The Impact of Using Electronic Consents on Documentation of Language-Concordant Surgical Consent for Patients with Limited English Proficiency.

BACKGROUND: Although access to a professional medical interpreter is federally mandated, surgeons report underutilization during informed consent. Improvement requires understanding the extent of the lapses. Adoption of electronic consent (eConsent) has been associated with improvements in documentation and identification of practice improvement opportunities. The authors evaluated the impact of the transition from paper to eConsent on language-concordant surgical consent delivery for patients with limited English proficiency (LEP). METHODS: The study period (February 8, 2023, to June 14, 2023) corresponds to the period immediately following the institutional adoption of eConsents. Inclusion criteria included age > 18 years, documented preferred language other than English, and self-signed eConsent form. The authors assessed documentation of language-concordant interpreter-mediated verbal consent discussion and delivery of the written surgical consent form in a language-concordant template. Performance was compared to a preimplementation baseline derived from monthly random audits of paper consents between January and December 2022. RESULTS: A total of 1,016 eConsent encounters for patients with LEP were included, with patients speaking 49 different languages, most commonly Spanish (46.5%), Chinese (22.1%), and Russian (6.8%). After the implementation of eConsent, overall documentation of language-concordant interpreter-mediated consents increased from 56.9% to 83.9% (p < 0.001), although there was variation between surgical services and between languages, suggesting that there is still likely room for improvement. Most patients (94.1%) whose preferred language had an associated translated written consent template (Spanish, Chinese, Russian, Arabic), received a language-concordant written consent. CONCLUSION: The transition to eConsent was associated with improved documentation of language-concordant informed consent in surgery, both in terms of providing written materials in the patient's preferred language and in the documentation of interpreter use, and allowed for the identification of areas to target for practice improvement with interpreter use.

"It Gives Me Peace of Mind So I Can Focus on Healing": Views on Advance Care Planning for Older Surgical Patients.

Introduction: The period of time before an elective operation may be an opportune time to engage older adults in advance care planning (ACP). Past interventions have not been readily incorporated into surgical workflows leaving a need for ACP tools that are generalizable, easy to implement, and effective. Design: This is a qualitative study. Setting and Subjects: Older adults with a history of cancer and a recent major operation were recruited through their surgical oncologist at a tertiary medical center in the United States. Interviews were conducted to determine how to adapt the validated PrepareForYourCare.org ACP program with electronic health record prompts for the perioperative setting and openness to introducing ACP during a presurgical visit. We used qualitative content analysis to determine themes. Results: Eight themes were identified: (1) ACP as static and private, (2) people expected a prompt, (3) family trusted to do the "right" thing, (4) lack of relationship or comfort with providers, (5) a team-based approach can be helpful, (6) surgeon's expertise (e.g., prognosis and surgical risk), (7) ACP belongs on the surgical checklist, and (8) patients would welcome a conversation starter. Discussion: Older surgical patients are interested in engaging with ACP, particularly if prompted, and believe it has a place on the preoperative "checklist." Conclusions: To effectively engage patients with ACP, a combination of routine prompts by the health care team and patient-centered follow-up may be required.

Advanced Care Planning Content Encoding with Natural Language Processing.

While advanced care planning (ACP) is an essential practice for ensuring patient-centered care, its adoption remains poor and the completeness of its documentation variable. Natural language processing (NLP) approaches hold promise for supporting ACP, including its use for decision support to improve ACP gaps at the point of care. ACP themes were annotated on palliative care notes across four annotators (Fleiss kappa = 0.753) and supervised models trained (Huggingface models bert-base-uncased and Bio_ClinicalBERT) using 5-fold cross validation (F1=0.8, precision=0.75, recall=0.86, any theme). When applied across the full note corpus of 12,711 notes, we observed variability in documentation of ACP information. Our findings demonstrate the promise of NLP approaches for informatics-based approaches for ACP and patient-centered care.

Finding the time: Hourly variation in average daily census on a hospital medicine service.

