Introduction:Pediatric urology is a much-needed subspecialty with a breadth of complex disorders that can often prove challenging to diagnose and manage. Exacerbating this need is the minimal exposure medical trainees receive to pediatric urology. Pediatric urology arrived in West Virginia in 1983 but the subspecialty has been inconsistently represented since then. Currently there are 2 fellowship-trained pediatric urologists in the state of West Virginia, which has an area of approximately 24,038 square miles. We review our experience with the use of telemedicine in providing outreach to the wider parts of our medically underserved state and ultimately evaluate its efficacy from a patient-centric cost analysis and diagnosis concordance perspective. We hypothesized that the use of telemedicine would be cost and time-effective for patients in our rural state.Methods:We retrospectively reviewed our series of patients presenting from outside telemedicine “referral centers” in Martinsburg, Parkersburg and Wheeling for pediatric urological consultation. We evaluated reason for consultation, geographic driving distance, drive time and travel cost saved from telemedicine consultation.Results:A total of 92 patients presented to outside designated telemedicine centers from August 2018 to April 2020. The mean driving time saved utilizing telemedicine consultation was 4 hours and 46 minutes, and mean driving distance saved was 299.8 miles. Travel costs saved in terms of fuel averaged $173.88 per patient. The most common reason for consultation was undescended testis, followed by recurrent urinary tract infection and nocturnal enuresis. Of the 23 patients who required surgery, only 2 (8.7%) had an initial diagnosis that was not concordant with their operating room examination.Conclusions:While modest, our data indicate a modern solution to a historical need in our state. Our high diagnosis concordance rate (91.3%) shows that a well-trained advanced practice provider can adequately perform an operative evaluation via telemedicine.
BackgroundTelemedicine is now commonplace and an accepted modality for delivering health care due to the coronavirus pandemic. It has proven useful in increasing access to traditionally limited subspecialties and bridged the gap of local regional geographic restraints. We report a follow up of our experience building tele-consultation capacity for pediatric urology in a resource constrained area. Specifically, we hypothesize that hybrid tele-consultation is a safe modality for postoperative evaluation. A secondary goal of this study is to evaluate perceived barriers to implementing this practice from the perspective of advanced practice providers (APPs).MethodsAfter obtaining IRB approval (IRB# 1910741113), patients were prospectively recruited for tele-consultation encounters with a tertiary academic center between August 2018 and March 2020 (pre-dating the coronavirus pandemic). Advanced practice providers received additional training in physical diagnosis and examination prior to returning to satellite clinics in their local communities and facilitating tele-consultation with an academic pediatric urologist. Postoperative outcomes were analyzed out to eight weeks and any peri- and postoperative complications were assessed using the Clavien-Dindo classification system. Finally, anonymous surveys were administered to the APPs at the conclusion of the recruitment period to assess their satisfaction with telemedicine clinics and perceived barriers to implementation.Results92 telemedicine encounters took place between August 2018 and March 2020. The most common reasons for presentation were undescended testis (UDT) (n=15), urinary tract infection (n=13) and enuresis (n=13). The most common surgical case booked by the APPs in the satellite clinic was orchiopexy (n=10). Mean distance travel saved was 299.8 miles. In 23 patients who were schedule surgery, only two patients (8.7%) had an initial diagnosis that differed with their APP pre-operative diagnosis. Of the 22 patients who underwent surgery, all elected telemedicine visits for postoperative evaluation. No patient experienced complications. Initial consultations averaged 14 minutes (range 9 to 20 minutes), while mean duration of postoperative evaluations was 9 minutes (range 6 to 13 minutes). With regards to surveys, APPs reported an overall positive experience with tele-consultation (4.5/5, n=7) and all planned on incorporating it into their future practice (4.9/5, n =7).ConclusionA hybrid tele-consultation video conferencing clinic with heavy reliance on APPs is a safe, reliable and economical way to address pediatric subspecialty surgical needs in the rural setting. With proper training and exposure, APPs can safely perform preoperative assessments and correctly refer patients for surgical intervention, adding efficiency to the surgical subspecialty workflow.
rate shows that a well-trained advanced practice provider can adequately perform an operative evaluation via tele-medicine.
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