key: cord-0698496-0ya9tf2w
authors: Winkelman, Andrew J.; Beller, Haerin L.; Morgan, Kathryn E.; Corbett, Sean T.; Leroy, Susan V.; Noona, Sean W.; Berry, Kaitlin L.; Kern, Nora G.
title: Benefits and Barriers to Pediatric Tele-urology During the COVID-19 Pandemic
date: 2020-10-08
journal: J Pediatr Urol
DOI: 10.1016/j.jpurol.2020.09.028
sha: f1ae076a4883625b256844dfbc8f68aa7fb4e5cc
doc_id: 698496
cord_uid: 0ya9tf2w

INTRODUCTION: Telemedicine video visits are an under-utilized form of delivering health care. However due to the COVID-19 pandemic, practices are rapidly adapting telemedicine for patient care. We describe our experience in rapidly introducing video visits in a tertiary academic pediatric urology practice, serving primarily rural patients during the COVID-19 pandemic. OBJECTIVE: The primary aim of this study was to assess visit success rate and identify barriers to completing video visits. The secondary aim identified types of pathologies feasible for video visits and travel time saved. We hypothesize socioeconomic status is a predictor of a successful visit. MATERIALS AND METHODS: Data was prospectively collected and analyzed on video visits focusing on visit success, defined by satisfactory completion of the visit as assessed by the provider. Other variables collected included duration, video platform and technical problems. Retrospective data was collected via chart review and analyzed including demographics, insurance, and distance to care. Socioeconomic status was estimated using the Distressed Communities Index generated for patient zip code. RESULTS/DISCUSSION: Out of 116 attempted visits, 81% were successful. The top two reasons for failure were “no-show” (64%) and inability to connect (14%). Success versus failure of visit was similar for patient age (p=0.23), sex (p=0.42), type of visit (initial vs. established) (p=0.51), and socioeconomic status (p = 0.39). After adjusting for race, socioeconomic status, and type of provider, having public insurance remained a significant predictor of failure (p = 0.017). Successful visits were conducted on multiple common pediatric urologic problems (excluding visits requiring palpation on exam), and video was sufficient for physical exams in most cases (Summary Table). A median of 2.25 hours of travel time was saved. CONCLUSIONS: While socioeconomic status, estimated using the Distressed Communities Index, did not predict success of video visits, patients with public insurance were more likely to have a failed video visit. There is compelling evidence that effective video visits for certain pathologies can be rapidly achieved in a pediatric urology practice with minimal preparation time.

The COVID-19 pandemic has had an enormous impact on pediatric urologic practices throughout the world, necessitating postponement of elective surgical procedures and non-urgent patient appointments [1, 2] . Emergency surgeries continue to be performed, but questions remain as to what non-urgent surgeries can safely be postponed [2, 3] . Similar questions arise for postponement of office visits. Delay of pediatric urologic care in certain cases (e.g. obstructive uropathy) could lead to worse outcomes or allow for progression of irreversible conditions, without being immediately life-threatening. To prevent morbidity associated with the postponement of care during the COVID-19 pandemic, methods that safely allow for high quality care have been implemented.

The COVID-19 pandemic has drastically accelerated the adaptation of telemedicine within pediatric urology [4] . Telemedicine allows for the delivery of care while maintaining safe social-distancing measures. Remote video visits (VVs) have been used successfully for years in pediatric urology for the delivery of postoperative care [5, 6] and prenatal urologic consultation [7] . Yet overall, there is a paucity of existing research on the use of telemedicine for general pediatric urologic conditions. The DCI generates a normalized, comparative distress score ranging from 0 ("prosperous") to 100 ("distressed") for each zip code. The distress score is a composite of seven variables: rate of graduation, housing vacancy rate, unemployed adults, poverty rate, median income, change in employment, and change in the number of business establishments. DCI scores were licensed for use in this publication.

Descriptive variables are presented as median (interquartile range IQR) and count (percentage) as appropriate. Independent t-tests and Chi-Square tests were used as J o u r n a l P r e -p r o o f appropriate to compare successful versus failed VV based on characteristics described above. Univariate and multivariable logic regression modeling was used to analyze the effect of study variables on VV success. The final model included patient and clinical variables with p < 0.20 on univariate analysis. Study data were collected and managed using REDCap electronic data capture tools [9] . SAS version 9.4 (SAS Institute Inc. Cary, NC) was used to perform statistical analysis with a statistical significance threshold set at 0.05.

During the seven-week study period, 116 patients scheduled for a VV were included in our cohort. Three additional patients were asked to participate in a VV but declined due to lack of internet availability. Table 3) .

The most common primary diagnoses addressed for a VV included bladder and bowel dysfunction (37%), post-operative care (18%), and penile conditions (16%) ( Table   4 ). Most visits were for established patients (62%) and less for new patients (38%). 33%

of patients had imaging done prior that was discussed during their VV. -200) to get to the in-person appointment.

