A Critical Appraisal of the American College of Surgeons Medically Necessary, Time Sensitive Procedures (MeNTS) Scoring System, Urology Consensus Recommendations and Individual Surgeon Case Prioritization for Resumption of Elective Urological Surgery During the COVID-19 Pandemic
2020; Lippincott Williams & Wilkins; Volume: 205; Issue: 1 Linguagem: Inglês
10.1097/ju.0000000000001315
ISSN1527-3792
AutoresJoshua A. Cohn, Eric Ghiraldi, Robert G. Uzzo, Jay Simhan,
Tópico(s)Healthcare cost, quality, practices
ResumoYou have accessJournal of UrologyAdult Urology1 Jan 2021A Critical Appraisal of the American College of Surgeons Medically Necessary, Time Sensitive Procedures (MeNTS) Scoring System, Urology Consensus Recommendations and Individual Surgeon Case Prioritization for Resumption of Elective Urological Surgery During the COVID-19 Pandemic Joshua A. Cohn, Eric M. Ghiraldi, Robert G. Uzzo, and Jay Simhan Joshua A. CohnJoshua A. Cohn *Correspondence: Einstein Healthcare Network and Moss Rehabilitation Institute, Fox Chase Cancer Center, 50 Township Line Rd., Suite 202, Elkins Park, Pennsylvania 19027 telephone: 215-663-6067; FAX: 215-663-7089; E-mail Address: [email protected] Department of Urology, Einstein Healthcare Network, Philadelphia, Pennsylvania Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania , Eric M. GhiraldiEric M. Ghiraldi Department of Urology, Einstein Healthcare Network, Philadelphia, Pennsylvania , Robert G. UzzoRobert G. Uzzo Department of Urology, Einstein Healthcare Network, Philadelphia, Pennsylvania Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania , and Jay SimhanJay Simhan Department of Urology, Einstein Healthcare Network, Philadelphia, Pennsylvania Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania View All Author Informationhttps://doi.org/10.1097/JU.0000000000001315AboutAbstractPDF Cite Export CitationSelect Citation formatNLMIEEEACMAPAChicagoMLAHarvardTips on citation downloadDownload citationCopy citation ToolsAdd to favoritesTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Abstract Purpose: Resumption of elective urology cases postponed due to the COVID-19 pandemic requires a systematic approach to case prioritization, which may be based on detailed cross-specialty questionnaires, specialty specific published expert opinion or by individual (operating) surgeon review. We evaluated whether each of these systems effectively stratifies cases and for agreement between approaches in order to inform departmental policy. Materials and Methods: We evaluated triage of elective cases postponed within our department due to the COVID-19 pandemic (March 9, 2020 to May 22, 2020) using questionnaire based surgical prioritization (American College of Surgeons Medically Necessary, Time Sensitive Procedures [MeNTS] instrument), consensus/expert opinion based surgical prioritization (based on published urological recommendations) and individual surgeon based surgical prioritization scoring (developed and managed within our department). Lower scores represented greater urgency. MeNTS scores were compared across consensus/expert opinion based surgical prioritization and individual surgeon based surgical prioritization scores. Results: A total of 204 cases were evaluated. Median MeNTS score was 50 (IQR 44, 55), and mean consensus/expert opinion based surgical prioritization and individual surgeon based surgical prioritization scores were 2.6±0.6 and 2.2±0.8, respectively. Median MeNTS scores were 52 (46.5, 57.5), 50 (44.5, 54.5) and 48 (43.5, 54) for individual surgeon based surgical prioritization priority 1, 2 and 3 cases (p=0.129), and 55 (51.5, 57), 47.5 (42, 56) and 49 (44, 54) for consensus/expert opinion based surgical prioritization priority scores 1, 2, and 3 (p=0.002). There was none to slight agreement between consensus/expert opinion based surgical prioritization and individual surgeon based surgical prioritization scores (Kappa 0.131, p=0.002). Conclusions: Questionnaire based, expert opinion based and individual surgeon based approaches to case prioritization result in significantly different case prioritization. Questionnaire based surgical prioritization did not meaningfully stratify urological cases, and consensus/expert opinion based surgical prioritization and individual surgeon based surgical prioritization frequently disagreed. The strengths and weaknesses of each of these systems should be considered in future disaster planning scenarios. Abbreviations