Social distancing has formed the backbone of public health responses to the COVID-19 pandemic. These approaches have slowed the spread of COVID-19. However, they have dramatically changed the delivery of health care in many jurisdictions. While some regions have returned to a large proportion of in-patient interactions, many jurisdictions have continued with telemedicine, e-consults, virtual care, hospital-at-home approaches with early discharge and remote monitoring, and virtual conferences/tumor boards that were initiated during the initial wave of the pandemic.7 While none of these approaches are novel, prior to COVID-19, they were not widely adopted in urology.8,9
In a recently accepted collaborative review article in European Urology, we examined the evolution of care for patients with genitourinary cancers following the initial COVID-19 outbreak. As a part of this review, we highlighted the role of socially distanced medical care going forward. Telemedicine represents the best-known form of this care, though there are other forms as well, including e-consults, virtual care, hospital-at-home approaches with early discharge, and remote monitoring.
Telehealth: Prior to COVID-19, telemedicine was sparingly used in urology.8 However, because of social distancing requirements, many have transitioned to telemedicine-based consultations in place of in-person office visits. Although not new, the pandemic has accelerated adoption of this approach due to necessity and regulatory changes.9
In contrast to many other aspects of changing care, the role of telemedicine in urology and genitourinary oncology has previously been assessed8 with the bulk of the literature assessing its role in the care of patients with prostate cancer. The use of telehealth in prostate cancer has spanned the disease trajectory from treatment decision-making through intervention to follow-up and survivorship. In each case, telemedicine-based interventions have been used to supplement rather than replace in-person interactions. We will review some of the data supporting this complimentary use of telemedicine, though little data exist assessing it in the supplanting role that it has taken on.
In the context of treatment decision-making, Schaffert and colleagues described their approach to developing an online tutorial to assist patients with localized prostate cancer with treatment decision-making.10 The authors surveyed patients following utilization of the online tutorial and after their treatment decision. The use of the online tool was associated with good decisional preparedness.10 Although this is a small single-arm study, a similar approach has been reported by Berry and colleagues utilizing the Personal Patient Profile-Prostate (P3P) in a multi-center randomized trial.11 When compared with the “usual care” comparator, the use of the online P3P intervention was associated with lower decisional conflict.
In a randomized trial, Parsons et al. demonstrated that a telephone-based intervention, compared with written materials, could meaningfully modify dietary behavior in men with prostate cancer.12 While this study did not show a clinical benefit, it offers promise for the value of remote patient counseling. Because each of these studies also included in-person interactions, they demonstrate the added value of remote interactions to further support treatment decision-making, but these studies do not suggest that virtual approaches replace in-person care. Further investigations comparing these approaches are necessary if teams are to use virtual care to replace face-to-face visits prior to these critical treatment choices.
Data are available describing the role of telemedicine and virtual care in the survivorship setting as well. Skolarus and colleagues recruited 556 patients with prostate cancer in the US Veterans Affairs care system who reported symptom burden between 1 and 10 years following treatment.13 These men were randomized to a personally tailored, automated telephone symptom management intervention in addition to continued routine in-person or usual care consisting of one non-tailored self-management newsletter with continued in-person follow-up. Patients receiving the tailored intervention had improved EPIC scores across all domains, although the differences were not statistically significant. Viers et al. report a randomized comparison of telemedicine visits and traditional office-based consultation among 55 selected patients who had previously undergone radical prostatectomy.14
They found no differences in terms of measures of efficiency but more importantly no differences in patient satisfaction, education quality, or confidentiality in this population. Patients receiving telemedicine visits reported significantly lower costs associated with travel and loss of work compared with office visit patients. Among patients having undergone radiotherapy, Leahy et al. showed similar satisfaction to a follow-up using a nurse-led telephone consultation compared with standard office visits in a non-randomized comparison.15 Recently, Belarmino and colleagues demonstrated the feasibility of a smartphone app for monitoring of post-operative recovery and Kegel teaching following radical prostatectomy, though no assessment of outcomes was reported,16 while Lange et al. offered some cautionary data demonstrating poorer psychological outcomes for patients utilizing an online peer chat-group compared with usual care.17 A number of other studies have assessed the feasibility of behavioral interventions (predominantly in activity/exercise engagement) in patients with prostate cancer.18,19 Taken together, these studies demonstrate that—in most cases—remote virtual care appears feasible to support or possibly replace a portion of in-person clinician interactions.