Monitoring the average daily census (ADC) is crucial for managing patient flow and allocating resources. This study analyzed hourly fluctuations in the ADC on a hospital medicine service at an academic medical center. Data from 8342 encounters and 6178 unique patients were collected over a year. The ADC peaked at 11 a.m. (164.1 patients/day) and was lowest at 7 p.m. (155.0 patients/day), accounting for a variation of up to 9.1 patients (5.5% of peak census) depending on the time of day the measurement was taken. Understanding how ADC changes throughout the day will help hospital medicine programs to partner with administrators to optimize resource allocation and staffing. Measuring ADC at midnight, as traditionally done, may underestimate workload and therefore contribute to staffing shortages and physician burnout. Hospitals should consider measuring ADC at its peak, between 7 a.m. and 11 a.m., to ensure adequate staffing and high-quality patient care.

Large Language Model-Based Chatbot vs Surgeon-Generated Informed Consent Documentation for Common Procedures.

Importance: Informed consent is a critical component of patient care before invasive procedures, yet it is frequently inadequate. Electronic consent forms have the potential to facilitate patient comprehension if they provide information that is readable, accurate, and complete; it is not known if large language model (LLM)-based chatbots may improve informed consent documentation by generating accurate and complete information that is easily understood by patients. Objective: To compare the readability, accuracy, and completeness of LLM-based chatbot- vs surgeon-generated information on the risks, benefits, and alternatives (RBAs) of common surgical procedures. Design, Setting, and Participants: This cross-sectional study compared randomly selected surgeon-generated RBAs used in signed electronic consent forms at an academic referral center in San Francisco with LLM-based chatbot-generated (ChatGPT-3.5, OpenAI) RBAs for 6 surgical procedures (colectomy, coronary artery bypass graft, laparoscopic cholecystectomy, inguinal hernia repair, knee arthroplasty, and spinal fusion). Main Outcomes and Measures: Readability was measured using previously validated scales (Flesh-Kincaid grade level, Gunning Fog index, the Simple Measure of Gobbledygook, and the Coleman-Liau index). Scores range from 0 to greater than 20 to indicate the years of education required to understand a text. Accuracy and completeness were assessed using a rubric developed with recommendations from LeapFrog, the Joint Commission, and the American College of Surgeons. Both composite and RBA subgroup scores were compared. Results: The total sample consisted of 36 RBAs, with 1 RBA generated by the LLM-based chatbot and 5 RBAs generated by a surgeon for each of the 6 surgical procedures. The mean (SD) readability score for the LLM-based chatbot RBAs was 12.9 (2.0) vs 15.7 (4.0) for surgeon-generated RBAs (P = .10). The mean (SD) composite completeness and accuracy score was lower for surgeons' RBAs at 1.6 (0.5) than for LLM-based chatbot RBAs at 2.2 (0.4) (P < .001). The LLM-based chatbot scores were higher than the surgeon-generated scores for descriptions of the benefits of surgery (2.3 [0.7] vs 1.4 [0.7]; P < .001) and alternatives to surgery (2.7 [0.5] vs 1.4 [0.7]; P < .001). There was no significant difference in chatbot vs surgeon RBA scores for risks of surgery (1.7 [0.5] vs 1.7 [0.4]; P = .38). Conclusions and Relevance: The findings of this cross-sectional study suggest that despite not being perfect, LLM-based chatbots have the potential to enhance informed consent documentation. If an LLM were embedded in electronic health records in a manner compliant with the Health Insurance Portability and Accountability Act, it could be used to provide personalized risk information while easing documentation burden for physicians.

Impact of an automated peri-procedural digital health intervention on rates of emergency department visits and readmissions.

