Healthcare systems and governments in the United States and much of the world have had to take unprecedented emergency measures to contain the coronavirus disease 2019 (COVID-19) pandemic. Social distancing has been a key component in the effort to prevent person-to-person transmission of SARS-CoV-2, the novel coronavirus that causes the disease. Medical practices have had to postpone elective procedures and cancel non-urgent face-to-face patient encounters. Patients have avoided going to emergency departments out of fear they might contract COVID-19, perhaps delaying diagnoses of serious diseases.
Lessons learned from the pandemic may trigger an evolution in American healthcare delivery. The crisis has compelled the use of telemedicine across medical specialties, which could lead to entrenchment of this modality in clinical practice if healthcare providers and patients find that they like this type of interaction. COVID-19 prompted healthcare providers to think about ways to protect vulnerable populations, such as patients on dialysis or those with compromised immune systems. Physicians could discover how much delays matter in the diagnosis and treatment of certain diseases. The pandemic may accelerate adoption of tests that make invasive procedures unnecessary and change how clinical trials are conducted.
“Telemedicine is assuming tsunami-like growth and has reached the critical mass where patients will expect that their provider will be able to conduct a virtual visit,” said Neil Baum, MD, Professor of Clinical Urology at Tulane Medical School in New Orleans, a proponent of virtual medicine. “Practices that don’t offer telemedicine will find that patients will seek out a provider who does offer this service.”
Telemedicine can enable urologists to improve access to their practices, reduce costs, enhance productivity, improve patient satisfaction, and perhaps reduce the high rate of physician burnout, Dr Baum said. “I would like to think that this COVID-19 crisis has opened up a new way for the urologist to implement telemedicine into their practices,” he told Renal & Urology News.
Only a few years ago, the use of telemedicine was relegated to treating patients in rural areas or patients who were far from “bricks and mortar practices,” Dr Baum said. The COVID- 19 crisis and relaxation of Centers for Medicare and Medicaid Services (CMS) requirements for conducting telemedicine have made this modality attractive to urologists. “Now urologists can treat patients 24/7 from their homes using laptops and even mobile devices to communicate with patients,” Dr Baum said. “What was once done using a telephone is now accomplished using synchronous audiovisual communication.”
“It has greatly accelerated our telemedicine efforts,” said urologic oncologist John L. Gore, MD, MS, Professor in Urology and Adjunct Professor in Surgery at the University of Washington in Seattle, referring to the pandemic. “We’ve converted the overwhelming bulk of our practice to telemedicine.” Nephrologists also have greatly expanded their use of telemedicine, which provides a safer way to care for patients with end-stage renal disease (ESRD). This patient population is at high risk of contracting infections and suffering severe complications from them as a result of underlying health problems.
“Health professionals across the US are witnessing a radical transformation from in-person face-to-face care to virtual [care] as we strive to decrease the transmission of COVID-19 to healthcare professionals and ESRD patients,” nephrologist Martin J. Schreiber, MD, Chief Medical Officer for DaVita Home Modalities, said in an April 9 webinar that was part of a COVID-19 webinar series sponsored by the American Society of Nephrology (ASN). “We are seeing great telehealth adoption that would previously take years to advance, now occurring in literally weeks.”
Despite “myths” that virtual health is too difficult or not effective or that patients prefer in-person encounters, “we now see that COVID has proved to be the ultimate virtual health myth buster,” Dr Schreiber added.
Virtual visits skyrocket
At DaVita Inc., one of the two major providers of dialysis care in the United States, total telemedicine appointments rose by 950% from before the COVID- 19 pandemic to April 3, Dr Schreiber reported. Between the time before the pandemic and March, the percentage of physician visits completed via telemedicine rose by 659%. Fresenius Medical Care North America (FMCNA), the other major dialysis provider, reported that its telemedicine workflow grew by more than 150,000 virtual visits from late March to the end of April.
