Telemedicine Use across Medical Specialties and Diagnoses.

BACKGROUND: The COVID-19 (coronavirus disease 2019) pandemic rapidly expanded telemedicine scale and scope. As telemedicine becomes routine, understanding how specialty and diagnosis combine with demographics to impact telemedicine use will aid in addressing its current limitations. OBJECTIVES: To analyze the relationship between medical specialty, diagnosis, and telemedicine use, and their interplay with patient demographics in determining telemedicine usage patterns. METHODS: We extracted encounter and patient data of all adults who scheduled outpatient visits from June 1, 2020 to June 30, 2021 from the electronic health record of an integrated academic health system encompassing a broad range of subspecialties. Extracted variables included medical specialty, primary visit diagnosis, visit modality (video, audio, or in-person), and patient age, sex, self-reported race/ethnicity and 2013 rural-urban continuum code. Six specialties (General Surgery, Family Medicine, Gastroenterology, Oncology, General Internal Medicine, and Psychiatry) ranging from the lowest to the highest quartile of telemedicine use (video and audio) were chosen for analysis. Relative proportions of video, audio, and in-person modalities were compared. We examined diagnoses associated with the most and least frequent telemedicine use within each specialty. Finally, we analyzed associations between patient characteristics and telemedicine modality (video vs. audio/in-person, and video/audio vs. in-person) using a mixed-effects logistic regression model. RESULTS: A total of 2,494,296 encounters occurred during the study period, representing 420,876 unique patients (mean age: 44 years, standard deviation: 24 years, 54% female). Medical diagnoses requiring physical examination or minor procedures were more likely to be conducted in-person. Rural patients were more likely than urban patients to use video telemedicine in General Surgery and Gastroenterology and less likely to use video for all other specialties. Within most specialties, male patients and patients of nonwhite race were overall less likely to use video modality and video/audio telemedicine. In Psychiatry, members of several demographic groups used video telemedicine more commonly than expected, while in other specialties, members of these groups tended to use less telemedicine overall. CONCLUSION: Medical diagnoses requiring physical examination or minor procedures are more likely to be conducted in-person. Patient characteristics (age, sex, rural vs. urban, race/ethnicity) affect video and video/audio telemedicine use differently depending on medical specialty. These factors contribute to a unique clinical scenario which impacts perceived usefulness and accessibility of telemedicine to providers and patients, and are likely to impact rates of telemedicine adoption.

Patterns of Health Portal Use by Regular Portal Users Among Patients With Cancer: Results From the UWCCC Survivorship Program.

PURPOSE: We sought to evaluate the patterns of portal usage among patients with cancer who regularly log in to the portal. These data will inform approaches to facilitate portal use among patients with cancer. PATIENTS AND METHODS: We conducted a retrospective analysis of patient portal usage by patients with cancer at the University of Wisconsin Carbone Cancer Center. Our analysis focuses on patterns of portal use by regular users (≥ 2 portal logins/year, > 3 months) receiving ongoing oncology care between January 1, 2017, and December 31, 2019. Demographics, cancer characteristics, number of oncology visits per month, and portal usage data were extracted. Regular portal users were grouped and compared on the basis of their frequency of use. A linear mixed-effects model was used to determine if the frequency of oncology visits influenced the number of logins. RESULTS: We identified 2076 regular portal users. The median number of portal logins/year was 72 for the entire cohort. Age and race were associated with frequency of portal logins. There was no difference in frequency of portal login on the basis of cancer type or stage. Each additional oncology office visit in a month increased the frequency of portal logins by 3.05 ± 0.11 (SE) within the same month. Messages and test result functionalities were used by 98.7% and 98.9% of the regular users, respectively. Regular users who logged in to portal more frequently used all five studied portal functionalities. CONCLUSION: Patients with cancer who use portals regularly use it more in proximity to an oncology office visit and use multiple available portal functionalities. These findings can direct strategic planning to facilitate portal utilization among those not engaged with this tool.

Prospective Study of PET/MRI Tumor Response During Chemoradiotherapy for Patients With Low-risk and Intermediate-risk p16-positive Oropharynx Cancer.

