key: cord-306293-miyc5kok
authors: Sherman, Courtney B; Said, Adnan; Kriss, Michael; Potluri, Vishnu; Levitsky, Josh; Reese, Peter P.; Shea, Judy A.; Serper, Marina
title: In‐Person Outreach and Telemedicine in Liver and Intestinal Transplant: A Survey of National Practices, Impact of COVID‐19 and Areas of Opportunity
date: 2020-08-09
journal: Liver Transpl
DOI: 10.1002/lt.25868
sha: 
doc_id: 306293
cord_uid: miyc5kok

Little is known about national practices and use of in‐person outreach clinics and telemedicine in transplantation. We initially aimed to assess contemporary use of in‐person outreach and telemedicine in liver and intestinal transplantation in the U.S. We conducted a national survey of liver and intestinal transplant programs to assess use of outreach and telemedicine from January to March of 2019. Given the coronavirus disease 2019 (COVID‐19) pandemic, we distributed a second survey wave in April 2020 to assess changes in telemedicine use. Of the 143 programs surveyed, the initial response rate was 51% (n=73) representing all 11 Organ Procurement and Transplantation Network (OPTN) regions and 29 states. Pre‐COVID‐19, a total of 42 (59%) surveyed programs had in‐person outreach clinics only while 12 (16%) programs in only 6 states used telemedicine. Centers with higher median MELD at transplant were more likely to utilize telemedicine (p=0.02). During the COVID‐19 pandemic, among 55 of the 73 original responding programs (75%) from all 11 OPTN regions, telemedicine use increased from 16% to 98% and was used throughout all phases of transplant care. Telemedicine utilization was very low prior to COVID‐19 and has increased rapidly across all phases of transplant care presenting an opportunity to advocate for sustained future use.

the initial response rate was 51% (n=73) representing all 11 Organ Procurement and Transplantation Network (OPTN) regions and 29 states. Pre-COVID-19, a total of 42 (59%) surveyed programs had in-person outreach clinics only while 12 (16%) programs in only 6 states used telemedicine. Centers with higher median MELD at transplant were more likely to utilize telemedicine (p=0.02). During the COVID-19 pandemic, among 55 of the 73 original responding programs (75%) from all 11 OPTN regions, telemedicine use increased from 16% to 98% and was used throughout all phases of transplant care. Telemedicine utilization was very low prior to COVID-19 and has increased rapidly across all phases of transplant care presenting an opportunity to advocate for sustained future use.

Due to the coronavirus disease 2019 (COVID-19) pandemic, access to care for transplantation has been compromised due to conservation of healthcare resources and concerns regarding spread of infection for immunocompromised patients.(1) Telemedicine may improve access and quality of care, but previously was underutilized. (2, 3) Herein we report data from a national survey conducted in 2019 to assess the now historical use of in-person outreach clinics and telemedicine in liver and

This article is protected by copyright. All rights reserved intestinal transplantation. Given the COVID-19 pandemic, we conducted an abbreviated second wave of the survey to investigate differences in telemedicine use in the COVID-19 era.

We conducted a national survey of all liver and intestinal adult and pediatric transplant programs active in 2018 in UNOS to assess practice patterns of in-person outreach clinics and telemedicine from January to March 2019. Surveys were administered using QualtricsXM (Qualtrics, Provo, UT), (Supplement 1). We assessed the use of outreach clinics as well as live video and asynchronous telemedicine (e.g. electronic consultation by review of medical records or imaging studies), including the frequency of telemedicine, duration of use, phase of transplant care in which it was used, providing care across state lines, and reimbursement.

We obtained a single response per center from a transplant provider aware of outreach and telemedicine practices at that center. The study received exempt status from the Institutional Review Board at the University of Pennsylvania. Only centers that responded (n=73) to the initial survey were invited to complete the COVID-19 follow-up survey. We assessed interval implementation and utilization of telemedicine since March 2020. Given high clinical demands during the COVID-19 pandemic, our follow-up survey asked targeted questions limited to: 1) use of synchronous telemedicine modality (live video, telephone, both), 2) type of provider using telemedicine, 3) phase of transplant care for which telemedicine was used.

Descriptive statistics including proportions as well as mean, standard deviation, median, interquartile range were calculated for categorical and continuous variables as appropriate. Bivariate comparisons were conducted with Wilcoxon rank sum tests and Kruskal Wallis for continuous as well as chi-squared or Fisher's exact tests for categorical variables where appropriate. Among the 61 centers that did not have telemedicine, 34 (56%) planned to use telemedicine "in the near future". Among the 19 programs that did not have outreach, 13 (68%) planned to use in-person outreach clinics in the future and 7 (37%) planned for future telemedicine.

