Improving Enrollment and Adherence to the Lung Transplant Home Spirometry Program

In May 2020, we implemented a home spirometry program (HSP) to facilitate remote monitoring of lung function in lung transplant recipients in response to the COVID-19 pandemic. We found enrollment and adherence rates were below the program goal of 75%. We developed a quality improvement project to optimize the HSP enrollment and onboarding in order to improve enrollment and adherence rates. Gap analysis was performed through observation and qualitative interviews of patients, nurses, and physicians. A fishbone analysis found three main opportunities to improve adherence including a variable onboarding process, no foreign language offerings, and suboptimal educational material. We developed and launched a standardized workflow, a new educational video, and educational materials in 5 languages. In-process metrics were tracked through the use of an EMR "smartphrase" and QR code to indicate use of the new workflow and educational video. Enrollment and adherence were measured by the % of patients submitting more than one FEV1 value in the first 30 days after discharge. After implementation in August 2022, we found the new onboarding process, as indicated by the use of our"smartphrase", and the new educational video, as indicated by the use of the QR code, were utilized for 100% of new patients over the first two months. We found an absolute increase of 85% of patients submitting an FEV1 value in the first month following discharge from lung transplantation (Figure 1). We were able to improve the process of onboarding and education through the development of a new standardized workflow and video. This was found to be reliably executed and resulted in an improvement in patient enrollment and adherence. Moving forward we will track the impact of our new onboarding and video educational tool on long-term adherence. [ABSTRACT FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

OPERATIONAL IMPACT AND COST AVOIDANCE FROM USE OF AN ONLINE COVID-19 SYMPTOM CHECKER

STATEMENT OF PROBLEM/QUESTION: During the COVID pandemic, symptom checkers have been a crucial tool for providing patients with ondemand access to triage recommendations. Faced with high demand for COVID testing and care and staffing shortages, health systems are in desperate need of automated, self-service tools. However, they may be hesitant to invest in designing and implementing online symptom checkers because their impact on operational efficiency and cost avoidance have not been studied. DESCRIPTION OF PROGRAM/INTERVENTION: We previously published one of the first reports of the design, implementation and results of an online COVID-19 self-triage and self-scheduling tool in a large academic health system. In March 2020, we implemented this tool alongside a COVID19 telephone hotline. Ambulatory patients with symptoms can use the online tool or hotline to be triaged and connected to care via an identical triage protocol. MEASURES OF SUCCESS: In this retrospective analysis, we quantify the operational efficiency and cost avoidance associated with use of an online COVID symptom checker as an alternative to a telephone hotline. We included symptomatic adults who used the online tool or called the hotline between Dec 10, 2020-March 10, 2021. We used a combination of telephone call logs and EHR data to determine the types and duration of calls required to resolve each encounter. We calculated costs using average hourly wages for each type of employee staffing the hotline. FINDINGS TO DATE: During the 90-day study period, there were 3,809 total symptomatic COVID triages, of which 1,411 (37%) were completed on the telephone hotline and 2,398 (63%) were completed using the online symptom checker. Patients who used the symptom checker also called the hotline 17.6% of the time. Patients who used the online tool and were given the option to self-schedule were six times more likely to do so online than by calling the hotline (46% vs. 7.7%). Triage and scheduling encounters completed exclusively using the hotline required an average total of 47.4 minutes of triage staff time per encounter, while triages that involved the symptom checker took an average of 6.3 minutes of triage staff time per encounter, resulting in lower average per-encounter triage and scheduling costs ($81.02 vs. $9.81). The estimated cost avoidance attributable to the symptom checker during the 3-month period was $170,753. After including product development costs, the estimated first-year return was 9.3 times the investment. KEY LESSONS FOR DISSEMINATION: We demonstrate that when given the option, most patients with COVID symptoms complete the triage and self-scheduling process online, resulting in substantial efficiency gains and operational cost avoidance compared to triage and scheduling by phone. The potential cost savings far outweighed development costs. This is the first known study to quantify these benefits. These findings may encourage health system investment in such tools, particularly as ambulatory demand for COVID testing and care continues to be high.