OBJECTIVE: The objective of this study was to examine tumor response with positron emission tomography (PET)/magnetic resonance imaging (MRI) during chemoradiotherapy as a predictor of outcome in patients with p16-positive oropharynx cancer. MATERIALS AND METHODS: Patients with p16-positive oropharynx cancer were treated with chemoradiotherapy. Low-risk (LR) disease was defined as T1-T3 and N0-2b and ≤10 pack-years and intermediate-risk (IR) disease as T4 or N2c-3 or >10 pack-years. Patients underwent a PET/MRI scan pretreatment and at fraction 10. Change in value of imaging means were analyzed by analysis of variance. K-means clustering with Euclidean distance functions were used for patient clustering. Silhouette width was used to determine the optimal number of clusters. Linear regression was performed on all radiographic metrics using patient and disease characteristics. RESULTS: Twenty-four patients were enrolled with 7 LR and 11 IR patients available for analysis. Pretreatment imaging characteristics between LR and IR patients were similar. Patients with LR disease exhibited a larger reduction in maximum standardized uptake value (SUV) compared with IR patients (P<0.05). Cluster analysis defined 2 cohorts that exhibited a similar intratreatment response. Cluster 1 contained 7 of 7 LR patients and 8 of 11 IR patients. Cluster 2 contained 3 of 11 IR patients. Cluster 2 exhibited significant differences compared with cluster 1 in the change in primary tumor peak SUV and largest lymph node median SUV. CONCLUSIONS: We identified that IR p16-positive oropharynx cancers exhibit heterogeneity in their PET/MRI response to chemoradiotherapy. These data support further study of intratreatment imaging response as a potential mechanism to identify patients with IR oropharynx cancer suitable for treatment deintensification.

Opportunistic osteoporosis screening using routine computed tomography images to identify bone loss in gynecologic cancer survivors.

OBJECTIVE: Cancer treatment-induced bone loss is a known side effect of cancer therapy. Computed tomography (CT) bone mineral density screening is a novel tool for identifying bone loss. This study aims to use routine CT images to determine long-term bone mineral density changes and osteoporosis risk among women with gynecologic cancers. METHODS: Bone loss was evaluated in a retrospective cohort of women ≤65 years old with gynecologic cancer who underwent oophorectomy from January 2010 to December 2014. Opportunistic CT-based bone mineral density measurements (Hounsfield units, HU) were performed at baseline and intervals up to 5 years after cancer diagnosis. Osteoporosis risk was categorized by HU. Bivariate and multivariate analyses were performed to compare baseline to follow-up bone mineral density at 1, 3, and 5 years and to identify predictors of bone loss following diagnosis. RESULTS: A total of 185 patients (median age 53 years, range 23-65 years, 78.1% ovarian cancer) were included. Bone mineral density significantly decreased between baseline and 1 year (p<0.001), 3 years (p<0.001), and 5 years (p<0.001). Half with normal bone mineral density at baseline had risk for osteopenia or osteoporosis at 5 years. Four percent had osteoporosis risk at baseline compared with 1 year (7.4%), 3 years (15.7%), and 5 years (18.0%). Pre-treatment bone mineral density was a significant predictor at 1 and 5 years (1 year: p<0.01; 5 years: p<0.01). History of chemotherapy predicted bone loss at 1 year (p=0.03). More lifetime chemotherapy cycles were associated with increased risk of osteoporosis at 1 year (p=0.03) and 5 years (p=0.01). CONCLUSIONS: Women with gynecologic cancers may experience accelerated cancer treatment-induced bone loss. Routine CT imaging is a convenient screening modality to identify those at highest risk for osteoporosis who warrant further evaluation with dual-energy X-ray absorptiometry. Routine bone mineral density assessments 1 year following oophorectomy for cancer treatment may be warranted in this population.

Reported Concerns and Acceptance of Information or Referrals Among Breast Cancer Survivors Seen for Care Planning Visits: Results from the University of Wisconsin Carbone Cancer Center Survivorship Program.