Detailed information on telemedicine use characteristics of the 12 centers with telemedicine pre-COVID-19 is presented in Supplemental Table 2 . Most centers started using telemedicine in the recent past; 9 (75%) in the past 1-3 years and 3 (25%) within one year of when the survey was conducted. Telemedicine use was only noted in 6 states and in UNOS regions 2, 4, 5, 7 and 11 with Accepted Article most of these programs (42%) located in Region 2 (Supplemental Figure 1) . Pre-COVID-19, telemedicine was reported to be reimbursed by payers in 7 (58%) centers and was delivered across state lines by 8 centers (67%).

In the second wave of our survey (conducted the week of April 13 th , 2020), 55 of the 73 original programs (75%) responded after 3 attempts to reach transplant center staff. These programs represented all UNOS regions and 35 DSAs. Among these, 54 of 55 (98%) now used telemedicine (Table 1, Figure 1 ). Transplant center, provider and care characteristics during the COVID-19 pandemic are shown in Table 1 . Characteristics of transplant centers currently using telemedicine were similar to those that reported in-person outreach and/or telemedicine use during the first survey. With nearly universal telemedicine utilization among responding programs, telemedicine was used by 35 (65%) programs to conduct transplant evaluations, 32 (58%) for waitlist management, and 53 (98%) for post-transplant care. Most centers (82%) used a combination of live video and/or telephone (Supplemental Table 2 ).

In a 2019 national survey of liver and intestinal transplant programs, we identified a high uptake of inperson outreach clinics (71% of programs), whereas telemedicine utilization was low at 16%. During this period, we observed that telemedicine and in-person outreach were more often used in programs with higher MMaT, however, use was not related to center volume or population density.

Patients living in less populated areas would arguably derive the most benefit from telemedicine but did have not enough access, highlighting issues of inefficiency and inequity. Importantly, an updated survey conducted in the COVID-19 era showed unprecedented shifts in care delivery with a nearuniversal uptake of synchronous telemedicine use given the temporary relief in regulatory and reimbursement barriers in this public health emergency.(3) During this second survey wave, our questions were targeted to characterize telemedicine utilization in response to the COVID-19 pandemic; therefore, direct comparisons of pre-COVID-19 and COVID-19 era patterns are not feasible. We did not assess the rationale for in-person outreach and/or telemedicine. Motivations for use of remote care strategies may include expanding access to transplant care, reducing patient Accepted Article travel and cost, attracting candidates to a transplant center and providing care via telemedicine when in-person visits are limited due to exposure risks during the COVID-19 pandemic. We did not evaluate clinical outcomes, financial implications, or patient and provider satisfaction with these care delivery strategies.

Telemedicine has an emerging evidence base in transplantation, but most examples from the literature derive from integrated care systems such as the Veteran Affairs (VA) due to regulatory and reimbursement barriers. For example, Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO) has demonstrated increased efficiency and access to specialty hepatology care, improved survival for patients with liver disease and reduced time from referral to initial liver transplant evaluation by a hepatologist and placement on the waitlist. The main barriers to widespread telemedicine adoption have not been related to technology, which is low-cost and easy to implement, but rather to arcane interstate licensing barriers and highly variable reimbursement (4).

In our initial 2019 survey, only 7 programs using telemedicine (58.3%) were reimbursed with 2 of these being VA programs.

Since the COVID-19 pandemic, key legislative changes have occurred to make telemedicine a short- Leveraging telemedicine technology serves two critically important functions: 1) allowing for continued patient care remotely during outbreaks while protecting patients, providers, and the community from exposure, and 2) expanding access and efficiency across the continuum of transplant care that can last well beyond the pandemic. However, barriers to implementation persist, including lack of digital literacy, potential disparities in technology access and use by patient age, race/ethnicity, and socioeconomic status.(5) Moreover, telemedicine for new patients, symptomatic Accepted Article presentations, and serious illness conversations is not always appropriate. Widespread judicious and optimal use of telemedicine has yet to be established. Nonetheless, the future of telemedicine for transplantation is promising as long as it is viable from a financial and regulatory perspective. We urge transplant centers to advocate for policy changes at the local, state and federal levels in order to allow continued use of this essential healthcare delivery modality. 

This article is protected by copyright. All rights reserved 

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