and Acronyms COVID-19 coronavirus disease 2019 EOP consensus/expert opinion based surgical prioritization ISP individual surgeon based surgical prioritization MeNTS Medically Necessary, Time Sensitive Procedures QSP questionnaire based surgical prioritization TURP transurethral resection of the prostate The spread of COVID-19 has strained health care resources throughout the United States.1–4 The long-term impact of the unprecedented diversion of resources from elective surgeries toward the care of such patients may be profound, as delays in surgery have been associated with adverse outcomes in urological cancer5–7 and prolonged suffering from nonlife threatening conditions refractory to medical management.8 As health care resources remain scarce,3 administrators and surgeons must ensure that resumption of elective surgical care balances surgical acuity, patient and provider risk, and resource utilization. Nonspecific constructs provide guidance for triage and resource allocation but require supplementation with case specific prioritization.9 Approaches to surgical prioritization may be categorized as professional society based, cross-discipline surgical prioritization (QSP), specialty society expert opinion priority tiering (EOP) or individual surgeon case-by-case priority stratification (ISP). The American College of Surgeons endorsed the use of a QSP system called the "Medically-Necessary, Time-Sensitive Procedures."10 The MeNTS score is calculated for each case over 21 distinct items, including procedure factors (7 questions), disease factors (6 questions) and patient factors" (8 questions), with scores ranging from 21 to 105 (supplementary Appendix 1, https://www.jurology.com).11 Low scores suggest higher priority, lower resource utilization and lower patient risk. Scores can be compared across specialties, making QSP appealing to administrators tasked with directing case prioritization across departments. Recently published urology based expert opinion recommendations from more than 13 national urological associations provide a specialty specific alternative to QSP and will most certainly be considered for use.12 Some focus on delay of all but the most urgent cases.13 However, others, such as those from that of the AUA (American Urological Association) prioritize elective surgical procedures.14 Individual (operating) surgeon case prioritization may closely resemble expert opinion prioritization in regard to priority tiering but presents the operating surgeon with a greater degree of autonomy. Neither MeNTS,11 urological expert opinion recommendations12–14 or surgeon scoring underwent validation. However, understanding of surgical prioritization strategies is paramount, as these strategies have implications presently and at future times of scarcity.15 We performed a practical appraisal of representative QSP, EOP and ISP systems in a large urological practice. We hypothesized that QSP may not provide meaningful stratification of case prioritization for urological procedures and that the rigidity of EOP would lead to frequent disagreement with ISP. Methods This quality improvement project was exempted by our Institutional Review Board. Following March 13, 2020 urology faculty postponed elective operative procedures over the ensuing 12 weeks in accordance with hospital and state regulations. Elective cases were defined as those where a reasonable delay would be acceptable. Nonemergent but time critical procedures such as advanced kidney cancers or symptomatic ureterolithiasis were expedited per institutional policy and not included in this initiative (fig. 1). Each case underwent MeNTS (ie QSP),11 EOP14 and ISP scoring. Figure 1. Summary of analyses performed Download PPT Assignment of QSP Scores: Calculation of Patient, Procedure and Disease MeNTS Scores MeNTS scores were calculated (by EMG, JAC and JS) with group consensus for each case, aided by consultation with the literature, review of case times and discussion with the operating surgeons (supplementary Appendix 1, https://www.jurology.com).11 No patient was assumed to have COVID-19 risk factors (eg recent exposure, respiratory symptoms). Multiple elements of the MeNTS Procedure and Disease Factors scores were ambiguous for specific procedures and/or conditions. Therefore, low and high Disease and Procedure MeNTS scores were calculated for each procedure, generic to that procedure's range of indications and resource utilization. For