Rationing endoscopy during the COVID-19 lockdown was safe: The experience of an Australian hospital

Background and Aim: Coronavirus disease 2019 (COVID-19) is now a worldwide pandemic. Gastrointestinal endoscopy is considered an aerosol-generating procedure (AGP) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission. On 25 March 2020, the Prime Minister of Australia announced a nationwide suspension of all non-urgent endoscopy. There are limited data to provide insight into creating a safe model for rationing gastrointestinal endoscopy that does not compromise patient care. Our hospital mobilized a model of care, deferring all non-urgent category 2 and all category 3 cases, and created specific clinics with experienced endoscopists to re-triage outstanding cases. We aimed to conduct a retrospective study to evaluate this single-center experience. Methods: We collected data on patients who had an emergency (performed within 48 h of emergency admission) or elective gastroscopy or colonoscopy during the 5-week lockdown period (26 March to 1 May 2020). For comparison, the same analysis was performed on all those who underwent an endoscopic procedure during the same period 12 months earlier. Our primary objective was to compare the rate of highly significant abnormalities detected during these two periods. Highly significant abnormalities were defined as upper or lower gastrointestinal malignancy, adenomatous polyps larger than 2 cm, or a new diagnosis of inflammatory bowel disease. Furthermore, we evaluated all gastrointestinal malignancy diagnoses over the past 2 years, identifying the triage category, indication, endoscopic and histological findings, and the rate of malignancy diagnosis. Results: During the COVID-19 era, 66% fewer procedures were performed than in the previous year's corresponding period (141 procedures [79% category 1, 21% category 2] vs 410 procedures [45% category 1, 45% category 2, 10% category 3];P < 0.001). The numbers of emergency endoscopies were similar (16 in COVID-19 era vs 18 pre-COVID-19). A comparable number of highly significant abnormalities were found (Table 1). The six new malignancy diagnoses in the COVID-19 era were in keeping with our median monthly cancer rate of 5.5 (IQR, 3-6.3) over the past 2 years. Of the 4621 gastroscopies and 4573 colonoscopies performed in the past 2 years, 94% of the newly diagnosed upper and lower gastrointestinal cancers were triaged as category 1, 6% as category 2, and none as category 3. Conclusion: Our findings suggest that significant and time-critical abnormalities are unlikely to be missed by a model of care prioritizing category 1 and urgent category 2 upper and lower endoscopies, as we did during the COVID-19 shutdown. These reassuring findings may help guide the approach to endoscopy management if another shutdown occurs here or overseas, especially given the recent spike in COVID-19 cases in Victoria.

Silver lining of a very dark cloud: Telehealth virtually perfect in the COVID-19 era

Background and Aim: Public hospital outpatient departments are a critical interface between acute and specialist hospital services and primary care. Failure of patients to attend is an expensive and persistent issue worldwide, with reported did-not-attend (DNA) rates of up to 30% in some centers. Non-attendance is influenced by many factors, such as logistics in getting to the hospital, work commitments, financial hardship, transportation access, and competing health interests. Telehealth has been available for some years, but its implementation and uptake have been limited. Telehealth is defined as “information and communications technologies to deliver health and transmit health information over both long and short distances,”1 and it can be conducted via videoconferencing or telephone. It represents an attractive model to increase outpatient clinic appointments, which is important given the long waiting times for many clinics. Telehealth also provides avenues to continue critical outpatient management during the coronavirus disease 2019 (COVID-19) pandemic and for ongoing clinical management for furloughed or isolated staff who can still be engaged in outpatient care. At our institution, the COVID-19 pandemic stimulated the immediate and almost universal implementation of the telehealth model of care for outpatient appointments. We aimed to evaluate the experience of the telehealth model in the first 3 months of the COVID-19 pandemic in Victoria, focusing on the impact of telehealth on the number of scheduled appointments and clinic DNA rates. Methods: Over a 9-week period during the first COVID-19 lockdown in Melbourne, scheduled appointment numbers and patient attendance rates at 13 gastroenterology and hepatology outpatient clinics at a single tertiary hospital were evaluated through the hospital's online patient administration system, following rapid implementation of the telehealth model of outpatient care. Appointment numbers and attendance were compared with the average attendance rate over the same period in the preceding 5 years. Data collected included patient DNA rates for every scheduled clinic and appointment type (videoconferencing, telephone, or face-to-face consultation). Results: A total of 2626 outpatient clinic appointments were scheduled during the first 9-week COVID-19 lockdown, with 2237 appointments (85%) attended and 389 DNAs (15%), an improvement of 2.2% in attendance rate compared with the average attendance rate during the same 9-week period in the preceding 5 years (P = 0.035). Of the 2626 appointments, 1319 (50%) were video consultations, and 1307 (50%) were telephone consultations. In the preceding 5 years, an average of 2304 outpatient clinic appointments (322 fewer appointments) were scheduled during the same 9-week period, with 1912 appointments (83%) attended and 392 (17%) not attended. Of these 2304 appointments, 2271 (99%) were face-to-face consultations and only 33 (1%) were video consultations. Attendance rates differed according to clinic type. Compared with previous years, outpatient clinics with significantly lower DNA rates during COVID-19 included combined general gastroenterology (15% vs 20%, P = 0.014), satellite inflammatory bowel disease (2% vs 10%, P = 0.033), satellite liver clinic (20% vs 28%, P = 0.198), and privatized liver clinic (13% vs 18%, P = 0.051). Clinics with higher numerical DNA rates included hepatoma (18% vs 12%, P = 0.731) and weight management (20% vs 15%, P = 0.343). When evaluating the appointment type, we found that consultations carried out by telephone resulted in a significantly lower DNA rate, compared with video consultations (9% vs 21%;P < 0.001). Furthermore, an additional 37 clinic lists occurred during this 9-week period, equivalent to four additional lists per week, compared with the average number in the preceding 5 years. Conclusion: Despite the upheaval of clinical services during the COVID-19 pandemic, the major and rapid systems change to overhaul outpatient clinics to an almost exclusively telehealth model was highly succes ful. A total of 1319 video consultations occurred during the 9-week period, compared with just 43 in the preceding year, demonstrating the rapid and widespread implementation of telehealth. Importantly, there was a significant overall reduction in DNA rates, by 2.2%, using the telehealth model. Phone calls were particularly effective for clinic consultations, with DNA rates of only 9.0%. Telehealth has the potential to improve outpatient clinic attendance and efficiency, and our data strongly advocate for ongoing support for telehealth models, including both video and telephone consultation, beyond the COVID-19 era.