Telemedicine as a model for RCC surveillance during the COVID-19 pandemic

"Certainly, telemedicine is not a replacement for in-person encounters for all urologic conditions, but rather another tool in our armamentarium," writes Adele M. Caruso, DNP, CRNP, FAANP.

Dr Caruso is a nurse practitioner at the University of Pennsylvania Health System, Philadelphia.

The standard components of care for renal cell carcinoma are active and post intervention surveillance. The COVID-19 pandemic presented challenges for urology patients to receive care in the format of the traditional in-person clinic visit. The telemedicine (defined as a televideo encounter) visit format ensured continuity of care during this past year. What have we learned after 1 year? Perhaps that telemedicine is a good model for renal cancer surveillance.

Challenges of COVID-19

The COVID-19 pandemic presented challenges for urology patients, especially in early 2020. Urologists and urology advanced practice providers (APPs) were faced with delivering care while preventing patients from getting COVID-19 and protecting themselves as health care providers. Telemedicine visits were offered as an alternative. What was the patient perspective? As one might expect, and according to Boehm et al,1 who conducted phone interviews at the onset of the pandemic, 84.7% wished for a telemedicine visit. A visit was not conducted 17.3% of the time due to a technical limitation. In this study, which also looked at risk factors, patients with renal cancer had the highest number of risk factors, followed by urothelial cancer, prostate cancer, then nononcological disease.

Alternative to traditional care, a model during the COVID 19 pandemic

Preliminary findings of 100 patients at the University of Pennsylvania identified telemedicine for renal cancer patients as a good alternative to traditional care during the COVID-19 pandemic.2 The study was conducted solely via televideo platform. Patients perceived telemedicine care favorably. More than 80% of respondents agreed the patient/provider interaction was positive and their visit was effective. More than 78% of respondents reported that the telemedicine platform was easy to access. This conclusion validates the hypothesis that patients found the telemedicine/televideo platform a valuable tool and appropriate mode to receive care with ease of use. Patients expressed a positive experience with their patient/provider interaction with telemedicine/televideo.

Urology as a high user of telemedicine across subspecialties

In a recent investigation by Chao et al,3 of 4405 active surgeons, 2508 utilized telemedicine with 109,610 visits, and urology ranked the highest user of telemedicine across subspecialities. For new patients, urology came in first at 14.3% (prepandemic conversion rate, 7.7%) with neurosurgery at 13.8% (prepandemic conversion rate, 3.7%). The conversion rate defined as new telemedicine visits divided by the mean total of new patient visits. Further analysis supported urology as the leading subspecialty for established patients at 21.6%. Overall, with all patients, prepandemic visits were less than 1% for new patients, which increased to 34% at the height of telemedicine use, followed by a decrease to 3% during the later months, which were indicative of prepandemic levels.4 Other findings related to patient characteristics for new patients showed higher use by women, patients younger than 60 years of age, nonrural area, and a mean income of above $56,458.

Benefits to patients and benefits to providers

Telemedicine afforded continuity of care for needed medical access while abiding by the initial stay-at-home orders. Telemedicine continues to support a safe environment when needed during the COVID-19 pandemic. Additionally, this modality offers convenience to patients with quicker access to health care providers, and minimizes travel time and expense. The question that remains, however, is that of effective patient-provider connection. Is this form of communication appropriate for difficult conversations or managing strong emotions?5 I would say that for certain urologic conditions, and specifically with the population of renal cancer surveillance patients, preliminary evidence is favorable.

Socioeconomic disparities

Do social disparities play a role in telehealth? One recent study sought to assess demographics and socioeconomic factors and insurance status associated with patient participation in telehealth during the COVID-19 pandemic.6 The cohort included more than 1000 otolaryngology patients with greater than 400 telehealth visits in a tertiary care, academic, multispecialty, multisite practice. The findings suggested that age, sex, median household income, and marital status play roles in patient participation. The findings identify vulnerable populations who may not engage with telehealth, yet still require medical care in a changing health care delivery landscape. In the Philadelphia Veterans Administration, observations of a group of urology patients who acknowledge transportation issues and cost related to transportation, and who are adept with their mobile phone, seem receptive to telemedicine and to receive care though this modality.

Barriers to reimbursement

Federal and state emergency declarations early on in the COVID-19 pandemic waived barriers for out-of-state medical licenses in order for providers to treat out-of-state patients. However, the future of licensure reciprocity is unclear. Several reforms have been suggested, including state-based medical licensing, licensure reciprocity, a proposal to practice medicine on the basis of the physician’s location instead of the patient location, or the implementation of a federal medical license.7 Insurance and reimbursement legislation would need to coincide for this to be a viable solution.

Certainly, telemedicine is not a replacement for in-person encounters for all urologic conditions, but rather another tool in our armamentarium. As we rely on and incorporate telemedicine into our daily practice, I would say, consider telemedicine/televideo as a model for your renal cancer surveillance patients, and for other select urology patient populations.

What does the future hold? Is telemedicine here to stay? Time will tell.

As always, please feel free to provide your perspective by emailing me at urology_times@mmhgroup.com

References

1.Boehm K, Ziewers S, Brandt MP, et al. (2020) Telemedicine online visits in Urology during the COVID-19 pandemic-potential risk factors, and patients’ perspective. Eur Urol. 2021;78(1)16-20. doi:10.1016/j.eururo.2020.04.055

2. Caruso AM, Lin G, Malkowicz SB. (2021). Telemedicine/Televideo Platform as a preferred mode for renal cell carcinoma surveillance during the COVID-19 Pandemic. Presented at the meeting of the American Urological Association Meeting 69th Annual 2021 Meeting. Urologic Care for the Advanced Practice Provider.

3.Chao GF, Li KY, Zhu Z, et al. Use of telehealth by surgical specialties during the COVID-19 pandemic. JAMA Surg. Published online March 26, 2021. doi:10.1001/jamasurg.2021.0979.

4. Kapadia MR, Kratzke IM, Sugg SL. The rise and fall of surgical telehealth-can lack of patient connection be blamed? JAMA Surg. Published online March 26, 2021. doi:10.1001/jamasurg.2021.0989

5. Kapadia MR, Kieran K. Being affable, available, and able is not enough: prioritizing surgeon-patient communication. JAMA Surg. 2020;155(4):277-278. doi:10.1001/jamasurg.2019.5884

6.Darrat I, Tam S, Boulis M, Williams AM. Socioeconomic disparities in patient use of telehealth during the coronavirus disease 2019 surge. JAMA Otolaryngol Head Neck Surg. 2021;147(3):287-295. doi:10.1001/jamaoto.2020.5161

7. Mehrotra A, Nimgaonkar A, Richman B, et al. Telemedicine and medical licensure - potential paths for reform. N Engl J Med. 2021;384(8):687-690. doi:10.1056/NEJMp2031608