example, TURP may be estimated to take 30 minutes or as long as 60 to 120 minutes. For the low calculation for this Procedure Factor, this question was assigned a 1 and for the high calculation, this was assigned a 3. Accordingly, similar spreads could be conceived for disease factors. For example, physical therapy for management of stress urinary incontinence could be considered 60% to 95% as effective as surgery,16 associated with a high score of 4, or not at all effective, equating to a low score of 1. Each procedure was consolidated, and a spread for the Disease and Procedure Factors calculated based on potential variability in case duration, hospital stay, efficacy of nonsurgical options and consequences of delayed intervention. Assignment of EOP and ISP Scores EOP scores were assigned for each case according to recently outlined urology expert recommendations as defined by the official periodical of the AUA, where applicable.14 These recommendations were selected among other urological society recommendations12 because they applied to resumption of elective cases, covered general and subspecialty urology, and were published by the organization that represents all members of our department. A pre-templated priority score for urological procedures (supplementary Appendix 2, https://www.jurology.com), ranging from 0 (emergency) to 4 (nonessential), with scores of 2 through 4 representative of nontime critical elective urological procedures was assigned,14 and scores were adjusted to a 1 to 3 scale. For ISP scoring urologists within the department (6) assigned a priority score of 1 (most urgent) to 3 (least urgent) for each of their own postponed cases, based upon individual surgeon knowledge of the patient, disease and available local resources. Our institution planned a strategy for prioritization of elective cases that progressed from outpatient procedures to those requiring hospital stays in accordance with state/federal guidance. Assessment of QSP, EOP and ISP Scoring MeNTS tertiles were calculated by dividing total number of cases by 3 and assigning the lowest third of scores to tertile 1 (highest priority), 2 or 3. Tertiles were selected to align with expert opinion and individual surgeon prioritization scores. Median MeNTS were compared across EOP and ISP scores. A sunflower plot graphed EOP and ISP scores against total MeNTS scores. MeNTS tertiles, EOP and ISP scores were assessed for agreement. Continuous variables were described with means and compared by 1-way ANOVA test while medians were assessed by Kruskal-Wallis test. Categorical variables were described with frequencies and proportions. Proportions were compared by Fisher's exact test. Cohen's Kappa was used to assess agreement between QSP, EOP and ISP scores. Statistical significance was considered for 2-sided alpha <0.05 and performed using Stata® v. 14. Results A total of 204 urological cases were included in this analysis, including 26 oncology (12.8%), 50 female/neurourology (female pelvic medicine) (24.5%), 55 male reconstruction/prosthetics (27.0%), 51 endourology (25.0%) and 22 general urology (10.8%). Patient demographics according to MeNTS Patient Scores are presented in the table. The overall median patient score was 14 (IQR 10–16) with no difference between subspecialties (p=0.057). Table. Patient demographics according to the MeNTS scoring system No. age (%): Younger than 20 Not applicable 21–40 31 (15.2) 41–50 22 (10.8) 51–65 75 (36.8) Older than 65 76 (37.3) No. lung disease (%):* None 180 (88.2) Minimal (rare inhaler) 11 (5.4) More than minimal 13 (6.4) No. obstructive sleep apnea (%): None 194 (95.1) Moderate (no continuous positive airway pressure) 9 (3.4) Severe (on continuous positive airway pressure) 3 (1.5) No. cardiovascular disease (%):† None 81 (39.7) Minimal (no medications) 7 (3.4) Mild (1 medication) 42 (20.6) Moderate (2 medications) 39 (19.1) Severe (3 or more medications) 35 (17.2) No. diabetes (%): None 162 (79.4) Mild (no medications) 2 (1.0) Moderate (PO medications) 24 (11.8) Severe (insulin) 16 (7.8) No. immunocompromised (%):‡ None 192 (94.1) Moderate 6 (2.9) Severe 6 (2.9) No. no influenza symptoms (fever, cough, sore throat, body aches, diarrhea) (%) 204 (100) No. no COVID-19 exposure (%) 204 (100) Assuming no patients have COVID-19-like symptoms or exposure to COVID-19. Includes asthma, chronic obstructive pulmonary disease and cystic fibrosis. Includes hypertension, congestive heart