At Integrated Medical Professionals, a Farmingdale, New York-based independent urology group of more than 100 providers and a clinical affiliate of The Mount Sinai Health System in New York City, 73% of medical encounters in the week ending April 17 were patients waiting to be evaluated for kidney transplantation.
The pandemic prompted Dr Formica’s team to rethink how they manage patients in the first year post-transplant. For example, instead of twice-weekly, inperson follow-up visits, they are considering substituting one of the visits with a telemedicine encounter. They also have looked at replacing some surveillance biopsies with a new blood test that has been shown to be a reliable substitute for those procedures.
Marcus R. Pereira, MD, a transplant infectious disease specialist at Columbia University College of Physicians and Surgeons in New York City, said he predicts the pandemic will result in a long-term focus on, and investment in, infection prevention and control at transplant centers, with an emphasis on vaccinations, not just against the SARSCoV- 2, but against viruses in general.
Ramped up vaccination efforts
At Columbia, he and his colleagues are preparing for a surge of respiratory illness among transplant recipients that may result when influenza adds to the COVID- 19 caseload. “Come the end of fall, we’re going to have a whole different approach to respiratory infections that come along with fall and winter. I think that there will be a much greater concentration of effort for vaccinating these patients.”
He added, “We had already been in the process of revising our vaccine protocols since last year, recognizing that not 100% of patients were getting the fully recommended schedule. So that’s actually well underway, and I think that will definitely be highlighted once we have a vaccine for this particular [SARS-CoV-2] virus. I think people will definitely pay a lot of attention [to vaccinations] and set up resources to make sure our patients, both pre- and post-transplant, get all the required vaccines.”
Transplant recipients are not the only patients at risk of infection because of immunosuppression. Patients with glomerular diseases, such as lupus nephritis and glomerulonephritis (GN), can be at risk as well. In an article published online April 24 in the Clinical Journal of the American Society of Nephrology, Andrew S. Bomback, MD, and colleagues at the Center for Glomerular Diseases at Columbia University College of Physicians and Surgeons described how they adapted their care of glomerular diseases to decrease complications from COVID-19 infections. For example, nephrologists at the center still advise patients at high risk of progression to ESRD without immediate therapy to begin standard of care immunosuppressive regimens. For many patients who have a less ominous disease course but who otherwise would be treated with immunosuppression, they advise postponing treatment until the patients’ local COVID-19 transmission rates are low enough that social distancing measures are no longer recommended.
Dr Bomback and his coauthors also speculated about the impact of COVID- 19 on their future practice.
“We anticipate that our management of glomerular disease patients will be altered by our current COVID-19- influenced practices even when the current pandemic has resolved,” they wrote. “We have seen significantly lower rates of rapidly progressive GN in our hospitalized patients and disease relapses in our clinic patients since widespread adoption of social distancing…This seemingly quiescent disease state supports the hypothesis that environmental exposures, including but not limited to infections, may be a major trigger of glomerular disease onset and relapse.”
Another possible effect of the pandemic is delayed diagnosis of cancer and other diseases because people have avoided emergency departments and other healthcare encounters out of concern about contracting COVID-19.
“The number of new cancer cases has gone down quite a bit,” said Dr Gore, who is on the Fellowship Committee of the Society of Urologic Oncology. Men have not been receiving PSA-based prostate cancer screenings, leading to a drop in referrals for prostate biopsies and, consequently, new prostate cancer diagnoses, Dr Gore said. Cases of kidney cancer, an incidentally detected malignancy, are down because people are not going to emergency departments with symptoms such as abdominal pain, which would trigger radiographic studies.
Dr Gore related that his institution is preparing for a surge of patients this summer and fall, a group that will include individuals with lower-risk cancers whose care had been deferred and those with urologic cancers that had not been diagnosed because they avoided doctors. Treatment deferrals have had a negative impact on patients, he said. “Even if we reassure them that [they have] a low-risk cancer and it’s perfectly safe to wait, it’s a huge source of anxiety for patients,” Dr Gore said.