Moving forward, ongoing utilization of telemedicine offers many potential benefits as well as risks for our patients. Outside of urology, there is evidence of the benefits of telemedicine.20 Previous work in the primary care literature has identified younger patient age, ethnic minorities, full-time employment, and long commute times to work as barriers to patient access to traditional medical care.21 Telemedicine may obviate some of these barriers. As mentioned above, Viers et al. demonstrated that the use of telemedicine was associated with significantly decreased costs due to travel savings and decreased time off work.14 In the orthopedic literature, randomized data have demonstrated that the use of telemedicine for post-operative follow-up is associated with decreased time off work for both patients and caregivers.22 Additionally, telemedicine was found to be less time consuming from both the patient and physician perspective. Telemedicine could also facilitate visits outside of normal daytime clinic hours, expanding access to care for patients unable to take time off of work. Further, the use of telemedicine may allow tertiary or quaternary level care to be provided to patients in remote regions, potentially reducing geographic disparities in care.23 Finally, virtual care has the potential to positively impact carbon emissions.
However, reliance on telemedicine is not without risk.24 Conveying information on adverse prognosis through a telemedicine portal may inadequately guard the sensitive nature of these challenging conversations.25 The original SPIKES protocol for breaking bad news stressed the importance of a proper setting for disclosing serious news, even highlighting the importance of eye contact and potential physician contact (e.g. holding hand or touching shoulder, as appropriate).25 In a virtual visit, either explicit verbalization or other forms of signaling are necessary to take the place of these nonverbal clues to emphasize human connection. Further, while telemedicine can reduce barriers due to the time and cost required for in-person visits, it may also exacerbate disparities due to socioeconomic factors, health literacy, language, and technological capabilities. Patients must have a device capable of video-conferencing, reliable internet access, and technological proficiency to navigate the required software. Recent data indicate that more than one-quarter of all Medicare beneficiaries lack digital access at home, which would preclude their utilization of telehealth.26 Further, this disproportionately affected those with low socioeconomic status, those 85 years of age and older, and those in communities of color. Beyond a lack of digital access, patients may be unready for telehealth for a variety of reasons including inexperience with the necessary technology or physical limitations (hearing, vision, dexterity).
Taking these into account, it is estimated that nearly 40% of older adults (age 65 years and older) representing 13 million individuals are not ready for video visits.27 Additionally, many tools are only available in English and are not targeted to those with lower health literacy. Thus, a transition to the widespread use of telehealth may exacerbate existing disparities in care, and implementation of these approaches needs to be mindful of this. While there have been concerns regarding patient privacy, numerous telehealth platforms have addressed this through compliance with privacy standards and regulations. Finally, there has been little study of patient comprehension or engagement during video visits.
Beyond patient-facing concerns, there are institutional and physician-level issues that arise with a widespread transition to this approach. There may be a widening disparity between large healthcare systems that can invest and maintain telehealth solutions and those (typically smaller) practices that cannot. This may result in the centralization of health care administration. The economic impact of telemedicine is currently unclear28,29 — the question of billing or remuneration for these interactions remains to be settled in many jurisdictions. For physicians who are salaried, this is less of a concern, however, the ongoing acceptance of telemedicine billings from payors will clearly influence the viability of this approach going forward.
The role of trainees and advanced practice providers in telehealth remains an actively evolving area with the potential to affect both trainees’ educational experiences and the clinic workflow. It can be more challenging to directly oversee a trainee or other care providers in a virtual setting and to provide real-time teaching. The review article cited experience from some of the included authors of integrating trainees into the telemedicine consultation process, though with a loss of fluidity: in this structure, the trainee initiates a virtual consultation with the patient, then telephones the supervising physician to review and discuss care, before both the trainee and supervising physician return to the virtual interaction with the patient. A similar approach may be feasible with advanced practice providers.
In addition to telehealth, other remote care avenues offer even further opportunities.