failure and coronary artery disease. Medications include antihypertensives and blood thinners. Includes hematological malignancy, stem cell transplant, solid organ transplant, active/recent cytotoxic chemotherapy, anti-TNF or other immunosuppressants, more than 20 mg prednisone equivalent per day, congenital immunodeficiency, hypogammaglobulinemia on intravenous immunoglobulin, and AIDS. Median total MeNTS score was 50 (IQR 44, –55), and mean EOP and ISP scores were 2.6±0.6 and 2.2±0.8, respectively. Of 193 cases evaluable by EOP 20 (10.4%), 30 (15.5%) and 143 (74.1%) were priority 1 (ie highest priority), 2 and 3, respectively. By ISP scoring 48 (23.5%) cases were classified as priority 1, 60 (29.4%) as priority 2 and 96 (47.1%) as priority 3. MeNTS Disease and Procedure score spreads are presented in supplementary table 1 (https://www.jurology.com). Spreads ranged from 0 to 27, with a median (IQR) of 15 (9.5, 18) for all cases, and 22 (20, 22), 11 (5, 11), 15 (12, 18), 12 (3, 12) and 16 (16, 23) for endourology, female pelvic medicine, reconstruction and prosthetics, general urology and oncology subspecialty cases, respectively (p <0.001). Mean total MeNTS score, EOP and mean ISP scores by procedure are presented in supplementary table 2 (https://www.jurology.com). Within a given procedure, when more than 1 case of the same procedure type was scheduled (eg 13 scheduled TURPs, 18 ureteroscopies), surgeon prioritization scores differed between 2 or more cases in 24 of the 31 (77.4%) surgery types (eg range of TURP priority scores included 2 priority 1s, 6 priority 2s and 5 priority 3s). ISP and EOP scores are plotted against MeNTS scores in figure 2. There was considerable overlap between MeNTS scores within ISP categories. Specifically, median (IQR) total MeNTS scores were 52 (46.5, 57.5), 50 (44.5, 54.5) and 48 (43.5, 54) for ISP priority categories 1, 2 and 3, respectively (p=0.129). A similar pattern was observed for EOP, with median (IQR) MeNTS scores of 55 (51.5, 57), 47.5 (42, 56) and 49 (44, 54) for EOP priority scores 1, 2 and 3, respectively (p=0.002). There was a 7-point difference between MeNTS priority tertiles 1 and 3, suggesting significant potential change in urology specific MeNTS priority based upon variability in estimation of resources, operative time, efficacy of nonoperative options and consequences of delay. Among the 193 cases ratable by EOP there was "no" agreement with MeNTS tertiles (Kappa -0.122, p=0.999), and "none" to "slight" agreement with ISP scores (Kappa 0.131, p=0.002). Figure 2. Total MeNTS scores grouped by individual surgeon based prioritization scores (A) and consensus based surgical prioritization scores (B). Blue shading indicates MeNTS tertile 1 (highest priority). Yellow shading indicates MeNTS tertile 2. Red shading indicates MeNTS tertile 3 (lowest priority). Download PPT Discussion A global pandemic of the magnitude of COVID-19 has not been experienced for more than a century. In short order, our medical industrial complex has been challenged to focus all resources and efforts on the pandemic, thereby shutting down normal care delivery operations. As the situation unfolded it was unclear how to triage surgical care. Multiple frameworks were rapidly proposed to guide clinicians and health care networks in decision making. Broadly speaking, beyond governmental mandates, these included those proposed by professional organizations (QSP), specialty specific experts (EOP) and/or put in place by individual clinicians (ISP) responding to unique circumstances in their communities and hospitals. Inherent to each approach are a series of assumptions, tradeoffs, incentive structures and other guiding principles upon which final recommendations are made. Teleologically, these frameworks were intended to preserve resources. Standardizing triage is deemed critical during the ramp up of the crisis, making a "top down" approach desirable. Conversely, accounting for unique differences at the local/individual level during the ramp down may make a "bottom up" approach more appropriate. We found that cross-discipline, professional society prioritization scoring (eg MeNTS) did not provide meaningful stratification of case prioritization, and that the rigidity of expert opinion led to frequent disagreement with the perspective of the operating surgeon. Each approach to prioritization has relative merits and drawbacks to consider (see Appendix). Although EOP recommendations