Barriers to same-day discharge after percutaneous nephrolithotomy

Introduction & Objective: The COVID-19 pandemic has provided an impetus to reconsider traditional urologic practices and adapt to the unprecedented healthcare burden. Reducing length of stay after minimally invasive procedures is now more important than ever. Using percutaneous nephrolithotomy (PCNL) as a model, we sought to evaluate clinical barriers to same-day discharge in order to better understand the feasibility of outpatient surgery. Methods: Prospective data collected from 500 inpatient PCNLs performed at our institution between 2016 and 2020 was analyzed via the Registry for Surgery of the Kidney and Ureter (ReSKU). Preadmissions and aborted procedures were excluded. We analyzed issues and complications that warranted postoperative admission. Major categories included infection, bleeding, and excessive pain, which was defined as either a documented pain complication or administration of intravenous opioids within 24 hours after discharge from the recovery room. Multivariate statistics were used to assess risk factors for each outcome. Results: Excessive pain was the most common postoperative issue (40.9%). ASA score was inversely correlated with odds of having increased pain (OR 0.64, 95% CI 0.42-0.98) and was the only statistically significant predictor in our multivariate model that included dilated tract number, diameter, and location. The postoperative SIRS/sepsis rate within 7 days was 9.7%, and higher ASA score (OR 3.6, 95% CI 1.8-7.6) and incomplete stone clearance (OR 2.7, 95% CI 1.2-6.3) were significant predictors. Age, sex, body mass index (BMI), stone burden, and positive preoperative urine cultures were not associated with overall infection rate. In patients who had a postoperative infection, 34.1% of infections were detected intraoperatively or in the recovery room, and 48.8% were associated with the nephrostomy tube removal process on postoperative day 1. Patients who had a postoperative double-J stent rather than a nephrostomy tube had a lower overall infection rate (1.8%, p = 0.047). Finally, only 1.9% of patients had a bleeding complication, and 1.1% required a blood transfusion. Conclusions: Pain is the major barrier to same-day discharge after PCNL. Bleeding is infrequent and most infections can be recognized perioperatively or avoided with alternative tube management strategies. Rigorous patient selection for same-day discharge does not appear to be necessary. Optimizing pain control may be the key to performing outpatient surgery on a large scale.

Pain is the most common clinical barrier to same-day discharge after percutaneous nephrolithotomy

INTRODUCTION AND OBJECTIVE: The COVID-19 pandemic has provided an impetus to reconsider traditional urologic practices and adapt to the unprecedented healthcare burden. Reducing length of stay after minimally invasive procedures is now more important than ever. Using percutaneous nephrolithotomy (PCNL) as a model, we sought to evaluate clinical barriers to same-day discharge in order to better understand the feasibility of outpatient surgery. METHODS: Prospective data collected from 500 inpatient PCNLs performed at our institution between 2016 and 2020 was analyzed via the Registry for Surgery of the Kidney and Ureter (ReSKU). Preadmissions and aborted procedures were excluded. We analyzed clinical problems and complications that warranted postoperative admission. Major categories included infection, bleeding, and excessive pain, which was defined as either a documented pain complication or administration of intravenous opioids within 24 hours after discharge from the recovery room. Multivariate statistics were used to assess risk factors for each outcome. RESULTS: Excessive pain was the most common postoperative problem (40.9%). ASA score was inversely correlated with odds of having increased pain (OR 0.64, 95% CI 0.42-0.98) and was the only statistically significant predictor in our multivariate model that included dilated tract number, diameter, and location. The postoperative SIRS/sepsis rate within 7 days was 9.7%, and higher ASA score (OR 3.6, 95% CI 1.8-7.6) and incomplete stone clearance (OR 2.7, 95% CI 1.2-6.3) were significant predictors. Age, sex, body mass index (BMI), stone burden, and positive preoperative urine cultures were not associated with overall infection rate. In patients who had a postoperative infection, 34.1% of infections were detected intraoperatively or in the recovery room, and 48.8% were associated with the nephrostomy tube removal process on postoperative day 1. Patients who had a postoperative double-J stent rather than a nephrostomy tube had a lower overall infection rate (1.8%, p = 0.047). Finally, only 1.9% of patients had a bleeding complication, and 1.1% required a blood transfusion. CONCLUSIONS: Excessive pain is the most common clinical barrier to same-day discharge after PCNL and affects nearly half of all patients. Bleeding is infrequent, and most infections can be recognized perioperatively or avoided with alternative tube management strategies. Rigorous patient selection for same-day discharge does not appear to be necessary. Optimizing pain control may be the key to performing outpatient surgery on a large scale.

Acclimation to Telehealth in Radiation Oncology During COVID-10 Response: Demographic Trends and Challenges

The 2019 coronavirus pandemic (COVID-19) had a broad impact on the care of cancer patients, including the rapid adoption of telehealth video visits. On March 15, 2020, our institutional leadership recommended transition to video visits, which posed a risk of altering patients' access to care. We assessed the impact of this rapid transition on demographic patterns in an urban academic radiation oncology department. Consultation and follow-up visits from the pre-COVID-19 period (January 1, 2019 to March 14, 2020) and COVID-19 period (March 15, 2020 to August 31, 2020) in a single radiation oncology department were identified. Demographics and appointment data were abstracted from the institutional electronic health record. Time trends and patient and visit characteristics were compared across the pre-COVID-19 and COVID-19 periods. During the study period, 9,450 consult and follow-up visits were performed pre-COVID-19 and 3,298 visits in the COVID-19 period. The proportion of video visits increased markedly in the transition period, from 0.6% of all visits in the week of March 2, 2020, to 87% in the week of March 23, 2020. In-person visits decreased from 98% to 3%. Among all visits (in-person and telehealth), those during the COVID-19 period were less likely to be new consultations (43.1% from 60.1%;P < 0.001). There was a small and significant increase in the proportion of visits with patients who: identified as white (61.8% from 58.4%, P = 0.019), spoke English as their primary language (91.3% from 89.4%, P = 0.002), and had commercial insurance (34.1% from 32.0%;P = 0.009). The overall COVID-19 clinic population retained demographic features similar to the pre-COVID-19 population despite a very rapid near-complete transition to telehealth. Nonetheless, the telehealth-predominant COVID-19 period had slightly increased visits with patients who were white or primarily English speaking or had commercial insurance. Strategies for ensuring telehealth is accessible to diverse populations should be a priority as telemedicine is integrated into long-term clinical operations. [ABSTRACT FROM AUTHOR] Copyright of International Journal of Radiation Oncology, Biology, Physics is the property of Pergamon Press - An Imprint of Elsevier Science and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Implementation of a Chatbot Mobile Health Intervention with Home Spirometry to Monitor Lung Transplant Recipients Remotely

