Understanding virtual urology clinics: a systematic review.

OBJECTIVES: To perform a systematic review to identify the clinical, fiscal and environmental evidence on the use of urological telehealth and/or virtual clinic (VC) strategies, and to highlight research gaps in this rapidly evolving field. METHODS: Our PROSPERO-registered (CRD42019151946) systematic search of Embase, Medline and the Cochrane Review Database was performed to identify original research articles pertaining to adult urology telehealth or VC strategies. Risk-of-bias (RoB) assessment was performed according to the Cochrane 2.0 RoB tool or the Joanna Briggs Institute Checklist for non-randomized studies. RESULTS: A total of 5813 participants were included from 18 original articles (two randomized controlled trials [RCTs], 10 prospective studies, six retrospective studies). Urology sub-specialities comprised: uro-oncology (n = 6); general urology (n = 8); endo-urology (n = 2); and lower urinary tract symptoms and/or incontinence (n = 2). Across all sub-specialties, prospective studies using VCs reported a primary median (interquartile range [IQR]) VC discharge rate of 16.6 (14.7-29.8)% and a primary median (IQR) face-to-face (FTF) clinic referral rate of 32.4 (15.5-53.3)%. Direct cost analysis demonstrated median (IQR) annual cost savings of £56 232 (£46 260-£61 116). Grade II and IIIb complications were reported in two acute ureteric colic studies, with rates of 0.20% (3/1534) and 0.13% (2/1534), respectively. The annual carbon footprint avoided ranged from 0.7 to 4.35 metric tonnes of CO2 emissions, depending on the mode of transport used. Patient satisfaction was inconsistently reported, and assessments lacked prospective evaluation using validated questionnaires. CONCLUSION: Urology VCs are a promising new platform which can offer clinical, financial and environmental benefits to support an increasing urological referral burden. Further prospective evidence is required across urological sub-specialties to confirm equivalency and safety against traditional FTF assessment.

Clinical, fiscal and environmental benefits of a specialist-led virtual ureteric colic clinic: a prospective study.

OBJECTIVES: To evaluate the clinical, fiscal and environmental impact of a specialist-led acute ureteric colic virtual clinic (VC) pathway. PATIENTS AND METHODS: All patients with uncomplicated acute ureteric colic, referred to a single tertiary centre, were prospectively entered into the study over a 4-year period (January 2015-December 2018). Inclusion criteria were: low-dose non-contrast computed tomography of kidneys, ureters and bladder; white blood cell count <16 × 109/L; pain controlled; normal renal function; and no clinical concern. Primary outcomes were: time (days) from referral to VC outcome; VC outcome (discharge, further VC, face-to-face [FTF] clinic, extracorporeal shockwave lithotripsy [ESWL], ureterorenoscopy [URS], percutaneous nephrolithotomy [PCNL]); and adverse events (sepsis or obstruction). Secondary outcomes were patient and stone demographics, cost and environmental analysis. The minimum follow-up was 3 months. RESULTS: A total of 1008 patients entered the study, of whom 91.5% (n = 922) were of working age. The median (interquartile range) time from presentation to VC outcome was 2 (4) days. VC outcomes were as follows: 16.3% of patients (n = 164) were discharged; 18.2% (n = 183) were discharged after further VC; 17.2% (n = 173) underwent an intervention; and 48.4% (n = 488) were referred to an FTF clinic. Interventions comprised: PCNL 0.5% (n = 5); ESWL 7.7% (n = 78); and URS 8.9% (n = 90). Stone demographics were as follows: 570 patients (56.5%) had lower, 157 (15.6%) had upper, 96 (9.5%) had mid-ureteric and 163 (16.2%) had renal calculi, and in 22 patients (2.2%) the stones had recently passed. The mean (sd) stone size was 3.5  (2.3) mm. Two adverse events (0.2%) were reported. Introducing a VC saved £145,152 for Clinical Commissioning Groups, the equivalent NHS tariff payment of performing 106 URS procedures or 211 ureteric stent insertions. Overall, 15,085 patient journey kilometres were avoided, equal to 0.70-2.93 metric tonnes of carbon dioxide equivalent production and the need to plant 14.7 trees to achieve carbon balance. CONCLUSION: A specialist-led acute ureteric colic VC reduced time to treatment decision to a median of 2 days. This creates additional clinic capacity and reduces the fiscal burden of traditional clinics and their associated carbon footprint.