are based upon knowledge of conditions and evidence-based literature to support delays, certain fields may be at an advantage. Particularly in oncology, safety of delay, or a more time critical need to proceed, may be supported,5,17,18 and group consensus reassures providers that they are not acting counter to others in the field when data are scarce.19 However, nononcologic procedures may not have robust recommendations to intervene (or not) and standardized prioritization mechanisms might not capture quality of life declines with delayed management. Further, reliance on consensus may limit adaptation or other considerations for a given procedure and/or condition. Our data suggest the rigidity of EOP scoring systems fails to account for important case-by-case differences. For example, a patient comfortable with an indwelling catheter may receive similar priority for TURP as a catheter dependent patient in retention with constant discomfort and multiple traumatic catheterization episodes. It is possible that use of an alternative set of expert recommendations12 may confer advantages over those applied to our cases. However, we suspect all would be associated with similar strengths and limitations. In theory a QSP scoring system such as MeNTS synthesizes many variables to create objective measures of case priority that can be compared across surgical specialties. However, in practice, scoring 21 distinct factors for each patient makes such systems hard to implement, difficult to use in point of care interactions, and worse, highly variable depending on the disease or procedure. Nevertheless, large institutions and government authorities might advocate for such a system that can be applied across disciplines and other third parties (insurance companies, etc.) might intend to study any standardized factor in quality assurance reporting. The well-intentioned but overarching efforts of such QSP systems might be difficult to apply with meaningful results to real-time clinical scenarios observed in the present analysis. Patient, procedural and disease factors that are equally weighted create numerous scenarios where a final priority for any given case can be misrepresented. For example, patients with competing medical risks (eg lung disease, cardiovascular disease etc) who undergo an outpatient, 30-minute procedure with limited hospital resource utilization can be scored as a lower priority compared to a higher complexity outpatient operation in an otherwise medically fit young patient. How can such a mechanism reasonably adjudicate surgical priority? How can equally weighted factors determine case priorities when certain factors in certain situations simply should be more influential? We also demonstrated variability in MeNTS Procedure and Disease scores. Such objective factors are fraught with subjective decision making elements, which have significant implications for case prioritization that may not improve with another similarly intentioned QSP scoring system. Additionally, scoring systems like MeNTS may be challenging to adapt to a constantly changing landscape of medical knowledge and resources during a calamity event.20 To this end, complex models of surgical prioritization can be appealing,21 but excessive emphasis on cross-specialty prioritization can be associated with markedly decreased efficiency in case volumes and longer wait times.22 A case-by-case ISP system is consistent with what surgeons do in times of normal resource utilization, which is triage patients according to disease, risk, resources and patient motivation. Subtleties in clinical decision making and patient-provider discussions are naturally incorporated into prioritization. However, this type of system may have the greatest potential for surgeon bias and a phenomenon described as category creep, where similar cases and patients receive higher prioritization from the same surgeons over time,23 possibly due to financial or other incentives.24,25 The present analysis found that physician case prioritizations differed considerably from prior published algorithms.11,14 There are several limitations to this analysis. These cases are from a single department, and case mix and individual surgeon scoring may not be generalizable to other urology practices with a different make-up of provider background and experience. There may also be bias associated with the time frame chosen. Individual surgeon prioritization may have been more aligned