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Impact of the COVID-19 Pandemic on Urological Care Delivery in the United States

2021; Lippincott Williams & Wilkins; Volume: 206; Issue: 6 Linguagem: Inglês

10.1097/ju.0000000000002145

1527-3792

Daniel J. Lee, Jeremy B. Shelton, Paul Brendel, Rahul Doraiswami, Danil V. Makarov, William Meeks, Raymond Fang, Matthew T. Roe, Matthew R. Cooperberg,

Healthcare cost, quality, practices

Open AccessJournal of UrologyAdult Urology1 Dec 2021Impact of the COVID-19 Pandemic on Urological Care Delivery in the United States Daniel J. Lee, Jeremy B. Shelton, Paul Brendel, Rahul Doraiswami, Danil Makarov, William Meeks, Raymond Fang, Matthew T. Roe, and Matthew R. Cooperberg Daniel J. LeeDaniel J. Lee *Correspondence: Perelman Center for Advanced Medicine, 3400 Civic Center Blvd., 3rd Floor, West Pavilion, Philadelphia, Pennsylvania 19104 telephone: 215-662-2891; E-mail Address: [email protected] Division of Urology, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania , Jeremy B. SheltonJeremy B. Shelton Department of Urology, University of California Los Angeles, Los Angeles, California , Paul BrendelPaul Brendel Verana Health, San Francisco, California , Rahul DoraiswamiRahul Doraiswami Verana Health, San Francisco, California , Danil MakarovDanil Makarov VA New York Harbor Healthcare System and Departments of Urology and Population Health, New York University Langone Medical Center, New York, New York , William MeeksWilliam Meeks American Urological Association Education & Research, Department of Data Management & Statistical Analysis, Linthicum, Maryland , Raymond FangRaymond Fang American Urological Association Education & Research, Department of Data Management & Statistical Analysis, Linthicum, Maryland , Matthew T. RoeMatthew T. Roe Verana Health, San Francisco, California , and Matthew R. CooperbergMatthew R. Cooperberg Departments of Urology, and Epidemiology and Biostatistics, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California View All Author Informationhttps://doi.org/10.1097/JU.0000000000002145AboutAbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Abstract Purpose: We examined changes in urological care delivery due to COVID-19 in the U.S. based on patient, practice, and local/regional demographic and pandemic response features. Materials and Methods: We analyzed real-world data from the American Urological Association Quality (AQUA) Registry collected from electronic health record systems. Data represented 157 outpatient urological practices and 3,165 providers across 48 U.S. states and territories, including 3,297,721 unique patients, 12,488,831 total outpatient visits and 2,194,456 procedures. The primary outcome measure was the number of outpatient visits and procedures performed (inpatient or outpatient) per practice per week, measured from January 2019 to February 2021. Results: We found large (>50%) declines in outpatient visits from March 2020 to April 2020 across patient demographic groups and states, regardless of timing of state stay-at-home orders. Nonurgent outpatient visits decreased more across various nonurgent procedures (49%–59%) than for procedures performed for potentially urgent diagnoses (38%–52%); surgical procedures for nonurgent conditions also decreased more (43%–79%) than those for potentially urgent conditions (43%–53%). African American patients had similar decreases in outpatient visits compared with Asians and Caucasians, but also slower recoveries back to baseline. Medicare-insured patients had the steepest declines (55%), while those on Medicaid and government insurance had the lowest percentage of recovery to baseline (73% and 69%, respectively). Conclusions: This study provides real-world evidence on the decline in urological care across demographic groups and practice settings, and demonstrates a differential impact on the utilization of urological health services by demographics and procedure type. Abbreviations and Acronyms ADT androgen deprivation therapy AHRF Area Health Resource File AQUA American Urological Association Quality AUA American Urological Association BPH benign prostatic hyperplasia COVID-19 coronavirus disease 2019 CPT Current Procedural Terminology EHR electronic health record FPL federal poverty level ICD-9/ICD-10 International Statistical Classification of Diseases and Related Health Problems, ninth or tenth revision TURP transurethral