare delivery and acceptability for individual urological–oncologic diagnoses.

Methods

To provide timely and practical evidence in support of this topic, after IRB approval (HS-20-00458) we analyzed all urological visits performed at a tertiary referral center from March 1 to June 1, 2020 and matched it with the same time period in 2019. The percent of new and established patient visits was assessed. Face to face visits, telehealth visits and cancellations were categorized according to corresponding billing codes. Join point regression model was used to identify significant changes in trends for visits over time. Average weekly percentage change (AWPC) and 95% confidence intervals were estimated to summarize linear trends.

Results

Urological–oncologic appointments in the 2019 period (2,100) showed no significant changes (AWPC −0.2%, p=0.9). In 2020 oncologic appointments (1,381) had a significant decrease from weeks 1 to 3 (AWPC −28.1%, p <0.001). However, weeks 1 to 4 showed a significant increase in oncology telehealth appointments (AWPC +391.2%, p <0.001). A stable trend in all 2020 oncologic appointments continued between weeks 3 to 6 (AWPC −6.7%, p=0.6). In week 6 the overall trend inflected and had a significant increase until week 13 (AWPC +7.3%, p <0.001). Weeks 4 to 13 showed no significant trends in oncology telehealth appointments (AWPC −4.9%, p=0.4; see figure and table). During the study period, the percentage of patients evaluated with telehealth were 58.2% for prostate cancer, 51.7% for renal cancer, 54.2% for testicular cancer (primarily followup visits) and 42.1% for bladder cancer (see figure). There was a sharp decline in new and established visits during weeks 2 to 4 of the 2020 study period. In 2020 new patient oncologic visits significantly decreased while established patient oncologic visits significantly increased (AWPC −3.2% vs +0.8%; p <0.001) differing from trends seen in 2019 (AWPC −1.9% vs +0.5%, all p >0.2). Appointment cancellations showed a steep increase in the first 3 weeks studied in 2020 (AWPC +54.9%; p <0.001), stabilizing thereafter and showing a comparable trend with 2019 (AWPC +5.2% vs −0.9%, all p >0.1; see table).

Figure. Trends in urological–oncologic outpatient appointment trends in weeks from March 1 to June 1 between 2019 and 2020 ( A) and percentage of urological–oncologic telehealth appointments in 2020 period ( B) for prostate cancer (PCa), renal cancer (RCa), bladder cancer (BCa) and testis cancer (TCa). CMS, Centers for Medicare & Medicaid Services.

Table 1. Join point regression analysis of urological outpatient appointment trends in weeks from March 1 to June 1 between 2019 and 2020, and percentage of telehealth appointments in 2020 period.