with expert opinion based upon variations in regional conditions. Evaluation of patient records to identify patient risk factors reflects the real-world MeNTS calculations but is subject to errors of omission. Evaluation of cases according to an alternative expert opinion recommendations may have altered findings. However, in general EOP recommendations are fairly consistent.12 Lastly, this analysis is focused on urology, limiting evaluation of urological case prioritization relative to those in other surgical fields. In summary, this quality improvement initiative suggests significant variabilities between broad-range questionnaire based surgical prioritization, consensus/expert opinion based surgical prioritization and individual surgeon based surgical prioritization. Our observations suggest potential for different advantages and drawbacks depending on the strategy chosen. Accordingly, these findings should be integrated at the time of future disaster planning. Future studies should evaluate the efficiency, such as total case volumes and length of delay, and clinical consequences associated with each strategy. Conclusions This quality improvement initiative suggests significant drawbacks associated with consensus/expert opinion based and questionnaire based surgical prioritization scoring systems. Solutions must be developed with multiple stakeholders to identify when certain stringent criteria should be implemented and when other factors should be de-emphasized during the course of health crises. Such parameters should accordingly be tailored to existing conditions at individual centers, cities and geographical regions. Appendix. Comparison of systems for elective case prioritization Questionnaire-Based Surgical Prioritization Expert Opinion-Based Surgical Prioritization Individual Surgeon-Based Surgical Prioritization Advantages -Permits comparison across surgical disciplines -Relatively objective -Group consensus reassuring -Immune from conscious and unconscious bias -Relatively objective -Most patient-centered -Most adaptable Drawbacks -Significant potential variability based upon ambiguity of components -Time-intensive -Difficult to adapt to changing literature -May be unfairly punitive to certain variables/conditions -Fails to adjust for risk/resources/quality of life differences between cases for a given procedure -Lack of data to inform appropriate time frame for delay for many procedures -Unlikely to be comprehensive (i.e. certain uncommon procedures will not be prioritized) -Most susceptible to conscious and unconscious bias References 1. : Projecting hospital utilization during the COVID-19 outbreaks in the United States. Proc Natl Acad Sci U S A 2020; 117: 9122. Google Scholar 2. : Historic financial decline hits doctors, dentists and hospitals — despite covid-19 — threatening overall economy. Washington Post, May 4, 2020. Available at https://www.washingtonpost.com/business/2020/05/04/financial-distress-among-doctors-hospitals-despite-covid-19-weighs-heavily-economy/. Accessed May 5, 2020. Google Scholar 3. Hospital and Healthsystem Association of Pennsylvania: COVID-19 Newsroom. Available at https://www.haponline.org/Public-Health/COVID-19/COVID-19-Newsroom#COVID-19%E2%80%99s_Impact_on_Hospital_Finances. Accessed May 5, 2020. Google Scholar 4. : A global survey on the impact of COVID-19 on urological services. Eur Urol 2020; 78: 265. Google Scholar 5. : Cystectomy delay more than 3 months from initial bladder cancer diagnosis results in decreased disease specific and overall survival. J Urol 2006; 175: 1262. Link, Google Scholar 6. : Assessing the burden of nondeferrable major uro-oncologic surgery to guide prioritisation strategies during the COVID-19 pandemic: insights from three Italian high-volume referral centres. Eur Urol 2020; 78: 11. Google Scholar 7. : Collateral damage: the impact on outcomes from cancer surgery of the COVID-19 pandemic. Ann Oncol 2020; 31: 1065. Google Scholar 8. : "It's horrible": Hospitals cancel surgeries because of coronavirus, leaving Americans in pain. USA TODAY, April 1, 2020. Available at https://www.usatoday.com/story/news/nation/2020/04/01/coronavirus-surgery-cancellations-leave-thousands-pain-over-delays/5094469002/. Accessed May 5, 2020. Google Scholar 9. American College of Surgeons: COVID-19: Guidance for Triage of Non-Emergent Surgical Procedures. Available at https://www.facs.org/covid-19/clinical-guidance/triage. Accessed May 6, 