Prebay ZJ, Lankford J, Gunasekaran V et al: A cross-sectional analysis of factors associated with appointment completion and visit modality during virtual urology visits. Urol Pract 2021; https://doi.org/10.1097/UPJ.0000000000000263.

Like the rest of the country, our institution was forced to adapt to the new realities imposed by the coronavirus pandemic and embraced virtual medicine, fully transitioning our clinic operations to telehealth across all providers and subspecialties. As the only academic institution in the largest metropolitan area in Wisconsin, we have the privilege of treating a diverse patient population. We also have the responsibility to strive toward equitable care for all patients, which our institution and others have traditionally fallen short of. With this in mind, we asked how the transition to telehealth impacted access to care for our urological patients.¹ We asked 2 questions: were certain factors or demographics more commonly associated with appointment completion, and were the same factors associated with patients scheduling their appointment via telephone or video visits?

We retrospectively reviewed every patient appointment over the first 6 months of the pandemic. There were almost 4,000 appointments included, with approximately 80% of appointments completed and nearly 60% scheduled over video as opposed to telephone. Approximately three-quarters of our patients were male, with an average age of 60.5 years. Close to 80% of patients self-reported race as white, 12.1% reported Black race and the remaining 10% reported as other/unknown. We found that afternoon and telephone visits were more likely to be completed, as were visits scheduled with physicians rather than advanced practice providers (APPs; table 1). In terms of visit modality, females were more likely than males to use video visits (table 2). Perhaps unsurprisingly, multiple patient factors that could be considered social determinants of health were associated with both appointment completion and visit modality, specifically race, age, median income of home zip code and insurance provider (private vs Medicare vs Medicaid). We also noted patients were more likely to attend appointments and use video calls when scheduled through our institution’s satellite clinics, which may reflect hidden differences in social determinants of health between our various campuses. The division of urology and scheduled length of appointment also showed statistically significant differences for both appointment completion rate and visit modality, which we speculate indicates that new patient visits and visits for cancer-related care are more of a priority for patients and less likely to be missed. Additionally, these appointments may have favored video calls in order to facilitate a virtual “face-to-face” discussion. Patients were also less likely to complete visits by month over the course of the study.

Racial differences in care exist in urology, as noted recently by Bernstein et al regarding prostatectomy rates between white and Black patients over the pandemic,² and by Chen et al regarding differences in male fertility evaluation and treatment.³ Such disparities existed prior to the pandemic but have been exacerbated by responses to the pandemic. With our study, we sought to understand the impact of such disparities with telehealth. As we work to refine the role of telehealth, we have a potential opportunity to mitigate sociodemographic disparities, which we should not squander. Telehealth has the potential to positively impact care for patients and providers, and it has been shown to save patients time and money among a male infertility practice.⁴ Patients also have expressed positive experiences with telehealth, even prior to the pandemic.⁵ But to equitably ensure these benefits on a broad scale, community and infrastructure interventions will be required. To begin, efforts could focus on pre-appointment planning and counseling with the patient groups identified as being less likely to complete an appointment. We also believe it is important to continue offering and recognizing telephone calls as a valid care modality, as phone calls are more accessible for some patients. However, the ability to connect with a patient over video does have value, and not all patients have access to the requisite devices or internet connectivity. This represents an opportunity to integrate health care into the community. Places such as town halls or public libraries could serve as “virtual clinics” where community members could use community provided internet and computers or tablets to attend their appointment, which still would likely be more convenient than having to travel to a doctor’s office for care. The forced transition to telehealth has offered new avenues to improve patient care and ensure equitable access. The inherent inequities that have long existed in health care are embedded within telehealth as well, but with intentional efforts as a community we can continue to optimize telehealth and improve patient care.