The environmental impact of surgical telemedicine: life cycle assessment of virtual vs. in-person preoperative evaluations for benign foregut disease.

BACKGROUND: Health care accounts for almost 10% of the United States' greenhouse gas emissions, accounting for a loss of 470,000 disability-adjusted life years based on the health effects of climate change. Telemedicine has the potential to decrease health care's carbon footprint by reducing patient travel and clinic-related emissions. At our institution, telemedicine visits for evaluation of benign foregut disease were implemented for patient care during the COVID-19 pandemic. We aimed to estimate the environmental impact of telemedicine usage for these clinic encounters. METHODS: We used life cycle assessment (LCA) to compare greenhouse gas (GHG) emissions for an in-person and a telemedicine visit. For in-person visits, travel distances to clinic were retrospectively assessed from 2020 visits as a representative sample, and prospective data were gathered on materials and processes related to in-person clinic visits. Prospective data on the length of telemedicine encounters were collected and environmental impact was calculated for equipment and internet usage. Upper and lower bounds scenarios for emissions were generated for each type of visit. RESULTS: For in-person visits, 145 patient travel distances were recorded with a median [IQR] distance travel distance of 29.5 [13.7, 85.1] miles resulting in 38.22-39.61 carbon dioxide equivalents (kgCO2-eq) emitted. For telemedicine visits, the mean (SD) visit time was 40.6 (17.1) min. Telemedicine GHG emissions ranged from 2.26 to 2.99 kgCO2-eq depending on the device used. An in-person visit resulted in 25 times more GHG emissions compared to a telemedicine visit (p < 0.001). CONCLUSION: Telemedicine has the potential to decrease health care's carbon footprint. Policy changes to facilitate telemedicine use are needed, as well as increased awareness of potential disparities of and barriers to telemedicine use. Moving toward telemedicine preoperative evaluations in appropriate surgical populations is a purposeful step toward actively addressing our role in health care's large carbon footprint.

The impact of socioeconomic status on telemedicine utilization during the COVID-19 pandemic among surgical clinics at an academic tertiary care center.

BACKGROUND: The COVID-19 pandemic caused many surgical providers to conduct outpatient evaluations using remote audiovisual conferencing technology (i.e., telemedicine) for the first time in 2020. We describe our year-long institutional experience with telemedicine in several general surgery clinics at an academic tertiary care center and examine the relationship between area-based socioeconomic measures and the likelihood of telemedicine participation. METHODS: We performed a retrospective review of our outpatient telemedicine utilization among four subspecialty clinics (including two acute care and two elective surgery clinics). Geocoding was used to link patient visit data to area-based socioeconomic measures and a multivariable analysis was performed to examine the relationship between socioeconomic indicators and patient participation in telemedicine. RESULTS: While total outpatient visits per month reached a nadir in April 2020 (65% decrease in patient visits when compared to January 2020), there was a sharp increase in telemedicine utilization during the same month (38% of all visits compared to 0.8% of all visits in the month prior). Higher rates of telemedicine utilization were observed in the two elective surgery clinics (61% and 54%) compared to the two acute care surgery clinics (14% and 9%). A multivariable analysis demonstrated a borderline-significant linear trend (p = 0.07) between decreasing socioeconomic status and decreasing odds of telemedicine participation among elective surgery visits. A sensitivity analysis to examine the reliability of this trend showed similar results. CONCLUSION: Telemedicine has many patient-centered benefits, and this study demonstrates that for certain elective subspecialty clinics, telemedicine may be utilized as the preferred method for surgical consultations. However, to ensure the equitable adoption and advancement of telemedicine services, healthcare providers will need to focus on mitigating the socioeconomic barriers to telemedicine participation.

Association Between Androgen Deprivation Therapy and Mortality Among Patients With Prostate Cancer and COVID-19.

Importance: Androgen deprivation therapy (ADT) has been theorized to decrease the severity of SARS-CoV-2 infection in patients with prostate cancer owing to a potential decrease in the tissue-based expression of the SARS-CoV-2 coreceptor transmembrane protease, serine 2 (TMPRSS2). Objective: To examine whether ADT is associated with a decreased rate of 30-day mortality from SARS-CoV-2 infection among patients with prostate cancer. Design, Setting, and Participants: This cohort study analyzed patient data recorded in the COVID-19 and Cancer Consortium registry between March 17, 2020, and February 11, 2021. The consortium maintains a centralized multi-institution registry of patients with a current or past diagnosis of cancer who developed COVID-19. Data were collected and managed using REDCap software hosted at Vanderbilt University Medical Center in Nashville, Tennessee. Initially, 1228 patients aged 18 years or older with prostate cancer listed as their primary malignant neoplasm were included; 122 patients with a second malignant neoplasm, insufficient follow-up, or low-quality data were excluded. Propensity matching was performed using the nearest-neighbor method with a 1:3 ratio of treated units to control units, adjusted for age, body mass index, race and ethnicity, Eastern Cooperative Oncology Group performance status score, smoking status, comorbidities (cardiovascular, pulmonary, kidney disease, and diabetes), cancer status, baseline steroid use, COVID-19 treatment, and presence of metastatic disease. Exposures: Androgen deprivation therapy use was defined as prior bilateral orchiectomy or pharmacologic ADT administered within the prior 3 months of presentation with COVID-19. Main Outcomes and Measures: The primary outcome was the rate of all-cause 30-day mortality after COVID-19 diagnosis for patients receiving ADT compared with patients not receiving ADT after propensity matching. Results: After exclusions, 1106 patients with prostate cancer (before propensity score matching: median age, 73 years [IQR, 65-79 years]; 561 (51%) self-identified as non-Hispanic White) were included for analysis. Of these patients, 477 were included for propensity score matching (169 who received ADT and 308 who did not receive ADT). After propensity matching, there was no significant difference in the primary end point of the rate of all-cause 30-day mortality (OR, 0.77; 95% CI, 0.42-1.42). Conclusions and Relevance: Findings from this cohort study suggest that ADT use was not associated with decreased mortality from SARS-CoV-2 infection. However, large ongoing clinical trials will provide further evidence on the role of ADT or other androgen-targeted therapies in reducing COVID-19 infection severity.