Range/Segments	Lower End-point (week)	Upper End-point (week)	WAPC	Lower CI	Upper CI	p Value
Overall outpatient visits (2019):
Full Range	1	13	−0.5	−3.4	2.4	0.7
1	1	13	−0.5	−3.4	2.4	0.7
% Overall new pts (2019):
Full Range	1	13	−0.1	−1.7	1.5	0.9
1	1	13	−0.1	−1.7	1.5	0.9
% Overall stablished pts (2019):
Full Range	1	13	0	−0.6	0.7	0.9
1	1	13	0	−0.6	0.7	0.9
Oncology outpatient visits (2019):
Full Range	1	13	−0.2	−4	3.8	0.9
1	1	13	−0.2	−4	3.8	0.9
% New oncology pts (2019):
Full Range	1	13	−1.9	−5	1.4	0.2
1	1	13	−1.9	−5	1.4	0.2
% Established oncology pts (2019):
Full Range	1	13	0.5	−0.4	1.3	0.3
1	1	13	0.5	−0.4	1.3	0.3
Full Range	1	13	−0.9	−3.4	1.6	0.5
1	1	13	−0.9	−3.4	1.6	0.5
Overall outpatient visits (2020):
Full Range	1	13	−5.3	−11.8	1.6	0.1
1	1	3	−34.3	−51.3	−11.3	<0.001
2	3	6	−3.6	−28.6	30.2	0.8
3	6	13	4.2	0.1	8.5	<0.001
% Overall new pts (2020):
Full Range	1	13	0.1	−2.1	2.4	0.9
1	1	13	0.1	−2.1	2.4	0.9
% Overall established pts (2020):
Full Range	1	13	0	−0.6	0.6	1
1	1	13	0	−0.6	0.6	1
% Oncology outpatient vists (2020):
Full Range	1	13	−3.1	−10.3	4.7	0.4
1	1	3	−28.1	−48.2	−0.3	<0.001
2	3	6	−6.7	−32.8	29.4	0.6
3	6	13	7.3	2.7	12.1	<0.001
% New oncology pts (2020):
Full Range	1	13	−3.2	−6.3	−0.1	<0.001
1	1	13	−3.2	−6.3	−0.1	<0.001
% Established oncology patients (2020):
Full Range	1	13	0.8	0	1.6	<0.001
1	1	13	0.8	0	1.6	<0.001
% of Cancellation (2020):
Full Range	1	13	2.5	−7.4	13.6	0.6
1	1	3	54.9	0.6	138.3	<0.001
2	3	6	−26.6	−52.3	12.9	0.1
3	6	13	5.2	−0.7	11.4	0.1
% Overall televisits (2020):
Full Range	1	13	42.4	18	72	<0.001
1	1	4	408.3	133.5	1006.7	<0.001
2	4	13	−6.8	−19.1	7.4	0.3
% Oncology televisits (2020):
Full Range	1	13	43.4	20.7	70.2	<0.001
1	1	4	391.2	141.7	898.3	<0.001
2	4	13	−4.9	−16.5	8.2	0.4

Discussion

Our analysis indicates that a structured telehealth program mitigated the dramatic negative impact of the COVID-19 pandemic on outpatient urological visits.

Urological practices across the country have modified their activities to reduce physical contact and limit the risk of person to person transmission. ² Telehealth represents the ultimate venue for accomplishing these goals while maintaining access to health care. ^3–6

We found that after rapid adoption of telehealth pathways the trends of decreasing outpatient visits and increasing cancellations rapidly subsided. Moreover, our data suggest that telehealth was able to adequately supplement overall visits for new and established patients. Interestingly, the cancellation rates were similar between the time periods apart from weeks 3, 4 and 13. During 2020 those weeks coincided with the greatest rises in COVID-19 cases/initiation of lockdown measures (weeks 3 and 4), and the commencement of the #BlackLivesMatter protests (week 13). These likely contributed to the higher cancellation rates (28% in 2020 vs 20% in 2019).

Our data also show significant contrasting trends for overall new and established patient oncologic visits as well as differing rates of telehealth usage across urological–oncologic conditions. We observed decreases in new patient appointment rates for certain urological malignancies (renal and testicular) and comparable rates for others (prostate and bladder). These differences can possibly be attributed to patients' increased reliance on community hospitals for initial treatment of new malignancies, foregoing travel to tertiary care centers. Variation in initial telehealth evaluation of urological malignancies is likely related to the need for physical exam or in-office procedures. Patients with prostate or renal cancer exhibited higher percentages of telehealth use, as initial and followup visits rely primarily on clinicopathologic results and imaging. Patients with bladder cancer patients were primarily seen in person given the need for endoscopic evaluation or urgent surgical intervention.

Prompt modification in national reimbursement policies ^3,7 and physician and patient acceptance ⁸ represent the keys for successful adoption of a telehealth program with the goal of mitigating outpatient volume reductions. Integration of telehealth by tertiary care centers may also reduce loss to followup of geographically distant patients. ¹ This may avoid the potentially catastrophic effects that delays in diagnosis, treatment indication and inadequate followup adherence ⁹ could have on disease prognosis, quality of life and health care system costs. ¹⁰

In conclusion, telehealth implementation helped reverse the initial decline seen with urological outpatient volume at our institution. The acceptability and effectiveness of these appointments provide evidence that the rapid transition to televisits directly mitigated the sharp reduction in urological appointments during COVID-19.

Acknowledgments

We thank Tracy Campanelli and Kathy Campanelli for their fundamental support in this project.

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