Breast cancer survivors' experience physical and psychosocial concerns following active curative-intent treatment. Survivors' complex needs are often reviewed at survivorship care planning visits (SCP visits). However, little is known about the post-treatment concerns and resource needs addressed within the context of SCP visits. Using discretely collected electronic health record data, we examined characteristics, concerns, and acceptance of education materials and/or referrals among stages 0-3 breast cancer survivors seen for SCP visits. Most survivors reported concerns related to activity (n = 739; 72.7%) and nutrition (n = 677; 66.6%). Survivors of color were more likely to report concerns related to pain/swelling (odds ratio (OR), 4.4; 95% CI, 1.7-11.4) and employment/insurance (2.8; 1.4-5.7) compared to Whites. More than half accepted materials or referrals for concerns related to nutrition, activity/pain, substance use, sexual health, mood, and sleep (padj-value < 0.05). However, not all reported concerns led to acceptance of materials or referrals. Survivors seen for SCP visits report a wide range of concerns at the end of active curative-intent treatment but may not necessarily accept materials or referrals for their concerns within the context of these visits. Our findings highlight the importance of exercise, physical rehabilitation, and nutrition interventions for survivors following active curative-intent treatment. Further study is needed to elucidate the reasons for acceptance vs. non-acceptance of resources addressing reported concerns.

Patterns and predictors of cancer-specific patient health portal usage among patients with cancer: results from the UWCCC Survivorship Program.

BACKGROUND: Portals can assist patients in managing their healthcare. Understanding how patients with cancer use portals can facilitate improvements in patient engagement in cancer care. This study sought to determine if patients with cancer used portals differently for cancer versus noncancer purposes. The effects of geographic residence (rural vs. urban residence) and cancer stage on portal usage were also investigated. METHODS: We conducted a retrospective analysis of portal usage by patients seen at an NCI-designated cancer center between 2015 and 2019. Demographics, cancer characteristics, and portal usage (number of successful logins, messages sent, and results viewed) were extracted. Messages sent and results viewed in the portal were deemed oncologist-specific and cancer specific if sent to or ordered in medical oncology departments, respectively. RESULTS: The analysis included a total of 5950 patients with cancer. Patients were less likely to send and view oncologist-specific messages compared to non-oncologist-specific messages. They were also less likely to view cancer results compared to noncancer results. Compared to urban counterparts, patients residing in rural areas had lower odds of having any logins and logged in less frequently during the year of diagnosis. Compared to patients with non-metastatic disease, individuals with metastatic disease were more likely to become frequent portal users. CONCLUSIONS: Patients may use portals differently for cancer versus noncancer purposes; urban residence and metastatic cancer were associated with more frequent usage. Further investigation can inform interventions to increase accessibility for groups at a disadvantage related to the use of this technology and to help patients better leverage portals to manage their cancer.

Oncologist Perspectives on Telemedicine for Patients With Cancer: A National Comprehensive Cancer Network Survey.

PURPOSE: The use of telemedicine expanded dramatically in March 2020 following the COVID-19 pandemic. We sought to assess oncologist perspectives on telemedicine's present and future roles (both phone and video) for patients with cancer. METHODS: The National Comprehensive Cancer Network (NCCN) Electronic Health Record (EHR) Oncology Advisory Group formed a Workgroup to assess the state of oncology telemedicine and created a 20-question survey. NCCN EHR Oncology Advisory Group members e-mailed the survey to providers (surgical, hematology, gynecologic, medical, and radiation oncology physicians and clinicians) at their home institution. RESULTS: Providers (N = 1,038) from 26 institutions responded in Summer 2020. Telemedicine (phone and video) was compared with in-person visits across clinical scenarios (n = 766). For reviewing benign follow-up data, 88% reported video and 80% reported telephone were the same as or better than office visits. For establishing a personal connection with patients, 24% and 7% indicated video and telephone, respectively, were the same as or better than office visits. Ninety-three percent reported adverse outcomes attributable to telemedicine visits never or rarely occurred, whereas 6% indicated they occasionally occurred (n = 801). Respondents (n = 796) estimated 46% of postpandemic visits could be virtual, but challenges included (1) lack of patient access to technology, (2) inadequate clinical workflows to support telemedicine, and (3) insurance coverage uncertainty postpandemic. CONCLUSION: Telemedicine appears effective across a variety of clinical scenarios. Based on provider assessment, a substantial fraction of visits for patients with cancer could be effectively and safely conducted using telemedicine. These findings should influence regulatory and infrastructural decisions regarding telemedicine postpandemic for patients with cancer.