resection of prostate The COVID-19 pandemic caused severe disruptions along the continuum of medical care. Understanding national patterns of urological care—including effects on both urgent and nonurgent surgical procedures, cancer-related care, variations in care across a wide payer mix and trends based on patient demographics—will enable providers, policy leaders, patients and administration officials to optimally respond to ongoing and future changes as the COVID-19 pandemic and its sequelae continue to unfold.1–3 Therefore, we sought to understand the impact of the COVID-19 pandemic on temporal trends in urological care delivery using real-world evidence derived from a national urological data registry. We hypothesized that the pandemic would be associated with significant decreases in nonurgent patient visits and elective procedures but would have significant variation by race or insurance status. Materials and Methods American Urological Association Quality (AQUA) Registry In 2013, the American Urological Association (AUA) launched the AQUA Registry,4 and as of February 2021, over 50 million patient visits from 8.5 million unique patients populated the database. The AQUA Registry comprises extracted electronic health record (EHR)-derived data from participating urology practices nationwide. We limited our analysis to practices that contributed data at least once in both 2019 and 2020, through the end of February 2021. Of 235 total practices contributing to the AQUA Registry, 78 did not meet our inclusion criteria, leaving 157 practices covering 3,165 providers to define the study cohort. The AQUA Registry is supervised by a central institutional review board and there is no applicable IRB number. Patient Population The study period was from January 1, 2019 to February 28, 2021. Data from weekends and holidays were excluded. Rurality was defined based on the U.S. Department of Agriculture Rural-Urban Commuting Codes.5 Measures and Covariates Our primary outcome measures were daily outpatient visits and daily procedures per practice. To reduce day-to-day variations, we averaged the daily visits and daily procedures over each week. Based on observed trends, week 10 in 2020 was considered the inflection point for the pandemic impact, as the national state of emergency declaration was issued on March 13, 2020.6 The nadir was considered the lowest point after the baseline period (February 2020), while the recovery was defined as the highest point after the nadir. We also compared the average visits over the final month (February 2021) compared to the baseline in February 2020. Additional zip code level characteristics from 2010 U.S. Census data were also incorporated, including the percent below the federal poverty level (FPL) and household median income. Physician distribution data were obtained from the Area Health Resource File (AHRF).7 We evaluated the density of urologists per 100,000 and median income in the zip code according to the urology practice location. Finally, we categorized states in terms of timing of stay-at-home orders into early, middle and late tertiles (supplementary Appendix 1, https://www.jurology.com). The 12 most common diagnoses evaluated and managed in urology practices were identified. We also denoted among diagnoses a "nonurgent" subset based on recommendations from the AUA and American College of Surgeons to triage conditions and procedures that potentially require urgent evaluation during the COVID-19 pandemic (supplementary Appendix 2, https://www.jurology.com).8 Telemedicine video visits could not be identified by CPT codes alone, but telephone-only visits were identified by CPT code 99441-99443. Statistical Analysis We quantified the duration and extent of decline and recovery in patient visits (across patient-level and practice-level strata), disease-specific visits and procedures. We illustrated the 2019, 2020 and 2021 trends in overall visits, visits for select nonurgent and potentially urgent diagnoses, new patient visits and telehealth visits. We conducted Pearson's chi-square tests of independence to assess if there was a relationship between select visit types (age, race and tertile of state lockdown timing) and total visits in February (2020 and 2021). Thus, we assessed if the observed drop in February visits from 2020 (pre-pandemic) to 2021 (mid-pandemic) corresponded to what would be expected if each variable stratum responded