BACKGROUND: Providing timely peri-procedural education, reminders, and check-ins can improve patient adherence and clinical outcomes. We sought to retrospectively evaluate the impact of a peri-procedural digital health tool on emergency department (ED) visits and readmissions. METHODS: A digital health tool for peri-procedural care engaged patients at scheduled intervals, resulting in an overall engagement score. Multivariate models determined predictors of tool engagement and post-procedural 30- and 90-day rehospitalizations and ED visits. RESULTS: 11,737 unique completed procedures were analyzed from 10,438 patients. Patients of Black and Latinx race/ethnicity (vs White), those with Medicare and Medicaid insurance (vs commercial), and those with non-activated patient portals (vs activated) were less likely to engage. After adjustment for confounders, higher engagement with the tool was associated with lower rates of 30-day hospitalizations (OR 0.64), 90-day hospitalizations (OR 0.65), and 90-day ED visits (OR 0.77). CONCLUSIONS: Highly engaged patients had fewer 30-day and 90-day ED visit and readmissions, even after adjustment for key confounders. Engagement, and thus the resulting benefits, were not equitably distributed.

Transition to Reusable Surgical Gowns at a Hospital System.

This quality improvement study investigates the feasibility of transitioning back to reusable surgical gowns at a US tertiary hospital system and projected corresponding cost savings and solid waste reduction.

A Digital Health Intervention to Improve the Clinical Care of Inflammatory Bowel Disease Patients.

BACKGROUND: Inflammatory bowel disease (IBD) is a chronic condition that requires close monitoring. Digital health virtual care platforms can enable self-monitoring and allow providers to remotely surveil patients and efficiently identify those with active disease. OBJECTIVES: The primary aim was to design and implement an IBD remote monitoring program, identify predictors of patient engagement, and determine who found the chat to be a valuable tool. METHODS: We developed the IBD Virtual Care Chat, an electronic health record (EHR)-integrated chat to monitor electronic patient reported outcomes (ePROs), medication changes, and disease activity, and subsequently report concerning findings to providers via the EHR. All patients in the IBD practice over age 18 with a clinical encounter in the preceding 12 months were eligible to be enrolled. The primary aim was to identify predictors of patient engagement and determine who found the chat to be a valuable tool. RESULTS: Between May 2021 and March 2022, 2,934 patients were enrolled. A total of 1,160 engaged at least once and 687 (23.4%) continually engaged, submitting at least three ePROs. Disease severity (based on Harvey-Bradshaw Index or Simple Clinical Colitis Activity Index) did not impact ePRO submissions. Patients were significantly more likely to be continually engaged if they self-reported the presence of extraintestinal manifestations (7%, 95% confidence interval: 0.01-0.14; p = 0.04). Patient satisfaction remained moderately high with a median score of 8 (interquartile range: 5-10) on a scale of 1 (poor) to 10 (good). CONCLUSION: Our program demonstrates the potential for EHR-integrated digital health as part of routine IBD care to achieve sustained engagement with high patient satisfaction.

Development and applicability of a risk assessment tool for hospital-acquired mobility impairment in ambulatory older adults.

BACKGROUND: Mobility loss is common in hospitalized older adults, and resources to prevent mobility impairment are finite. Our goal was to use routinely collected data to develop a risk assessment tool that identifies individuals at risk of losing the ability to walk during hospitalization on the first hospital day. Second, we determined if the tool could inform the use of mobility-preserving interventions. METHODS: We included patients admitted to a general medical service, aged ≥65 years, who walked occasionally or frequently on admission (Braden Scale Activity subset > = 3). Patients were considered to have a new mobility impairment if, at discharge, their ability to walk was severely limited or nonexistent or they were confined to bed (Braden Scale Activity subset <3). We used predictors available on the first hospital day to develop (2017-18 cohort) and validate (2019 cohort) a risk assessment tool. We determined the association between predicted risk and therapy use in the validation cohort to highlight the model's clinical utility. RESULTS: 5542 patients were included (median age 76 years, 48% women); 7.6% were discharged unable to walk. The model included 5 predictors: age, medication administrations, Glasgow Coma Scale verbal score, serum albumin, and urinary catheter presence. In the validation cohort, the model discriminated well (c-statistic 0.75) and was strongly associated with hospital-acquired mobility impairment (lowest decile 1%, highest decile 25%). In the validation cohort, therapy consultation ordering increased linearly with predicted risk; however, observed mobility impairment increased exponentially. CONCLUSION: The tool assesses the risk of mobility impairment in all ambulatory hospitalized older adults on the first hospital day. Further, it identifies at-risk older adults who may benefit from mobility interventions.

