ABSTRACT
ED patients with lower-acuity care needs often have long wait times for evaluation because of higher-acuity patients receiving priority for available beds. Challenges posed by the Covid-19 pandemic accelerated the launch in December 2020 of an already-developed and approved plan to integrate virtual visits into clinical care at Stanford. For both adult and pediatric EDs, Stanford extended this model into the emergency care environment by converting its existing Fast Track care unit into a Virtual Visit Track (VVT). This was done to speed the ability to evaluate lower-acuity patients in more than one ED with a single physician located at a satellite location. In the VVT, a remote physician provided care to lower-acuity patients who presented at either of the two sites, the pediatric ED or the adult ED. The physician is supported by virtual visit-enabling hardware, software, workflow development, and training, as well as by VVT-trained support staff. In the first 11 months, 2,232 patients received care through the VVT. Stanford met its resource investment break-even point of 12 patients seen during an 8-hour shift on day 6, but this patient volume was not sustained until 7.5 months into the program;this volume has remained constant since then. In a matched cohort of patients, the median ED length of stay (EDLOS) for VVT patients was 1.9 hours compared with 4.2 hours for patients cared for in the typical main ED workflow (P < .001). Also, 17 of 50 VVT physicians (34%) rated their ability to deliver a comparable level of care to in-person consultation as excellent, with the remaining 33 of 50 (66%) rating it as very good. The authors observed that the age range for VVT patients was 2-94 years, but overall, they were younger than a matched cohort of main ED patients. This may reflect generational differences in comfort with a virtual physician encounter. Within the matched cohort, they also found that the median return visit rate among VVT patients was lower than among those in the main ED for 72-hour revisits (6.7% vs. 7.2%;P = .60) and 7-day revisits (10.4% vs. 12.4%;P = .09), but the differences were not statistically significant. This suggests that VVT visit quality is not likely worse than main ED care for similarly lower-acuity patients. The aim was not to determine that the VVT model was superior, but rather that it was not inferior. Virtual care is a fast-growing method of care delivery. Although typically applied when a patient is outside of the care environment, a VVT program can be used in other situations in which options for in-person evaluation are limited. © 2022 NEJM Catalyst Innovations in Care Delivery. All right reserved.
ABSTRACT
Aims: COVID-19 has had much publicised impacts on cancer diagnosis within Victoria. Statewide there are thought to be over 2000 undiagnosed malignancies since the start of the pandemic, particularly in men andwithin melanoma, prostate cancer and head and neck malignancies. Regional and local patterns of presentation may differ from statewide data and local data suggesting under diagnosis may assist in regional service planning. Method(s): Prior statistical analysis using Victorian Cancer Registry (VCR) data has been used to identify a shortfall in cancer diagnoses. VCR notifications for 2019-2021 inclusive for the Barwon southwest region were utilised for this review. Notifications for the five most common cancers were assessed for major variations in notifications, taking a pragmatic approach to classify a major variation where notifications changed by more than 10% from 2019 levels in either or both of 2020/2021. Result(s): Total notifications did not change significantly from 2019- 21 (3676, 3777, 3731, respectively). Likewise, there were no obvious reductions in notification by sex or in older patients. While breast cancer notifications dropped in 2021 but rebounded in 2022 (424, 348, 453), diagnoses of DCIS increased each year (36, 55, 68). Lung cancer notifications dropped in 2021-22 (336, 249, 269) as did notifications of colorectal cancer (452, 418, 361), while prostate cancer notifications rose (531, 662, 654) and melanoma notifications were fairly consistent (145, 158, 141). Conclusion(s): Using a pragmatic approach to identifying major variations in cancer notifications during the COVID-19 pandemic, regional data suggests a reduction in lung cancer and colorectal cancer diagnoses in our region. Unlike reported statewide data, there was not an obvious drop in notifications of prostate cancer or melanoma. Further analysis of this data may help better identify cohorts with under diagnosis in our region.