Time, cost and carbon-efficiency: a silver lining of COVID era virtual urology clinics?

Abstract

Introduction

The COVID-19 pandemic has demanded radical changes in service delivery. Our centre adopted the use of outpatient telemedicine to reduce close-contact interactions between patients and staff. We hypothesised that incidental gains may be associated with this. We evaluated financial, practical and environmental implications of substituting virtual clinics (VCs) for in-person urology outpatient appointments.

Methods

VCs were studied over a 3-month period. Based on patient-reported ‘usual mode of transport’ to the hospital, travel distance, time, petrol and parking costs, and the carbon emissions avoided by virtue of remote consultations were calculated. The underlying symptom/diagnosis and the ‘effectiveness’ of the VC were evaluated.

Results

Of 1,016 scheduled consultations, 736 (72.44%) were conducted by VCs over the study period. VCs resulted in an agreed treatment plan in 98.4% of a representative patient sample. The use of VCs was associated with an overall travel distance saving for patients of 31,038 miles (49,951km) over 3 months, with an average round-trip journey of 93.8 miles (151km) avoided for each rural-dwelling patient and an average financial saving of £25.91 (€28.70) per rural-dwelling car traveller. An estimated 1,257.8 hours of patient time were saved by avoidance of travel and clinic waiting times. Based on car-travelling patients alone, a 6.07-tonne reduction in carbon emissions was achieved with the use of VCs.

Conclusions

In appropriate clinical circumstances, VCs appear to provide efficiency across a number of domains. Future healthcare may involve offering outpatients the option of telemedicine as an alternative to physical attendance.

Introduction

The COVID-19 pandemic has led to large-scale restructuring of clinical care delivery globally. A notable feature of adaptation to the unprecedented challenges of 2020 has been the rapid implementation of virtual outpatient clinics.¹ Such clinics are characterised by patients’ planned clinical consultations with healthcare professionals being conducted by telephone or another mode of telecommunication, with the patients remaining remote from the hospital setting.² Virtual clinics (VCs) have the obvious advantage of minimising hospital ‘foot-fall’ and reducing close-contact interactions between patients and hospital staff. We were curious as to potential incidental benefits of virtual medicine, and hypothesised that additional economic and environmental gains may be encountered. Although perhaps eclipsed in the short-term by the COVID-19 outbreak, the potential impact of climate change on global health is formidable.³ Transport is the greatest source of carbon dioxide (CO₂) emissions in the UK and Ireland, and the fastest growing source of greenhouse gas production internationally.⁴ Delivering a urology service in an urban tertiary referral unit, we had previously been struck by the geographical distances travelled by patients to attend appointments; journeys often made by car. Attendance at outpatient appointments has also been shown to pose challenges to patients in terms of work schedules, clashes with conflicting hospital appointments, arranging care of children or dependent adults and other commitments.⁵ We aimed to evaluate the impact of our virtual outpatient clinics on travel time, monetary cost to patients and carbon emissions.

Methods

Format of virtual clinics

We adopted the use of VCs during the early phase of the SARS-CoV-2 outbreak and continue to conduct a large number of outpatient consultations accordingly. This applies to both general urology and subspecialist (including uro-oncology, urolithiasis and female, functional and reconstructive) urological referrals received. Outpatients are triaged to determine the clinical urgency and appropriateness of virtual review. Face-to-face consultations are scheduled when deemed preferable for the clinical scenario. Any necessary imaging or blood tests are arranged in advance of virtual consultations. Our VCs are currently performed by telephone call, although video-conferencing platforms are available if felt of added benefit. Symptoms are discussed, an investigation or treatment plan is agreed upon with the patient and documentation of the interaction is recorded in the chart. A letter to the patient’s general practitioner is generated, and a prescription, where required, is posted to the patient.

Evaluation

The study was approved by the hospital’s Research & Innovation office. Over a 3-month period, while the country was under moderate (‘Level 3’) restrictions, we assessed the number of VC appointments conducted and measured the distance from the patient’s hometown to the hospital. We determined patients’ ‘usual mode of transport’ to hospital visits by enquiry during clinical consultations. We used this information to calculate the travel time, petrol, toll and parking costs, and carbon emissions that would have been associated with hospital attendance for each patient. Travel distances, travel times and petrol costs were calculated using the AA Route Planner^© and Google Maps^©. Journeys were calculated based on a start time of 08:00 on a midweek morning. Carbon emissions were estimated using the online calculator provided by Carbon Footprint Ltd and the estimated number of trees required to absorb the emissions were calculated using the Tree Council of Ireland online information page.⁶ We used an average petrol engine car as the prototype for car travel. Carbon emissions were not calculated for public transport, on the assumption that the public transport vehicle would have operated irrespective of patients’ presence on board, with difficulty quantifying the potential reduction associated with less patient demand. Patients were classified into two groups, ‘urban-dwelling’ or ‘rural-dwelling’, based on their address relative to the hospital. Our institution is situated within a 572miles² (921km²) urbanised region; patients who resided beyond the perimeters of this area were deemed rural-dwelling. We also took a random sample of 250 VC patients and reviewed their symptoms or diagnosis, the proportion who were uncontactable and whether the VC appointment was ‘effective’, as determined by arrival of the doctor and patient at an agreed management plan or discharge decision. Data were synthesised and average time, patient costs and carbon emissions associated with a hospital round-trip journey were calculated for urban and rural-dwelling patients.

