Experts discuss disparities in access to urologic care

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“What is becoming increasingly evident is that the traditional health care model is falling short for patients in rural regions,” says Ramy Abou Ghayda, MD, MPH, MBA candidate.

In this interview, David Sheyn, MD, and Ramy Abou Ghayda, MD, MPH, MBA candidate, discuss disparities in access to urologic care, particularly among those in rural communities. Sheyn is an associate professor of urology and a division director of urogynecology and reconstructive pelvic surgery at University Hospitals (UH) Urology Institute in Cleveland, Ohio. Ghayda is an assistant professor of urology at Case Western University, an associate program director of the residency program at UH Urology Institute in Cleveland, Ohio, as well as the chief medical officer of GiveLegacy, a digital fertility startup providing better access to fertility care.

Could you discuss the current state of disparities in access to urologic care, particularly among those in rural communities?

David Sheyn, MD

David Sheyn, MD

Sheyn: I work directly in the rural space. I go to 2 hospitals, UH Portage and UH Geauga, both of which serve fairly rural communities. Just from my own personal experience, I've noticed a significant lack of access to not just general urologic care, but also subspecialty urologic care. The wait times are extremely long and travel distances are long, and they're affected by weather and by transportation issues. A lot of times, when I see a patient, they say they've been trying to get in to see me for months. I don't know if Dr. Ghayda has had different experiences.

Ramy Abou Ghayda, MD, MPH, MBA candidate

Ramy Abou Ghayda, MD, MPH, MBA candidate

Ghayda: It's been quite similar in my experience. I also serve the Ashland area, about an hour and a half from downtown Cleveland. What is becoming increasingly evident is that the traditional health care model is falling short for patients in rural regions. They face significant challenges accessing transportation, funding, and support systems. Consequently, we're witnessing a growing number of patients struggling to reach us for care. The notion of a urologist sitting idly in a clinic, awaiting patients, is swiftly evolving. This passive traditional approach to care isn't effective anymore for many individuals. We're witnessing adverse outcomes because patients encounter barriers to accessing care. At the Urology Institute, we're taking a proactive stance. For our health delivery strategy, we are considering the social determinants of health of our patient population, the unique characteristics of the areas we serve, the infrastructure of our clinics, and the support staff available. We aim to actively engage with these patients, rather than wait for them to seek us out. This proactive approach extends beyond clinical care; we're integrating this novel methodology it into our daily clinical operation, research endeavors, and overarching strategy.

What are the factors that might contribute to disparities? How do other factors such as demographics, race, socioeconomic status, etc. play a role in disparities to access?

Sheyn: I can talk about it specifically for my field, urogynecology, because there's a unique spin to it to where [there’s] a lack of awareness of these conditions, like incontinence and prolapse and pelvic pain. A lot of people think these are conditions are a normal part of aging or childbirth and/or that treatment elective and thus not covered by insurance. So, they'll often, even though they're suffering, will not come and see us because they think it's either not covered by insurance, even though a lot of them are insured, or they don't realize that anything can be done about this. Certainly, we see this in more urban areas, but there's more knowledge about these conditions and treatments in more populated locations. With the socioeconomic factors, a lot of people think that that's going to be out of pocket, even though a lot of this is considered standard medical care, so they might wait to save up money. A lot of these conditions will impact people's ability to work. They may not even be able to get a job and make money to come see us. Then there are issues with transportation. A lot of them are younger, so reliable childcare can be an issue as well, though I always encourage patients to bring their children if it makes it easier for them to attend a visit. Every barrier that you would experience in an urban setting is compounded by the distances and lack of resources that people experience a rural setting.

Ghayda: Absolutely, I share the same perspective. My focus is primarily on men's health, an area where a considerable body of evidence highlights the disparity in life expectancy between men and women. This discrepancy isn't solely due to biological factors but is heavily influenced by societal norms and health care-seeking behaviors. Men's health isn't solely about longevity; it is intricately linked to their overall quality of life. Many of the patients I see may not be grappling with life-threatening conditions, but their well-being is significantly compromised because they delay seeking care. There's a pervasive stigma surrounding men's health, with many men believing they should prioritize regular check-ups or address health concerns only once they reach a critical stage. This issue is compounded in rural communities where access to health care resources is limited, and financial constraints further deter individuals from seeking timely care. Despite efforts to raise awareness and promote proactive health care, these initiatives often overlook rural populations, concentrating primarily on urban areas. Dr. Sheyn rightly points out that addressing these disparities requires addressing a complex interplay of social, cultural, and systemic factors. It's not merely a matter of lacking resources or financial struggles; it's about bridging the gap in health care access and education. The consequences of this neglect are palpable in our daily practices as we witness the tangible impact on the health outcomes of rural populations.

What are some of the initiatives that have been implemented at UH to improve disparities in access?