Purpose The COVID-19 pandemic accelerated the need to develop remote monitoring of graft function in lung transplant (LT) recipients. While home spirometry has been used previously in LT, long-term engagement has been poor. We aimed to improve engagement and allow efficient data and symptom collection using Bluetooth enabled home spirometers coupled with a digital chatbot. Methods We implemented an automated, chat-based mobile health intervention via text message or email paired with Bluetooth-enabled hand-held spirometers. The chatbot engaged LT recipients weekly in a personalized, automated chat with symptom assessment, education modules, and spirometer data collection. Clinical team members received automatic notification of concerning symptoms or FEV1 declines of >10%. The correlation between home spirometry FEV1 values and lab-based values were assessed with Pearson's coefficient. Results We mailed home spirometers to 424 patients. Between 5/4/2020 and 10/21/2020, 311 patients enrolled in the automated chat and, of these, 273 patients submitted ≥1 FEV1 measure, (median 13;IQR 6-23) over 24 weeks. The largest drop in FEV1 engagement came after the first week in each patient's chat experience;65% of those that submitted an FEV1 at baseline entered a value at week one and 72% at week two. However, after this initial decline, engagement remained stable through 24 weeks (57-72%, Figure 1.A). Home spirometry FEV1 correlated closely with in-lab spirometry (rho = 0.94) (Figure 1.B) Conclusion

Ensuring equitable access to hepatology telemedicine during the COVID-19 pandemic

Background: The COVID-19 pandemic has led to an unprecedented expansion in telemedicine but has also exposed the deep underlying healthcare disparities in the US Vulnerable patients, including those with limited English proficiency, underrepresented minority groups, older adults, and those with lower socioeconomic status, are more likely to experience digital barriers to engaging in telemedicine Although our academic hepatology practice adopted telemedicine several years before COVID-19, there was a concerted effort to assist patients and providers with video visits during the pandemic We aimed to evaluate shifting demographics of patients accessing telemedicine pre- and post-COVID-19 Methods: Patient demographics, appointment date, and visit type were obtained from the electronic health record reporting database for all patients seen by the UCSF Hepatology and Liver Transplant clinic 1/2/2019-5/29/2020. Visits were stratified into pre-COVID-19 (1/2/2019-3/15/2020) and post-COVID-19 (3/15/2020- 5/29/2020) periods We compared characteristics of clinic patients seen 1) in the pre- vs post-COVID-19 periods;2) via in-person vs video visits;and 3) via video visits pre- vs post- COVID-19 Chi-square or Kruskal-Wallis tests were used to compare categorical and continuous variables, respectively Telephone visits were not included in the analysis Results: Pre-COVID-19, a total of 12,017 patients were seen, including 1,509 via video (12 5%) Post-COVID-19, 1,894 patients were seen, including 1,504 via video (79%) Over the entire study period, compared to patients seen in-person (n=9,344), patients seen via video (n=3,013) were younger and more likely to be Caucasian, speak English as their primary language, and have commercial insurance (p < 0 001 across all comparisons) Among all patients who completed video visits, those seen post-COVID-19 were older, were more likely to be non-Caucasian, non-English speaking and utilizing an interpreter for the visit, and have public insurance compared to pre-COVID-19 (p < 0 001 across all comparisons) Conclusion: Prior to COVID-19, video visits were relatively common in our clinic, but disparities in video visit utilization existed. Post-COVID-19, with significant efforts to convert clinic visits to video, the characteristics of patients seen via video changed to include more vulnerable patients If telemedicine is the future of hepatology, we must work to ensure that all of our patients have equitable access. (Table Presented).

Telemedicine in urology: A crash course during the COVID-19 pandemic

The State of Emergency for the COVID-19 pandemic has created an environment where urologists can continue to safely provide care through telemedicine. We hope this article helps urologists successfully implement telemedicine and video visits. This will maintain safety both for our patients and for the health care workers in our offices. © 2020 Advanstar Communications Inc.. All rights reserved.