Association of Housing Status With Types of Operations and Postoperative Health Care Utilization.

OBJECTIVE: To analyze the association between housing status and the nature of surgical care provided, health care utilization, and operational outcomes. BACKGROUND: Unhoused patients have worse outcomes and higher health care utilization across multiple clinical domains. However, little has been published describing the burden of surgical disease in unhoused patients. METHODS: We conducted a retrospective cohort study of 111,267 operations from 2013 to 2022 with housing status documented at a single, tertiary care institution. We conducted unadjusted bivariate and multivariate analyses adjusting for sociodemographic and clinical characteristics. RESULTS: A total of 998 operations (0.8%) were performed for unhoused patients, with a higher proportion of emergent operations than housed patients (56% vs 22%). In unadjusted analysis, unhoused patients had longer length of stay (18.7 vs 8.7 days), higher readmissions (9.5% vs 7.5%), higher in-hospital (2.9% vs 1.8%) and 1-year mortality (10.1% vs 8.2%), more in-hospital reoperations (34.6% vs 15.9%), and higher utilization of social work, physical therapy, and occupational therapy services. After adjusting for age, sex, comorbidities, insurance status, and indication for operation, as well as stratifying by emergent versus elective operation, these differences went away for emergent operations. CONCLUSIONS: In this retrospective cohort analysis, unhoused patients more commonly underwent emergent operations than their housed counterparts and had more complex hospitalizations on an unadjusted basis that largely disappeared after adjustment for patient and operative characteristics. These findings suggest issues with upstream access to surgical care that, when unaddressed, may predispose this vulnerable population to more complex hospitalizations and worse longer term outcomes.

Experiences with targeting inpatient advance care planning for emergency general surgery patients: A resident-led quality improvement project.

BACKGROUND: For patients who may permanently or temporarily lose their ability to communicate preferences, advance care planning is a critical mechanism to guide medical decision-making but is currently underused among surgical patients. METHODS: A resident-led quality improvement project, including education and performance measurement, was conducted on an emergency general surgery service to increase the completion of inpatient advance care planning notes using a specialized template in the electronic health record. Advance care planning documentation was defined as either preadmission advance care planning documentation (eg, advance directive) or inpatient advance care planning (use of the electronic health record template). Data from patients admitted to the emergency general surgery service for 12+ hours were analyzed, and baseline data (July 2020 to June 2021) were compared with data from the intervention period (July 2021 to June 2022). The chart review evaluated the content of the inpatient advance care planning documentation from the intervention period. RESULTS: The frequency of inpatient advance care planning documentation increased (9.3%, n = 56 to 16.6%, n = 92, P < .001) with a greater contribution of inpatient advance care planning notes by the surgery team (16.7% to 55.4%) in the intervention period. Content analysis indicated that 79.0% of inpatient advance care planning notes listed preferences for life-sustaining therapy, 78.3% listed surrogacy, 57.3% listed overall health goals, and 50.3% listed treatment goals specific to the surgical encounter. CONCLUSION: Although a resident-led quality improvement project contributed to greater adoption of standardized inpatient advance care planning documentation on an emergency general surgery service, progress was slow, and integration into standard work was not achieved. Future efforts are needed to better understand the integration of essential advance care planning elements into workflows and to establish inclusive educational programming to prepare all team members for conducting and documenting advance care planning conversations.

Disparities in advance care planning rates persist among emergency general surgery patients: Current state and recommendations for improvement.