Ghayda: Certainly, we're leading a transformative shift in medical services and health care delivery at the Urology Institute and Cutler Center for Men. We are engaging with communities, raising awareness, and educating about various impactful health conditions. One noteworthy initiative focuses on the intricate link between cardiovascular health and erectile dysfunction (ED). Research indicates a strong correlation between the 2, with individuals experiencing ED often harboring underlying cardiovascular conditions, predisposing them to strokes, cardiac events, and other cardiovascular diseases. Rather than adopting a passive approach and waiting for patients to seek assistance for their ED in our clinics, we’re taking our services directly to the community. We’ve forged partnerships with local establishments like barbershops frequented by underserved communities and collaborated with churches in the inner cities of Cleveland, with several pastors supporting our cause. Through this initiative, our aim is to engage with community members, offering free cardiovascular assessments, including heart calcium score CAT scans, and conducting surveys on ED and urological health. This proactive outreach serves multiple purposes. Firstly, it ensures that patients receive timely assessments, enabling early intervention if cardiovascular issues are detected. Additionally, it facilitates access to appropriate health care services: those identified with cardiovascular risks are referred to cardiology, while those with potential urological concerns are connected with primary care or our urology clinic.

This endeavor, funded by the NIH as part of the broader Achieve Greater initiative spanning Detroit, Michigan, and Cleveland, Ohio, underscores our commitment to equitable health care access. By prioritizing education, awareness, and community engagement, we're not only addressing immediate health needs but also fostering long-term health outcomes for underserved populations.

Sheyn: We are also trying to reach more people by leveraging telehealth. We've started rural telemedicine clinics where people will go to a regular doctor's office–we partnered with their primary care doctors–and they'll get checked in and triaged just like they would for a normal visit with us. Then we do a virtual visit. We do everything except for a pelvic exam. In some cases, we've trained some of the staff in these primary care offices to do a pelvic exam for pelvic floor disorders. In other cases, we can potentially treat something based on history alone, because we know that history is predictive of a lot of pelvic floor disorders without a pelvic exam. If we think there is management that we can do without doing an exam, then we will try that first. In this way, we're capturing patients that may not have otherwise come to us initially. We're doing some education, and if we need to see them in our own offices, then we'll have them come. Instead of having 4 or 5 visits with us when they have to travel 50 miles each way, they might have to come and see us 1 time. We're also trying to use more machine learning and artificial intelligence technology. So, for instance, we partnered with a company named Renalis Health. That is a digital platform for treating incontinence with pelvic floor therapy and behavioral modification. We'll sign up these patients for this instead of going to a pelvic floor therapist, which may not be available in their locations. And 5 out of 10 times, a lot of these patients will get better, and then they can continue to use this technology rather than having to come see us.

Ghayda: Additionally, I'd like to shed light on some broader initiatives within the Urology Institute. Our flagship center, the Cutler Center for Men's Health, plays a pivotal role in this regard. Here, we organize regular monthly events tailored specifically for individuals residing in rural and underserved communities. For instance, one of our initiatives includes hosting movie nights accompanied by refreshments, providing a relaxed and inviting atmosphere for men to seek assistance without hesitation. During these movie nights, attendees gather to enjoy a film together, fostering a sense of camaraderie and comfort, allowing for informal discussions and interactions. These events serve a dual purpose: they offer men a glimpse into our supportive environment, encouraging them to seek help when needed, and foster community bonds.

These activities exemplify our department's commitment to holistic care through the Cutler Center. By creating inclusive spaces and facilitating open dialogue, we strive to break down barriers and stigma to health care access and promote overall well-being within our communities.

Could you expand on how telehealth has impacted access to care?

Sheyn: I definitely think it has benefited people that would otherwise not have come in for care. I think it has cut down on costs and increased the number of patients that will receive care. Just from my own personal experience, a lot of times, including for post-operative care, I can do virtual visits and partner with someone who is familiar with [the patient]. So, for instance, a general surgeon might help me with post-operative care. Many times, I'll just meet someone once and then I care for them for years just through virtual visits. That can be through telephone, that can be an audiovisual visit. But in any case, I think across all settings, including even densely populated areas, telehealth has drastically changed the way we can allow people access to not only urologic care, but just care in general. I think it's the biggest silver lining that came out of the pandemic.

Ghayda: Absolutely, I concur. We're encountering similar scenarios here at Cutler. For patients facing mobility constraints, residing in nursing homes, or situated far from our facility without access to transportation, telehealth emerges as an invaluable solution. Not only does it ensure continuity and quality of care, but it also maintains the crucial patient-physician connection.

Telehealth serves as a powerful tool, offering convenience and accessibility for both patients and health care providers. While there may be technological hurdles to overcome in the future, its current impact is undeniable. It presents an excellent opportunity to bridge gaps in care delivery and ensure that patients receive the attention they need, regardless of their location or circumstances. As we continue to refine and adapt telehealth practices, we can further enhance its effectiveness in delivering seamless health care experiences for all involved.

Is there anything else that you want to add?

Sheyn: I just want to underscore what Dr. Ghayda said about how conventional health care delivery is not going to be possible for most people moving forward, but especially people in rural areas. There's a massive shortage of doctors, especially in certain areas that treat older adults, like urology and urogynecology, and this is very true for rural patients who tend to be older. I think getting creative with figuring out how to get these people access to care and expanding telehealth and cementing it as something that's going to be fundamentally covered by all insurance is going to be important to the future of health care delivery in this group of people, and maybe in all people.

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