Clinical benefits of a combined physician associate and senior specialist-led emergency surgery ambulatory emergency care clinic introduced in response to the COVID-19 pandemic.

INTRODUCTION: A well-designed ambulatory emergency care (AEC) can alleviate demand for inpatient beds by reducing admissions or supporting early discharges. Increasing service demands and workforce gaps present major challenges to surgical departments. Physician's associates (PAs) have been suggested as one way to address this, but previous barriers include lack of job role clarity, and inability to prescribe or request ionising radiation. An AEC clinic using PAs supported by senior decision-makers could improve patient care and provide workforce stability alongside a new capacity for successful PA positions. METHODS: An emergency surgery AEC pathway was introduced to a single centre in anticipation of a second COVID-19 wave. All emergency surgical referrals were prospectively collected over 3 months (November 2020 to February 2021) with minimum 30-day follow-up. The primary aims were to evaluate clinical outcomes and success of a new AEC PA role. RESULTS: A total of 175 patients were entered into the study. The median time from request for senior review to treatment decision was 26 min (IQR 9-62 min). The primary discharge rate was 38.3% (n=67), while the overall discharge rate without needing admission was 84% (n=147). Of the total 28 (16.0%) patients requiring admission, 18 (10.3%) were clinically appropriate. Four patients represented with Clavien-Dindo Grade II complications and above: two grade II (1.1%) and two grade IIIb respectively (1.1%). The role of the PA was well defined with no team discord. No patient complaints were received. CONCLUSION: During the COVID-19 pandemic, an emergency surgery AEC pathway was implemented by combining a PA with a senior decision-maker, enabling fewer emergency admissions and significantly reduced time-to-reach-treatment decisions. This in turn facilitates bed-flow and minimises delays in patient treatment. The use of a well-defined PA role in this setting shows initial success and should be considered as a long-term role.

Implementation of a medical education programme for addictions MDT members to improve knowledge and confidence in managing substance users with complex comorbidities.

BACKGROUND: Public Health England (PHE) has highlighted a rising number of deaths due to addiction, and notable changes in patient profiles. Management is now frequently intertwined with medical comorbidities and polypharmacy, as the patient group presents with more complex needs. Early detection is vital to minimise harm. Mental health frequently needs treating in tandem, but 'cross-referral' services can fail to recognise or meet these needs. A cohesive, confident multidisciplinary team (MDT) is vital for holistic care and accelerating recovery in cost-effective ways. Furthermore, MDTs are uniquely placed to effectively broker communications between multiple care inputs. METHODS: MDT members of an addictions centre participated in a three-and-a-half-months education programme, encompassing eight PHE-recommended topics. These related to physical and mental health substance misuse sequelae, and specific population treatment needs. RESULTS: There was a statistically significant improvement in all areas including: recognising early physical and/or mental health deterioration signs, providing basic health advice and appropriate escalation. Regarding PHE topics, biggest mean improvements were in managing substance misuse with physical comorbidities and pregnancy (38.2% and 35.9% respectively, p<0.0001). Additionally, biological mechanisms increased 26.0%, physical health consequences 24.2%, hepatic disorders 31.7%, older people 31.3%, homeless populations 31.8% and coexisting mental health 24.6% (all p≦0.002). Confidence communicating concerns to internal and external clinicians also increased (14% and 21%, respectively, p≦0.001). CONCLUSION: A teaching programme improved MDT knowledge and confidence in early detection, escalation and communication of physical and mental comorbidities associated with substance misuse. This intervention should support harm reduction strategies on individual and wider-community levels. Introducing an education programme ensures a sustainable approach to workforce development and helps facilitate holistic care cost-effectively. Clear communication between multiple 'cross-referral' services involved with complex needs is essential for comprehensive integrated care.