BACKGROUND: Unanticipated changes in health status and worsening of chronic conditions often prompt the need to consider emergency general surgery (EGS). Although discussions about goals of care may promote goal-concordant care and reduce patient and caregiver depression and anxiety, these conversations, as well as standardized documentation, remain infrequent for EGS patients. METHODS: We conducted a retrospective cohort study using electronic health record data from patients admitted to an EGS service at a tertiary academic center to determine the prevalence of clinically meaningful advance care planning (ACP) documentation (conversations and legal ACP forms) during the EGS hospitalization. Multivariable regression was performed to identify patient, clinician, and procedural factors associated with the lack of ACP. RESULTS: Among 681 patients admitted to the EGS service in 2019, only 20.1% had ACP documentation in the electronic health record at any time point during their hospitalization (of those, 75.5% completed before and 24.5% completed during admission). Two thirds (65.8%) of the total cohort had surgery during their admission, but none of them had a documented ACP conversation with the surgical team preoperatively. Patients with ACP documentation tended to have Medicare insurance (adjusted odds ratio, 5.06; 95% confidence interval, 2.09-12.23; p < 0.001) and had greater burden of comorbid conditions (adjusted odds ratio, 4.19; 95% confidence interval, 2.55-6.88; p < 0.001). CONCLUSION: Adults experiencing a significant, often abrupt change in health status leading to an EGS admission are infrequently engaged in ACP conducted by the surgical team. This is a critical missed opportunity to promote patient-centered care and to communicate patients' care preferences to the surgical and other inpatient medical teams. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Pandemic Recovery: Persistent Disparities in Access to Elective Surgical Procedures.

OBJECTIVE: To examine potential disparities in patient access to elective procedures during the recovery phase of the COVID-19 pandemic. SUMMARY OF BACKGROUND DATA: Elective surgeries during the pandemic were limited acutely. Access to surgical care was restored in a recovery phase but backlogs and societal shifts are hypothesized to impact surgical access. METHODS: Adults with electronic health record orders for procedures ("procedure requests"), from March 16 to August 25, 2019 and March 16 to August 25, 2020, were included. Logistic regression was performed for requested procedures that were not scheduled. Linear regression was performed for wait time from request to scheduled or completed procedure. RESULTS: The number of patients with procedure requests decreased 20.8%, from 26,789 in 2019 to 21,162 in 2020. Patients aged 36-50 and >65 years, those speaking non-English languages, those with Medicare or no insurance, and those living >100 miles away had disproportionately larger decreases. Requested procedures had significantly increased adjusted odds ratios (aORs) of not being scheduled for patients with primary languages other than English, Spanish, or Cantonese [aOR 1.60, 95% confidence interval (CI) 1.12-2.28]; unpartnered marital status (aOR 1.21, 95% CI 1.07-1.37); uninsured or self-pay (aOR 2.03, 95% CI 1.53-2.70). Significantly longer wait times were seen for patients aged 36-65 years; with Medi-Cal insurance; from ZIP codes with lower incomes; and from ZIP codes >100 miles away. CONCLUSIONS: Patient access to elective surgeries decreased during the pandemic recovery phase with disparities based on patient age, language, marital status, insurance, socioeconomic status, and distance from care. Steps to address modifiable disparities have been taken.

Impact of patient portal-based self-scheduling of diagnostic imaging studies on health disparities.

While many case studies have described the implementation of self-scheduling tools, which allow patients to schedule visits and imaging studies asynchronously online, none have explored the impact of self-scheduling on equitable access to care.1 Using an electronic health record patient portal, University of California San Francisco deployed a self-scheduling tool that allowed patients to self-schedule diagnostic imaging studies. We analyzed electronic health record data for the imaging modalities with the option to be self-scheduled from January 1, 2021 to September 1, 2021. We used descriptive statistics to compare demographic characteristics and created a multivariable logistic regression model to identify predictors of patient self-scheduling utilization. Among all active patient portal users, Latinx, Black/African American, and non-English speaking patients were less likely to self-schedule studies. Patients with Medi-Cal, California's Medicaid program, and Medicare insurance were also less likely to self-schedule when compared with commercially insured patients. Efforts to facilitate use of patient portal-based applications are necessary to increase equitability and decrease disparities in access.