2020. Google Scholar 10. American College of Surgeons: Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic. Available at https://www.facs.org/covid-19/clinical-guidance/roadmap-elective-surgery. Accessed May 4, 2020. Google Scholar 11. : Medically necessary, time-sensitive procedures: scoring system to ethically and efficiently manage resource scarcity and provider risk during the COVID-19 pandemic. J Am Coll Surg 2020; 231: 281. Google Scholar 12. : Forecasting the future of urology practice: a comprehensive review of the recommendations by international and European associations on priority procedures during the COVID-19 pandemic. Eur Urol Focus 2020; 6: 1032. Google Scholar 13. : Considerations in the triage of urologic surgeries during the COVID-19 pandemic. Eur Urol 2020; 22: 663. Google Scholar 14. : Recommendations for tiered stratification of urological surgery urgency in the COVID-19 era. J Urol 2020; 204: 11. Link, Google Scholar 15. Anon: Guidance on Ambulatory Surgical Facilities' Responses to COVID-19.2020. Available at https://www.health.pa.gov/topics/disease/coronavirus/Pages/Guidance/Ambulatory-Surgical-Facilities-Guidance.aspx. Accessed November 3, 2020. Google Scholar 16. : Efficacy of pelvic floor muscle exercises in women with stress, urge, and mixed urinary incontinence. Am J Obstet Gynecol 1996; 174: 120. Google Scholar 17. : Optimizing time to treatment to achieve durable biochemical disease control after surgery in prostate cancer: a multi-institutional cohort study. Cancer Epidemiol Biomarkers Prev 2019; 28: 570. Google Scholar 18. : Delay to curative surgery greater than 12 weeks is associated with increased mortality in patients with colorectal and breast cancer but not lung or thyroid cancer. Ann Surg Oncol 2013; 20: 2468. Google Scholar 19. : A war on two fronts: cancer care in the time of COVID-19. Ann Intern Med 2020; 172: 756. Google Scholar 20. : Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet 2020; 396: 27. Google Scholar 21. : A model to prioritize access to elective surgery on the basis of clinical urgency and waiting time. BMC Health Serv Res 2009; 9: 1. Google Scholar 22. : Long waiting times for elective hospital care—breaking the vicious circle by abandoning prioritisation. Int J Health Policy Manag 2020; 9: 96. Google Scholar 23. : Clinical categorization for elective surgery in Victoria. ANZ J Surg 2003; 73: 839. Google Scholar 24. : Characteristics of urologists predict the use of androgen deprivation therapy for prostate cancer. J Clin Oncol 2007; 25: 5359. Google Scholar 25. : Urologist practice affiliation and intensity-modulated radiation therapy for prostate cancer in the elderly. Eur Urol 2018; 73: 491. Google Scholar No direct or indirect commercial, personal, academic, political, religious or ethical incentive is associated with publishing this article. © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited bySmith J (2020) This Month in Adult UrologyJournal of Urology, VOL. 205, NO. 1, (1-3), Online publication date: 1-Jan-2021. Volume 205Issue 1January 2021Page: 241-247Supplementary Materials Peer Review Report Open Peer Review Report Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.Keywordssurgical proceduresoperativedisaster planningelective surgical proceduresMetrics Author Information Joshua A. Cohn Department of Urology, Einstein Healthcare Network, Philadelphia, Pennsylvania Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania *Correspondence: Einstein Healthcare Network and Moss Rehabilitation Institute, Fox Chase Cancer Center, 50 Township Line Rd., Suite 202, Elkins Park, Pennsylvania 19027 telephone: 215-663-6067; FAX: 215-663-7089; E-mail Address: [email protected] More articles by this author Eric M. Ghiraldi Department of Urology, Einstein Healthcare Network, Philadelphia, Pennsylvania More articles by this author Robert G. Uzzo Department of Urology, Einstein Healthcare Network, Philadelphia, Pennsylvania Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania More articles by this author Jay Simhan Department of Urology, Einstein Healthcare Network, Philadelphia, Pennsylvania Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania More articles by this author Expand All No direct or indirect commercial, personal, academic, political, religious or ethical incentive is associated with publishing this article. Advertisement Advertisement PDF downloadLoading ...
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