Results

Demographics

Of 1,016 scheduled consultations, 736 (72.44%) were conducted by VCs over the study period. Of VC patients, 40% (295 of 736) were considered ‘rural-dwelling’. Mean patient age was 62.9 years (range 18–95) and a significant portion of patients were of ‘working age’; 54.7% of patients (403 of 736) were 66 years old or younger, the state retirement age, and 68.75% (506 of 736) were aged 70 years or below.

Clinical outcomes

Study of a representative portion of VC patients (n = 250) identified the most frequently encountered symptoms or diagnoses (Table 1). The VC appointment was effective in producing an agreed management plan in 98.4% (240 of 244) of cases. In 1.6% (4 of 244) of cases, a face-to-face clinic appointment was booked by the doctor conducting the VC appointment, generally to facilitate physical examination. We noted that 4% (10 of 250) patients had attended the hospital upon instruction prior to the VC appointment to undergo an up-to-date x-ray of kidneys, ureters and bladder (XR KUB). Had these patients been seen at a face-to-face clinic, the x-ray would have been obtained on the day of the clinic appointment and, although waiting times would have been reduced, we did not consider these patients to have been ‘saved’ a journey to the hospital.

Table 1 .

Clinical outcomes of virtual clinics in a sample of 250 patients

		Number of patients (%)
Most common indication for consultation	Elevated prostate-specific antigen	51 (20.4)
	Lower urinary tract symptoms	46 (18.4)
	Surveillance (uro-oncology) post treatment	41 (16.4)
	Urolithiasis	26 (10.4)
	Active surveillance prostate cancer	22 (8.8)
	Follow-up of diagnostic imaging	14 (5.6)
	Postoperative review	13 (5.2)
	Infection	12 (4.8)
	Haematuria follow-upa	8 (3.2)
	Other	11 (4.4)
Appointment type	New	14 (5.6)
	Return	236 (94.4)
Patient contactable	Contactable	244 (97.6)
	Uncontactable	6 (2.45)
Management plan agreed upon	Yes	240 (98.4)c
	Nob	4 (1.6)c

^a Most seen at haematuria clinic with cystoscopy

^b Face-to-face appointment booked

^c n = 244

Impact on time, cost and carbon emissions

With the use of VCs, an overall reduction in round-trip distance travelled by patients of 31,038 miles (49,951km) over 3 months was observed, with a mean saving of 93.8 miles (151km) per rural-dwelling patient (Table 2). Car travel was the usual mode of transport to the hospital reported by 71.4% of rural-dwelling patients and by 59.3% VCs of patients overall. Using for ‘car travellers’ (n = 442), we calculated overall monetary savings for patients incorporating petrol, toll and parking costs estimated for a round-trip journey to the hospital. Over the study timeframe, we estimated overall financial savings of £6,655 (€7,372); an average saving of £25.91 (€28.70) per rural-dwelling patient and of £6.05 (€6.70) per urban-dwelling patient. Based on travel time, for car and public transport modes of travel, and averaging a 20-minute ‘wait to be seen’ in the clinic for each patient, we calculated a patient time saving of 1,257.8 hours overall, with a conservative mean time saving of 2 hours 40 minutes per rural-dwelling patient. The average rural-dwelling patient required two or three different modes of public transport (mean 2.34) to reach the hospital. Additional time savings would have been incurred with removal of time spent waiting for public transport, but this was not possible to quantify.

Table 2 .

Virtual clinic participants over 3 months

Overall consultations (%)		72.44
Rural-dwelling virtual clinic participants (%)		40
Proportion of patients who would travel by car (%)	Overall	59.3
	Rural-dwelling	71.4
Travel distance saved	Overall	31,038 miles (49,951km)
	Per rural-dwelling patient	93.8 miles (151km)
Patient cost saved	Overall	£6,655 (€7,372)
	Per Dublin-dwelling patient	£6.05 (€6.70)
	Per rural-dwelling patient	£25.91 (€28.70)
Patient time saved	Overall	1,257.8 hours
	Per rural-dwelling patient	2h 40min
CO2 emissions avoided		6.07 tonnes

The environmental impact of VC establishment was significant, with an estimated reduction of 6.07 tonnes of CO₂ emissions, based on the predicted carbon footprint of ‘car traveller’ patients alone. It was estimated that this volume of CO₂ emissions would have taken 434 established (10-year-old) evergreen trees to absorb in 1 year.

Discussion

A rapid uptake of telemedicine in surgical outpatient departments has been seen in recent times,^7–11 and indeed remote outpatient review has been recommended where possible in the UK.¹² Our results highlight some interesting incidental benefits to urology VCs born out of the COVID-19 era. Such potential gains have not been well explored to date in this context. We feel that our findings are likely relevant to surgeons and their patients in a wide variety of specialties at tertiary referral centres internationally.