similarly. We developed a mixed effects logistic regression model to predict the odds of having a >50% percent drop from week 10 to week 15 in total visits/practice. Because a particular practice is represented in multiple observations (by different age-gender-race-ethnicity combinations), a random intercept by practice was included to help account for the correlation within practices. The putative predictors of a percent drop in practice visits considered were age, gender, race, ethnicity and practice size (<15 providers vs ≥15 providers). Data management was performed with PySpark version 2.4.0 (Apache Spark™), and analyses were computed with R version 3.6.3 (R Core Team, Vienna, Austria). Results Characteristics of the unique patients and practices represented in our sample are summarized in table 1. The data include 13,108,874 total visits and 2,194,456 procedures. Table 1. Patient and practice characteristics No. % Age:* 65 yrs 1,735,551 51.12 Not available 39 0.00 Gender: Male 2,451,660 72.22 Female 942,335 27.76 Not reported 907 0.03 Race: Caucasian 1,844,801 54.34 Asian 61,674 1.82 Black or African American 234,964 6.92 Other 12,679 0.37 Unknown 1,240,784 36.55 Ethnicity: NonHispanic 2,208,653 65.06 Hispanic 187,336 5.52 Unknown 998,913 29.42 Insurance:† Commercial 702,043 20.68 Government 46,154 1.36 Medicaid 64,191 1.89 Medicare 350,488 10.32 Medicare Advantage 169,655 5.00 Military 36,538 1.08 No insurance 7,114 0.21 Unknown 2,336,836 68.83 Total practices 157 Practice size: 1–5 providers 36 22.93 6–14 providers 45 28.66 15+ providers 64 40.76 Practice region: Midwest 25 15.92 Northeast 20 12.74 South 71 45.22 West 41 26.11 Practice rurality: City 57 36.31 Rural 49 31.21 Suburban 39 24.84 Timing of stay-at-home orders by state of practice: Early 52 33.12 Mid 44 28.03 Late 61 38.85 Practices in zip codes with >25% population below FPL: Yes 18 11.46 No 137 87.26 Median income in practice zip code: <$50,000 63 40.13 $50,000–$100,000 82 52.23 >$100,000 10 6.37 No. urologists per 100,000 residents within each practice location: 0 26 16.56 1–4 44 28.03 5+ 85 54.14 Health Professional Shortage Area: Yes 144 91.72 No 11 7.01 Total number of patients was 3,394,902 and total number of visits was 13,108,874. Since this is age at visit date, some patients who had multiple visits appear in 2 age groups. Patients with multiple insurance types were classified based on first documented insurance in our study period. Outpatient Clinic Visits by Patient Characteristics The figure presents the unadjusted trends in outpatient clinic visits from January 2019 through February 2021 for overall, nonurgent diagnoses, potentially urgent diagnoses, new patient visits and telehealth visits. Overall, there was a similar pattern of a sharp decrease after week 10, followed by a gradual recovery that remained stable through the summer of 2020 to 2021. Figure. A to E, weekly average of outpatient clinic visits from January 2019 to February 2021 per practice for overall population (A), select nonurgent diagnoses (B), potentially urgent diagnoses (C), new patient visits (D), and telephone visits (E). Nonurgent subset included microscopic hematuria, overactive bladder, elevated prostate specific antigen, erectile dysfunction and BPH (B). Urgent subset included prostate cancer, bladder cancer, kidney cancer, kidney stones, urinary tract infection, gross hematuria and renal mass (C). Beginning in March 2020 (week 10), there was sharp, nearly 50%, decrease in total outpatient visits, which reached nadir in April (week 15), with rebound period stretching from May to June (weeks 16 to 24) and reaching 92% of baseline, followed by another decrease, with visits at 77% of baseline. There was a 50.6% decrease in daily outpatient visits at its lowest point, which gradually improved over time but still remained about 19% lower in February 2021 compared to baseline levels in February 2020 (table 2). Women, Asians and those with Medicaid or Medicare insurance had some of the largest decreases in outpatient visits during the peak of the pandemic. Smaller decreases were noted for Black patients, with decreases of 49.6% in daily visits at its nadir, which recovered from the nadir through week 22. Outpatient visits for elderly patients were also 21% lower in February 2021 than 2020 vs younger patients (p <0.001 in comparing total visits). In comparing February 2021 to February 2020, white patients had significantly