Prior to the COVID-19 pandemic, telemedicine was an under-utilized form of delivering health care in the field of pediatric urology [10] . Prior studies have demonstrated successful telemedicine encounters for post-operative visits as well as for prenatal consultations on urologic conditions, most commonly including urinary tract dilation [5] [6] [7] . Out of necessity, the pandemic has changed the way practitioners have traditionally provided services in order to maintain quality care for pediatric urologic patients. Due to this unforeseen adaptation of telemedicine into a solely in-person practice, this study aimed to understand factors that may lead to a successful VV and also [6] . There are many possible reasons for this discrepancy including demographics, nature of the visits, and potential differences in scheduling and reminders. While post-operative visits comprised 18% of our cohort, Finkelstein's study included only post-operative visits [6] . Postoperative visits have previously been found to be better attended than other follow-up appointments in an otolaryngology study [11] that may be explained by patients investing more in an appointment after a surgery. Only some of the patients received pre-appointment reminders, and these reminders are a proven method to reduce no-show rates for in-person visits [12] . Additionally, our success rate could have been higher if we included telephone conversion as a successful visit given many providers may feel telephone is sufficient. However, we did not consider these converted visits as a success given the element of video or visualization of the patient can be an important component of an office visit.

In the course of this study, we sought to understand what factors predict a failed VV. We presumed patient age and sex would not be predicting factors given the parent or J o u r n a l P r e -p r o o f guardian was the participant in the VV and not the child. We unfortunately did not have data on parents' demographics. We had anticipated higher SES would be positively correlated with visit success, as bandwidth and SES have been found to be barriers to the use of telemedicine in the past [13] . Alternatively, we found that DCI, a proxy for SES, did not predict visit failure. The DCI has been used in several medical studies including recent publications examining the relationship between SES and surgical risk [14, 15] . We, however, recognize the flaws in using DCI as a surrogate for SES given this score generalizes a community to their zip code and does not account for individuals who deviate within the mean. Additionally, given the popularity and widespread use of smart phones and computer technology in 2020, failure of VVs may not be representative of low SES as it may have been in the past. Interestingly, public insurance, that may be considered another alternate for low SES, significantly predicted a failed VV in a multivariate analysis.

Beyond the feasibility of VVs, there are many advantages of telemedicine for patients and families including a reduction in pre-appointment wait time [9, 14] , greatlyreduced travel time and rate of missing school or work for the appointment with equivalent clinical outcomes as compared to in-person visits [16] . Obviating the need to travel is an important benefit to emphasize, as our patients live throughout the state of Virginia and often need to travel great distances to attend an appointment. The patients in our cohort would have saved a median 2.25 hours in travel time. Although we serve a mainly rural population, the experience of our patients' families is not unique, as it has been found that 29% of the under-18 population in the United States lives at least 40 miles from the nearest pediatric urology practice [17] .

This time and travel savings has to be balanced with providing good quality care remotely. Within our cohort, the VVs were productive in that they lead to a change in plan of action in 69% percent of cases (i.e. prescription change, surgery or imaging scheduling, etc). To our knowledge, this is the first study to demonstrate the utility of telemedicine in pediatric urology beyond prenatal consultation and postoperative visits. In our study, telemedicine was used for decision-making that led to changes in care including surgery and medication changes. In scheduling the patients for VV, we recognized that a large number of patients required imaging results to have a meaningful visit. If patients were unable to get these studies, their visits were required to be delayed and did not merit a VV. Another barrier with telemedicine is the lack of ability to perform a thorough physical exam, especially one that requires palpation. Therefore, patients with undescended testes were strategically deferred for an in-person visit. Other conditions such as identifying a urethrocutaneous fistula or meatal stenosis after hypospadias repair may be quite challenging. From our secondary outcome, we found that post-operative visits were quite amenable to VV as previously demonstrated by others [6] , with no difficulties in examination; however 43% of exams were considered inadequate on initial visits that were reliant on the physical exam. While the number of difficult exams was small, it highlights that certain conditions are better suited for telemedicine compared to others. Future research should focus on success rates and outcomes of VV appointments broken down by diagnosis.

Several limitations should be noted. Our sample is a largely self-selected group of patients that had access to the equipment necessary for VVs, therefore may hold selection bias. It would be prudent to examine the rates of patients turning down the opportunity J o u r n a l P r e -p r o o f for VVs to gain a better understanding of what barriers in the community prevent patients from even attempting a VV. We also did not have demographic data on the parents to help identify factors that could influence the success or failure of VVs. Additionally, although providers deemed visits successful, it would be beneficial to examine patients' perception on whether they feel their goals were accomplished. Equally so, a comparison between VVs and in-person visits may be informative. Finally, as mentioned above, although we used DCI as a surrogate for SES, this score is certainly flawed due to its generalization based on zip code.

Our results provide compelling evidence that effective remote VVs can be rapidly achieved in a pediatric urology practice with minimal preparation time. Private insurance status was the most predictive factor for a successful VV. Certain pathologies are more amenable for a quality visit via telemedicine, mostly those visits less reliant on physical exam findings. Future use of telemedicine would allow for greater access to patients in need of pediatric urological services. J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f 

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