Postoperative venous thromboembolism in gynecologic oncology patients undergoing minimally invasive surgery: Does modality matter?

OBJECTIVES: Minimally invasive surgery (MIS) is increasingly utilized for gynecologic cancers. While incidence of venous thromboembolism (VTE) after MIS is low, some guidelines recommend extended chemoprophylaxis for these patients undergoing MIS. Our objectives were to determine incidence of postoperative VTE in patients undergoing MIS, evaluate differences in the incidence by MIS modality and assess the need for extended chemoprophylaxis. METHODS: We conducted a retrospective cohort study including all patients undergoing MIS (robot-assisted, multi-port laparoscopy, single-port laparoscopy) for gynecologic cancers between January 2014 and December 2018 at our institution. Demographic and perioperative variables were collected. Patients <18 years, with benign pathology, or on preoperative anticoagulation were excluded. Chi-square, Fisher's exact test, and one-way ANOVA were performed to determine risk factors related to VTE occurrence. RESULTS: We identified 806 patients who underwent MIS with median age 61. Most had Stage I disease (81.5%) and uterine cancer (81.5%). Five VTE events occurred within 90 days following surgery (0.6%). Incidence of 90-day VTE did not differ between MIS modalities (p = 0.6). Patients with longer OR times (p = 0.004) were more likely to experience VTE. Age, smoking status, BMI, type of cancer and stage were not significant risk factors for VTE. CONCLUSIONS: The incidence of postoperative VTE in patients with gynecologic cancers undergoing MIS is low and does not appear to differ by MIS modality. Given the very low incidence of postoperative VTE, extended chemoprophylaxis is unlikely to benefit patients with gynecologic malignancies undergoing MIS procedures.

Diagnostic Performance of MRI for Esophageal Carcinoma: A Systematic Review and Meta-Analysis.

Background Although CT, endoscopic US, and PET are critical in determining the appropriate management of esophageal carcinoma (squamous cell carcinoma and adenocarcinoma), previous reports show that staging accuracy remains low, particularly for nodal involvement sensitivity. Purpose To perform a systematic review and meta-analysis to determine the diagnostic performance of MRI for multiple staging thresholds in patients with biopsy-proven esophageal carcinoma (differentiation of stage T0 disease from stage T1 or higher disease, differentiation of stage T2 or lower disease from stage T3 or higher disease, and differentiation of stage N0 disease from stage N1 or higher disease [where T refers to tumor stage and N refers to nodal stage]). Materials and Methods Studies of the diagnostic performance of MRI in determining the stage of esophageal carcinoma in patients before esophagectomy and pathologic staging between 2000 and 2019 were searched in PubMed, Scopus, Web of Science, and Cochrane Library by a librarian and radiation oncologist. Pooled diagnostic performance of MRI was calculated with a bivariate random effects model. Bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (version 2) tool. Results Twenty studies with a total of 984 patients were included in the analysis. Pooled accuracy for stage T0 versus stage T1 or higher had a sensitivity of 92% (95% CI: 82, 96) and a specificity of 67% (95% CI: 51, 81). Pooled accuracy for stage T2 or lower versus stage T3 or higher had a sensitivity of 86% (95% CI: 76, 92) and a specificity of 86% (95% CI: 75, 93). Pooled accuracy for stage N0 versus stage N1 or higher had a sensitivity of 71% (95% CI: 60, 80) and a specificity of 72% (95% CI: 64, 79). The concern for applicability was low for the patient selection, index test, and reference test domains, except for 10% of studies (two of 20) that had unclear concern for patient selection applicability. Conclusion MRI has high sensitivity but low specificity for the detection of esophageal carcinoma, which shows promise for determining neoadjuvant therapy response and for detecting locally advanced disease for potential trimodality therapy. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Leeflang in this issue.