Using Electronic Health Record Meta-Data to Identify Variation in Trainee Progress Note Writing Patterns: Opportunity to Enhance Systems-Based Care.

OBJECTIVE: Daily progress notes are the backbone of all inpatient hospitalizations. Progress notes serve as a lasting record of a patient's diagnoses, condition, and planned interventions and are essential communication tools. We designed a study to identify patterns in progress note filing and use on general surgical services. METHODS: The electronic health record (EHR) data warehouse was queried for general surgical progress notes signed between July 1, 2020, and July 1, 2021. Only notes authored by resident physicians or advanced practice providers (APPs) were included, and those filed on the day of a surgery were excluded. 10 am was identified as a target for note completion as it coincided with multidisciplinary discharge rounds. Physician, case managers pharmacist, physical therapist, dietician, nurse (and collaborating disciplines) progress note views were measured using EHR access log data. RESULTS: A total of 8384 progress notes were analyzed; 4146 notes (49%) were authored by 81 trainees. A total of 4433 (53%) progress notes were filed before 10 am, 3673 (44%) were filed between 10 am and 6 pm, and 278 (3%) were filed after 6 pm. Variation in progress note file time was observed and associated with individual habits, residents vs APPs, day-of-week, and service structure. Surgery progress notes are viewed by collaborating disciplines throughout the workday, with high-volume viewership occurring by mid-morning. Each individual progress note received an average of 17.6 lifetime views with a range of 1 to 76. An average of 10.2 of those views occurred on the same day that the note was written. Notes that were filed after 10 am received a significantly lower number of same-day views compared to notes filed before 10am (8.4 vs 11.8, p < 0.0001). CONCLUSIONS: Progress notes are identified as a significant burden by trainees and even considered to contribute to duty hour violations, yet they are used regularly as a source of information for collaborating disciplines. Progress notes filed earlier are viewed more frequently. Efforts to identify barriers to timeliness may help communication and efficiency of inpatient surgical care.

Missed Opportunities and Health Disparities for Advance Care Planning Before Elective Surgery in Older Adults.

Importance: Advance care planning (ACP) prepares patients and caregivers for medical decision-making, yet it is underused in the perioperative surgical setting, particularly among older adults undergoing high-risk procedures who are at risk for postoperative complications. It is unknown what patient factors are associated with perioperative ACP documentation among older surgical patients. Objective: To assess ACP documentation among high-risk patients 65 years and older undergoing elective surgery. Design, Setting, and Participants: In this observational cohort study including 3671 patients 65 years and older undergoing elective surgery at a tertiary academic center in California, electronic health record data were linked to the National Surgical Quality Improvement Project outcomes data and the California statewide death registry. The study was conducted from January 1 to December 31, 2019. Data were analyzed from January to May 2022. Exposures: Elective surgery requiring an inpatient admission. Main Outcomes and Measures: ACP documentation, defined as a discussion regarding goals of care documented in an ACP note, an advance directive, or a physician order for life-sustaining treatment (POLST) form, within 90 days before elective surgery requiring inpatient admission. Multivariate regression was performed to identify factors associated with missing ACP. Results: Among 3671 patients (median [IQR] age 72 [65-94] years; 1784 [48.6%] female; 401 [10.9%] Asian, 155 [4.2%] Black, 284 [7.7%] Latino/Latina, 2647 [72.1%] White, and 184 [5.0%] of other races or ethnicities, including American Indian or Alaska Native, Native Hawaiian or Pacific Islander, multiple races or ethnicities, other, and unknown or declined to respond, combined owing to small numbers), 539 (14.7%) had ACP documentation in the 90-day presurgery window. Of these 539, 448 (83.1%) had advance directives, and 60 (11.1%) had POLST forms. The 30-day and 1-year mortality were 0.7% (n = 27) and 6.6% (n = 244), respectively. Missing ACP was significantly associated with male sex (adjusted odds ratio [aOR], 1.39; 95% CI, 1.14-1.69) and having a non-English preferred language (aOR, 1.78; 95% CI, 1.18-2.79). Medicare insurance was significantly associated with having ACP (aOR for missing ACP, 0.63; 95% CI, 0.40-0.95). Conclusions and Relevance: In this study, perioperative ACP was uncommon, particularly in men, individuals with a non-English preferred language, and those without Medicare insurance coverage. The perioperative setting may represent a missed opportunity for ACP for older surgical patients. When addressing ACP for surgical patients, particular attention should be paid to overcoming language-related disparities.