We found urology virtual clinics to achieve an agreed management plan for the vast majority of patients enrolled. This was a select group of patients who had been triaged as appropriate for VC. Our results show that VCs are primarily used for follow-up rather than first time consultations in our institution currently. This has been to allow new patients to establish rapport with the team and to facilitate examination; although VC use may increase for all cohorts as the COVID-19 pandemic continues or escalates. Early studies have indicated acceptable safety and patient satisfaction with the use of surgical telephone clinics,^7,13 although future research will need to interrogate both patient and clinician perceptions more closely to optimise delivery and select the context in which VCs are used.

We noted an extremely low ‘did not attend’ (DNA), or more accurately ‘failure to contact’, rate with VC use, perhaps because less organisation on the part of the patient is required to engage in an initiated phone conversation than to travel to the outpatient department, and because patients who had forgotten their scheduled appointment were reminded by the phone call. A significant reduction in DNA rate has been described by other authors with use of telehealth clinics.¹⁴ Our policy for patients who do not answer their phones is to telephone them at least twice at different times during the clinic, using all phone numbers provided on their chart. Should they still not be contactable, we add them to a further VC in the near future, having cross-checked the phone number, and should contact not be achieved, we write a letter to both the patient and their general practitioner.

A small number of our patients had potential gains of VC enrolment mitigated by the need to attend the hospital for a pre-clinic x-ray that otherwise could have been performed on the day of clinic. Nonetheless, their wait times and parking costs would have likely been reduced compared with waiting for a face-to-face review following the x-ray. Future improvements might include consideration of facilitating basic diagnostic imaging at patients’ local/district hospitals where significant travel distances are incurred with attendance at the tertiary referral centre. In Ireland, a national radiology viewing system would make this logistically feasible, but clear pathways for external clinicians to request and take responsibility for imaging findings would need to be established.

Fewer than 10% of patients were discharged from VCs in our series. Although this appears low, independent review of notes revealed return appointments to be appropriate and to reflect the high number of patients on surveillance protocols or being consulted for follow-up of complex stone disease or lower urinary tract symptoms.

The time and cost savings to patients in this study were significant. Our calculations were based on an estimated clinic wait time of 20 minutes, which was conservative, and time savings may, in fact, have been even greater. It has previously been reported that patients may find outpatient clinic attendance logistically difficult due to additional factors such as the need to arrange childcare or time off work,⁵ and these factors are at least partially circumvented by VCs. We evaluated the cost saving to the patient from avoidance of hospital travel. It is likely that financial savings were also encountered by other stakeholders. Previous studies within the National Health Service (NHS) have shown fiscal gains to the health service with the use of VCs.^15,16 Furthermore, as more than half of our VC patients were of working age, the decrease in lost working hours or days would have additional economic benefit.

One of the most striking findings of our study was the potential to markedly reduce carbon emissions with the use of VCs. Climate change poses a dire threat to human health.¹⁷ Health services are known to produce a large annual carbon footprint and have been urged to seek ways to reduce this.¹⁸ We noted a large number of our patient population to report typically travelling to hospital by car, similar to a study reporting 83% of NHS patients, staff and visitors to use cars or vans as their primary mode of transport.¹⁸ We used an ‘average’ petrol car to estimate predicted carbon emissions. It is quite likely that some patients would travel in vehicles with larger engines or a diesel fuel source, and that therefore the carbon savings were even greater than estimated. Either way, the environmental gains associated with reducing face-to-face clinic attendances are indisputable, and, if calculated for multiple specialties in multiple tertiary referral centres using VCs over a prolonged period, could be quite remarkable.

We acknowledge that our data arise from a urology setting only. Although we suspect that our findings could be broadly reproducible within other surgical disciplines, this might not be the case for all specialities.

We are aware of limitations to VCs, and we do not regard them as a substitute for face-to-face clinics for situations such as discussing new diagnoses and complex procedures, assessing patients in whom physical examination would influence immediate management or for those who are likely to suffer communication difficulties at VCs (for example, due to hearing impairment). We have, however, found them acceptable for a plethora of scenarios, such as the review of routine blood tests and the need to inform patients of negative diagnostic or surveillance imaging results. Given current evidence suggesting effectiveness, and the additional gains associated with VCs discovered in our study, we feel VCs may have a role beyond the COVID era. When ‘normal’ hospital life resumes following the COVID-19 pandemic, it may be worth offering appropriately selected patients the option of attending in person or receiving a phone call, in recognition of potential VC advantages and of geographical disparity, in the ethos of patient-centred and individualised care.

Conclusions

In a world facing numerous challenges in addition to COVID-19, any evolutions that may facilitate delivery of efficient, cost-effective and carbon-neutral care merit reflection. We have found such gains to be associated with use of VCs in an appropriately triaged patient population. We propose that select patients are offered the option to choose between virtual and face-to-face clinic attendance in the post-COVID era.

Author contributions

SMC undertook planning, data collection and writing of the manuscript. PR undertook planning and data collection. SC undertook data collection and reviewing the manuscript. AS undertook data collection. LS, IA, THL and RPM undertook planning, supervision and reviewing the manuscript.