Prior to the COVID-19 pandemic, telemedicine was a budding field within medicine. The initial goals of telemedicine were to use electronic, video, and audio communication to increase access to health care in rural and underserved areas. To remotely match specialists, such as urologists, with patients who might not otherwise have access to care was the target of early telemedicine. Compounded by worsening urologist workforce shortages, the need for effective telemedicine was obvious. However, there was not widespread utilization of telemedicine to effectively render this care to large populations, nor was there broad insurance or Medicare reimbursement for telemedicine outside of limited geographic or diagnostic restrictions.¹

Of the many changes wrought by the COVID-19 pandemic, the blossoming of telemedicine usage remains one of the most consequential advances. We assessed urologists’ trends in telemedicine usage by comparing AUA Census data from 2016 to 2021.² We also examined trends in urologists’ predictions for future telemedicine usage and potential barriers to more widespread telemedicine adoption beyond pandemic-related social distancing mandates. We used logistic regression to assess geographic variability in telemedicine usage.

Overall, urologists’ telemedicine usage rose dramatically from pre-pandemic to 2020/2021 levels. From 2016 to 2019, reported telemedicine usage rose only from 8.5% to 11.9%. Telemedicine usage exploded to 71.5% in 2020, likely due to the pandemic, and rose even higher in 2021 to 81.3%. The 2021 AUA Census also showed that 93.3% of urologists anticipated using telemedicine in some capacity in the future (part A of Figure). These increases are reflected across all practice types examined, including private practices, institutional practices, metropolitan practices, and nonmetropolitan practices (part C of Figure). Additionally, the 2021 AUA Census data showed that almost one-quarter of all practices were using telemedicine for >10% of all encounters, a 150% increase from 2018 levels (part D of Figure).

Figure. Current, past, and future telemedicine use by urologists.

Despite these large increases in telemedicine usage and predictions for increased use, AUA Census data also reveal that 41.0% of urologists anticipate decreased future telemedicine use and 6.7% anticipate that they will not use telemedicine at all (part B of Figure). The increases in telemedicine usage were also not uniform across practice types, as nonmetropolitan practices’ adoption of telemedicine lagged behind metropolitan practices’ adoption (part C of Figure). When stratified more specifically by practice type, solo practitioners’ 50.7% telemedicine usage also lags behind institutional and academic adoption of telemedicine (part E of Figure). Perhaps unsurprisingly, urologists at academic centers reported the highest telemedicine usage at 92.7%, which may reflect greater availability of resources and less concern about reimbursement.

AUA Census data also revealed interesting telemedicine usage patterns when stratified by geographic region as reported by AUA section. AUA Census data show that the sections with the lowest pre-pandemic telemedicine usage were the South Central, Northeastern, and New England sections (see Table). In 2020, the Northeastern section rose from the lowest usage to highest usage of telemedicine, and in 2021, New England urologists reported the highest telemedicine usage at 96.0%. The South Central section, however, did not see the same gains in telemedicine usage; urologists from this section reported the lowest telemedicine usage in both 2020 and 2021. These patterns stand in contrast to the proportion of urologists to population: the New England section, with the lowest proportion, had the highest telemedicine usage, while the South Central section, with the second lowest proportion, had the lowest telemedicine usage.

These geographic disparities in telemedicine might be mirroring the reported compensation for telemedicine: the South Central section reported the lowest percent compensation for telemedicine, and the Northeastern section, with the second lowest compensation, saw a drop in telemedicine usage from 2020 to 2021 (see Table). Despite these interesting patterns, after comparison of urologists’ telemedicine usage by AUA section to ratio of urologist to population, to percentage of urologists reporting compensation for telemedicine, and to AUA section population density, regression analysis did not reveal any significant correlations (see Table). Thus, the variability in usage by practice type may reflect providers’ concerns about telemedicine, patient-related concerns, and heterogeneity within and between AUA sections. Regarding barriers to telemedicine usage, providers specifically cited video/phone quality, patients lacking sufficient technology, and lack of high-speed internet in some areas as hurdles to widespread telemedicine utilization. Further, providers also perceived patients as preferring in-person visits likely as a result of patients’ cultural familiarity with the in-person medical visits.

The use of AUA Census data to draw broad generalizations is not without limitations. AUA Census data may be skewed by recall bias and selection bias. The AUA Census does not stratify “nonmetropolitan” urologists into more meaningful categories such as practicing in small cities or rural areas. The data also are limited to video or phone telemedicine usage, and the results are not specific to whether the reported telemedicine usage is in the outpatient setting, emergency setting, or inpatient setting. Finally, the role of “telesurgery” has not been assessed, as this field remains mostly experimental in nature.

Despite dramatic increases in telemedicine usage during the COVID-19 pandemic, disparities in usage persist both geographically and among practice types. AUA Census data do not show telemedicine being used to increase rural access, which is contrary to pre-pandemic predictions for its use. Worryingly, urologists foresee further slowing in telemedicine usage from their current levels, which may reflect equilibration to where telemedicine is efficient and economical for urologists. The anticipated decreased use likely stems from concerns about barriers to access such as connectivity/technology issues, patient preferences for in-person visits, and decreasing compensation. The AUA must continue advocating for patients by improving access to technology needed for telemedicine and for its members with goals of increasing telemedicine ease and economic viability for urologists.

Acknowledgments

We thank Raymond Fang, MSc, MASc, Director of AUA Data Management & Statistical Analysis, for his contributions.