fewer outpatient visits per day per practice compared to baseline (17% decrease) than Black patients (5% decrease, p 65 91.16 43.79 51.96 15 84.97 86.94 72.43 −20.55 18–65 62.00 32.04 48.32 15 54.94 76.44 51.91 −16.28 <18 1.22 0.42 65.63 16 1.08 82.57 0.85 −30.10 Gender: Male 115.32 58.22 49.51 15 105.96 83.61 95.05 −17.58 Female 39.01 18.03 53.79 15 34.42 78.16 30.08 −22.87 Race: Caucasian 89.42 42.35 52.64 15 80.98 82.07 74.11 −17.13 Black 10.93 5.51 49.56 15 10.16 85.89 10.38 −5.03 Asian 2.35 0.86 63.18 15 2.20 90.25 2.23 −4.99 Other 0.60 0.29 52.43 13 0.56 88.30 0.49 −18.63 Ethnicity: Hispanic 8.12 3.96 51.23 15 7.48 84.77 6.76 −16.67 NonHispanic 106.40 51.58 51.52 15 96.40 81.75 77.42 −27.24 Insurance: Commercial 34.97 16.89 51.69 15 31.96 83.33 24.95 −28.66 Government 2.59 1.37 47.00 15 2.21 68.81 1.83 −29.25 Medicaid 3.45 1.60 53.69 15 2.95 73.10 2.37 −31.32 Medicare 21.29 9.41 55.82 15 19.26 82.87 13.43 −36.93 Medicare Advantage 11.33 5.93 47.61 15 10.21 79.29 7.74 −31.70 Military 1.98 0.98 50.32 15 1.91 92.57 1.31 −33.75 Median income in zip code: <$50,000 46.77 24.71 47.17 15 43.84 86.72 35.77 −23.51 $50,000–$100,000 101.73 49.04 51.79 15 92.08 81.68 84.89 −16.56 >$100,000 7.09 3.21 54.76 15 6.60 87.34 6.37 −10.13 >25% Population below FPL: Yes 17.33 8.58 50.48 30 15.92 83.96 14.98 −13.57 No 138.27 68.38 50.55 15 126.35 82.94 112.06 −18.95 No. urologists per 100,000 residents within each practice location: 0 16.79 9.37 44.22 15 16.81 100.21 12.98 −22.72 1–4 29.34 15.93 45.70 15 26.26 77.05 22.62 −22.88 5+ 109.47 51.65 52.82 14 99.37 82.54 91.43 −16.47 Practice size: 1–5 providers 18.19 9.76 46.34 15 17.11 87.13 14.99 −17.58 6–14 providers 29.79 15.53 47.85 15 24.73 64.47 19.96 −32.98 15+ providers 112.83 53.59 52.51 14 104.59 86.10 94.74 −16.03 Practice region: Midwest 35.23 17.45 50.47 13 34.33 94.95 21.12 −40.05 Northeast 17.64 7.39 58.11 15 15.19 76.06 8.73 −50.50 South 73.52 34.95 52.47 15 72.14 96.42 70.94 −3.52 West 27.98 14.04 49.81 13 24.94 78.17 24.4 −12.79 Practice rurality: City 50.87 26.87 47.18 15 51.17 101.22 49.01 −3.66 Rural 32.88 16.75 49.07 14 29.38 78.30 18.15 −44.80 Suburban 63.76 29.95 53.03 13 57.73 82.15 57.05 −10.52 Stay-at-home order: Early 49.67 24.63 50.42 14 44.77 80.41 27.45 −44.73 Mid 57.65 27.77 51.83 15 54.37 89.02 58.62 1.69 Late 47.06 23.83 49.37 15 44.76 90.10 39.11 −16.88 Health professional shortage area: Yes 153.68 75.91 50.60 15 139.66 81.97 123.65 −19.54 No 1.92 0.99 48.47 14 1.69 75.66 3.38 76.64 Baseline=average daily visits per practice in February 2020. Nadir=lowest point of average daily visits after baseline. Recovery=highest point of average daily visits after nadir (examined up through week 52). Visits at week 30=average daily visits per practice in week 30 (July 2020). Nadir=lowest point after baseline up through 2020 week 20. Recovery=highest point after nadir through 2020 week 52. % Recovery from nadir=(recovery visit average − nadir visit average)/(baseline visit average − nadir visit average). Outpatient Clinic Visits by Practice Characteristics Practices that were larger, located in the Northeast, and in suburban and affluent areas had the largest percent decreases in outpatient visits. The largest practices (15+ providers) had the highest percent declines (52.5%) and largest percent recovery (−16% from baseline). Practices serving areas with no urologists per 100,000 had lower magnitude decreases in outpatient visits (44%) compared to practices with 5 or more urologists per 100,000 in the county (52.8%). Of note, outpatient visits in February 2021 remained much lower than February 2020 in practices in rural areas (44.8% of 2020), and located in Midwest and Northeast regions (40.1% and 50.5% of 2020, respectively). States that had early lockdown orders had similar percent decreases in outpatient visits compared to middle or late orders during the lockdown period but had lower magnitude recovery of those outpatient visits compared to pre-pandemic levels (44.7% lower, p 50%) decrease in outpatient visits (supplementary Appendix 3, https://www.jurology.com), elderly patients, women and Hispanic patients were more likely to have a large decline in outpatient visits compared with those under 65 years old, men and nonHispanics, respectively (p <0.001 for all). We did not find significant decreases based on practice size (≥15 providers or <15 providers) or race (Caucasian vs not Caucasian). Discussion We evaluated