Telemonitoring: Telemonitoring is a remote assessment of physiologic data on the basis of digital transmission. Telemonitoring has been used to facilitate early hospital discharge with ongoing home-based monitoring. In systematic reviews dating back to 2001, early hospital discharge with home-based post-operative care has been suggested to reduce pressure on acute hospital beds.30 More recent data from the cardiology literature has demonstrated that hospital-at-home care can increase the time from discharge to hospital readmission, reduce costs, and improve health-related quality of life.31 Further, treatment at home, rather than the hospital, is associated with improved functional outcomes for older patients deemed at need for hospital admission.32 In France, cancer treatment at home, rather than in the hospital, was associated with significant cost savings, particularly for patients with the most advanced disease.33
In the context of genitourinary oncology, the use of telemonitoring and home-based post-operative care may offer the greatest benefit in patients following radical cystectomy who typically have prolonged hospitalizations and—due to age, comorbidity, and the magnitude of the surgery— are at high risk of readmission.34,35 Initial pilot work has demonstrated the feasibility of using remote monitoring applications, such as personal activity trackers, wearables, and smartphone applications for perioperative monitoring.36-38 However, much more work is required to further delineate the role of this approach including assessment of the sensitivity of telemonitoring to identify issues before the symptomatic presentation, of the intensity and manner of monitoring of data being shared with clinicians, and of the balance of telemonitoring/in-person visits.39,40 However, utilization of these approaches may decrease the need for post-discharge nursing home care,41 as well as reducing emergency department presentations and hospitalizations through the early rescue of post-operative complications. Although “hospital-at-home” approaches have been described in the literature for well over 20 years,42 ongoing advances in technology, including wearable devices that can track physiologic parameters including most vital signs, have recently improved the level of care that may be provided at home.43,44
Other applications of virtual care: There are numerous other ways in which increasing utilization of technology may improve care for patients with urologic cancers. First, moving beyond direct patient interactions, many major academic centers have transitioned to remote, electronically facilitated, multi-disciplinary tumor boards. Although multi-disciplinary tumor boards have been demonstrated to improve the delivery of the complex care needed for patients with advanced cancers45, including more rapid time to multidisciplinary recommendations,46-48 they are not routinely utilized in the community setting despite their prevalence at academic institutions.49 Having made the transition to video tumor boards, ongoing use of this approach at academic institutions would allow the involvement of clinicians in geographically remote locations, thus facilitating the expertise of tertiary and quaternary care to rural and non-academic centers. Virtual tumor boards can also be beneficial to local community providers who cannot interrupt their practices to physically attend a University tumor board across town.
Second, electronic consults (e-consults) allow for asynchronous interactions between two physicians (one the consulter and one the consultee). E-consults can improve access to specialty expertise without the need for face-to-face specialist visits.50-52 This approach is associated with timely access to specialty expertise and is well received by primary care providers.53 The move to e-consults can overcome physical space limitations in healthcare facilities and allow for more flexible scheduling of outpatient care (not restricted by clinic space availability, outside traditional hours, and interspersed during operating day downtimes).
Third, although clinical decision support systems can provide real-time recommendations, an automated digital patient engagement platform can help patients manage acute, chronic, or peri-procedural care while also automating simple workflows (such as verifying an undetectable post-prostatectomy PSA at specified intervals).54-56 There are many examples outside urology and significant opportunities for improvement in urologic oncology care.
Conclusion: In summary, the COVID-19 pandemic has forced a rapid transition to telemedicine and teleconferencing. In many jurisdictions, this transition is continuing even following the resolution of the initial pandemic wave while in others, there has been a switch back to in-person care. A thoughtful and targeted increase in the use of telemedicine offers the potential to improve outcomes for patients by decreasing the time and financial burden of physician visits and reducing geographic barriers to tertiary and quaternary care expertise for patients with genitourinary cancer. However, such a change may also exacerbate disparities for many populations who already have poorer health outcomes. Thus, the targeted roll-out will be necessary to ensure the use of telemedicine does not widen existing disparities.
Written by: Christopher J.D. Wallis, MD, PhD, Vanderbilt University Medical Center, Nashville, Tennessee, USA and Zachary Klaassen, MD MSc, Medical College of Georgia, Augusta, Georgia, USA