Utilization patterns and efficiency gains from use of a fully EHR-integrated COVID-19 self-triage and self-scheduling tool: a retrospective analysis.

OBJECTIVE: Symptom checkers can help address high demand for SARS-CoV2 (COVID-19) testing and care by providing patients with self-service access to triage recommendations. However, health systems may be hesitant to invest in these tools, as their associated efficiency gains have not been studied. We aimed to quantify the operational efficiency gains associated with use of an online COVID-19 symptom checker as an alternative to a telephone hotline. METHODS: In our health system, ambulatory patients can either use an online symptom checker or a telephone hotline to be triaged and connected to COVID-19 care. We performed a retrospective analysis of adults who used either method between October 20, 2021 and January 10, 2022, using call logs, electronic health record data, and local wages to calculate labor costs. RESULTS: Of the 15 549 total COVID-19 triage encounters, 1820 (11.7%) used only the telephone hotline and 13 729 (88.3%) used the symptom checker. Only 271 (2%) of the patients who used the symptom checker also called the hotline. Hotline encounters required more clinician time compared to those involving the symptom checker (17.8 vs 0.4 min/encounter), resulting in higher average labor costs ($24.21 vs $0.55 per encounter). The symptom checker resulted in over 4200 clinician labor hours saved. CONCLUSION: When given the option, most patients completed COVID-19 triage and visit scheduling online, resulting in substantial efficiency gains. These benefits may encourage health system investment in such tools.

Identifying Barriers to Successful Completion of Video Telemedicine Visits in Urology.

OBJECTIVE: The utilization of video telemedicine has dramatically increased due to the COVID-19 pandemic. However, significant social and technological barriers have led to disparities in access. We aimed to identify factors associated with patient inability to successfully initiate a video visit across a high-volume urologic practice. MATERIALS AND METHODS: Video visit completion rates and patient characteristics were extracted from the electronic medical record and linked with census-level socioeconomic data. Associations between video visit failure were identified using multivariate regression modeling and random forest ensemble classification modeling. RESULTS: Six thousand eighty six patients and their first video visits were analyzed. On multivariate logistic regression analysis, Hispanic or Latino patients (OR 0.52, 95%CI 0.31-0.89), patients insured by Medicare (OR 0.46, 95%CI 0.26-0.79) or Medicaid (OR 0.50, 95%CI 0.29-0.87), patients of low socioeconomic status (OR 0.98, 95%CI 0.98-0.99), patients with an un-activated MyChart patient portal (OR 0.43, 95%CI 0.29-0.62), and patients unconfirmed at appointment reminder (OR 0.68, 95%CI 0.48-0.96) were significantly associated with video visit failure. Patients with primary diagnosis category of men's health (OR 47.96, 95%CI 10.24-856.35), and lower urinary tract syndromes (OR 2.69, 95%CI 1.66-4.51) were significantly associated with video visit success. Random forest analyses identified insurance status and socioeconomic status as the top predictors of video visit failure. CONCLUSION: An analysis of a urology video telemedicine cohort reveals clinical and demographic disparities in video visit completion and priorities for future interventions to ensure equity of access. Our study further suggests that specific urologic indications may play a role in success or failure of video visits.