continuous, nationwide data from the AQUA Registry to examine the impact of the COVID-19 pandemic on urological outpatient visits and surgical procedures. In our analyses, profound and rapid declines in visits and procedures were seen across all ages, races and practice types, followed by near-complete recovery and then a secondary decline that varied greatly in severity as COVID-19 case incidence surged again later in 2020. This study illustrates the power of real-world data from a specialty registry to facilitate evaluation of changing practice patterns and to identify at-risk patients to help guide policy and management. We observed that, although the COVID-19 pandemic affected individuals across the country, certain patient groups have not recovered as well as others, leaving certain patients more vulnerable than others. Some procedures and diagnoses were more impacted by the lockdown and recovery process than others. The impact of the COVID-19 pandemic has been immense in its magnitude and scope. Efforts to adapt and restore services must be able to measure the impact as broadly and as close to real-time as possible as we help identify potential levers to guide resources and public policy. However, existing data registries are often reliant solely on claims data with significant lag time and questionable reliability.9,10 This study is an example of how EHR-based registries can provide near real-time data that can be affordably scaled and used to help guide policy, especially during rapidly changing public health crises. Overall, outpatient visits and procedures for all patients decreased about 50% during the initial lockdown portion of the COVID-19 pandemic, but the magnitude of the decrease and degree of recovery were variable. We found that the elderly, females and patients with Medicaid insurance had the highest decreases in outpatient visits and among the lowest magnitude recovery compared to pre-pandemic levels. There appears to be an aspect of regional impact as well, as practices in rural areas, lower income areas, and especially the Northeast and Midwest have not fully recovered and are anywhere from 20%–45% below pre-pandemic levels. There may be multiple explanations for variations in patient visits observed during the different phases of the COVID-19 pandemic,11 including patient decisions to mitigate risks of COVID-19 infection by delaying or avoiding visits, difficulty obtaining appointments because of re-prioritization during the pandemic, or the possibility of urology offices remaining closed or operating at limited hours for safety, financial or other reasons. Nonetheless, we found no substantial difference in visits or procedures during the initial lockdown period based on the timing of stay-at-home orders across states. The stay-at-home orders issued may have created economic dislocation and exacerbated health disparities because of concerns for housing, food and financial security,12,13 further compounding the persistently disproportionate impact of COVID-19 on minority and vulnerable patient populations.14,15 However, our study found that the association between racial and socioeconomic factors and outpatient evaluations was nuanced and complex. Black patients had relatively smaller decreases in outpatient visits but improved to almost pre-pandemic levels. In comparison, those in poorer neighborhoods or rural counties with less access to urologists had relatively smaller decreases in outpatient visits initially but dramatically lower levels of recovery. These patterns could reflect multiple causes, including loss of employment or insurance coverage, financial insecurity or loss of clinics serving underserved areas. Tighter financial pressures have already led to closures of multiple clinics and hospitals, especially those in rural or underserved areas.1,16,17 In addition, given the aging workforce of physicians, with 46% of urologists aged 55 years or older,18 the current workforce disruptions and questionable financial stability may lead to higher rates of retirement and further compound existing shortages of care, especially in rural and underserved areas. An important lever may be improving the ability of diverse communities to access telemedicine and video visits. A recent cohort study of more than 148,000 patients found that patients who were elderly, female and from lower income levels were almost 30%–40% less likely to complete a telemedicine vis