Insights into care
In response to the pandemic, Dr Gore and his colleagues have stepped up use of surveillance for cases of lower-risk bladder cancers, small renal masses, and intermediate-risk prostate cancer. “We’re making decisions about who needs care and who doesn’t,” Dr Gore said.
Physicians in his department may come to realize it is perfectly safe to surveil cases currently thought of as requiring intervention and certain disease states usually considered urgent, such as high-risk prostate cancer, may not require immediate treatment, he said. Doctors also may gain insight into the impact of deferred diagnoses on such clinical factors as cancer stage at presentation and eventual cancer-specific outcomes, he said.
The impact of the COVID-19 pandemic on clinical trials could lead to changes in how these trials are conducted even after the crisis ends, according to the findings of a survey of clinical trial programs in the United States by the American Society of Clinical Oncology.
“Numerous challenges with conducting clinical trials were reported, including enrollment and protocol adherence difficulties with decreased patient visits, staffing constraints, and limited availability of ancillary services,” David M. Waterhouse, MD, MPH, of Oncology Hematology Care in Cincinnati, Ohio, and collaborators wrote in JCO Oncology Practice. The investigators based their findings on 32 survey respondents representing 14 academic and 18 community-based clinical trial programs. “Although the survey reflects a small sample of research programs in the United States during a rapidly changing situation, the results provide insight into the state of clinical trials across a range of types of research programs in the early weeks of the COVID- 19 pandemic,” the investigators wrote.
More than half of respondents said they observed a decrease in patient ability or willingness to come to their site, and cited the staff time needed to organize, implement, and conduct telehealth visits as a significant challenge. Results showed that 90% of respondents identified telehealth visits for participants as a potential improvement in conducting a clinical trial, and 77.4% indicated that remote patient review of symptoms held similar potential, according to the authors.
“One of the early lessons has been that it is possible to conduct more streamlined or pragmatic trials,” Dr Waterhouse and his coauthors wrote. “Many trials currently include tests, procedures, and strict data collection requirements and windows for assessment that are intended to maximize knowledge gained but may prove burdensome to both patients and trial programs.” Another lesson, they noted, is that trials could routinely leverage technology to limit in-person visits for trial programs and patients.
Many visits by industry sponsors and contract research organizations are being conducted remotely, or in some cases, eliminated altogether, according to the report.
“Given that trial activity is able to continue, many of these in-person visits should not be required post- COVID-19,” according to the report.
Other opportunities to improve clinical trials, according to survey respondents, include shipping oral drugs directly to patients, remote adverse event assessments, and patient review of symptoms as well as streamlined data collection, including decreased collection of “unnecessary data.”
“Increased remote work by research staff was noted as an opportunity to improve job productivity, satisfaction, and staff retention, as well as mitigate space issues at sites.”
Rough road ahead
Infectious disease specialists and public health officials agree that the pandemic will persist for the foreseeable future. Medical practices are adapting to the new environment and gearing up for the backlogs of cases that have built up as a result of elective procedures being postponed.
Such is the case at UroPartners, LLC, a large urology group practice that serves the Chicago area. Urologists are planning for a “tsunami” of cases in the next 2 or 3 months, said Richard Harris, MD, the group’s President and CEO, who is also President of the Large Urology Group Practice Association. “We have been putting policies in place for both patient and staff protection in order to do all of these cases safely,” he said.
The process will be slow. “Nobody’s going to be able to ramp up their pre- COVID levels [of cases] for a long time, maybe even a year,” he said.
He added, “This COVID pandemic is just not going to go away with the flip of a switch. What’s going to happen is, it may taper down over the summer months, but of course, there is concern that it’s going to resurface in the fall and winter. Until we can get massive testing and a vaccine, it’s going to continue to be somewhat perilous.”