A 29-year-old man presenting with a retroperitoneal mass was found to have a testis lesion consistent with mixed germ cell tumor and the RPLND specimen showed teratoma with an area of central nervous system-type primitive neuroectodermal tumor (PNET) not present in the testis. Whether such primitive tumor components represent a de novo tumor component or represent progression from existing neuroepithelial teratomatous elements is unclear. Given the high likelihood of residual tumor and possibility of malignant transformation, post-chemotherapy RPLND remains vital in treating patients with testis cancer. PNET is chemo-resistant and lesions should be resected, without clear evidence for adjuvant chemotherapy.
BACKGROUND Inadequate patient education and preparation for office-based procedures often leads to delayed care, poor patient satisfaction, and increased costs to the healthcare system. We developed and deployed a mobile health (mHealth) reminder and education program for patients scheduled for transrectal prostate biopsy. OBJECTIVE We aimed to evaluate the impact of an mHealth reminder and education program on appointment cancellation rates, communication frequency, and patient satisfaction. METHODS We developed a text message-based (SMS) program with seven reminders containing links to web-based content and surveys sent over an 18-day period (14 days before through 3 days after prostate biopsy). Messages contained educational content, reminders, and readiness questionnaires. Demographic information, appointment cancellations or change data, and patient/provider communication events were collected for 6 months before and after launching the intervention. Patient satisfaction was evaluated in the post-intervention cohort. RESULTS The pre-intervention (n=473) and post-intervention (n=359) cohorts were composed of men of similar median age, racial/ethnic distribution, and living a similar distance from clinic. The post-intervention cohort had significantly fewer cancelled or rescheduled appointments (33.8% vs 21.2%, p<0.01) and fewer same day cancellations (3.8% vs 0.5%, p<0.01). There was a significant increase in pre-procedural telephone calls (0.6 vs. 0.8 calls/patient, p=0.02) in the post-intervention cohort, but not a detectable change in post-procedural calls. The mean satisfaction with the program was 4.5 out of 5 (SD 0.9). CONCLUSIONS An mHealth peri-procedural outreach program significantly lowered appointment cancellations and was associated with high patient satisfaction scores with a slight increase in pre-procedural telephone calls. This led to fewer under-utilized procedure appointments and high patient satisfaction.
UNSTRUCTURED The digital transformation of our health care system will require not only digitization of existing tools but also a redesign of our care delivery system and collaboration with digital partners. Traditional patient journeys are reactive to symptom presentation and delayed by health care system–centric scheduling, leading to poor experience and avoidable adverse outcomes. Patient journeys will be reimagined to a digital health pathway that seamlessly integrates various care experiences from telemedicine, remote monitoring, to in-person clinic visits. Through centering the care delivery around the patients, they can have more delightful experiences and enjoy the quality of standardized condition pathways and outcomes. To design and implement digital health pathways at scale, enterprise health care systems need to develop capabilities and partnerships in human-centered design, operational workflow, clinical content management, communication channels and mechanisms, reporting and analytics, standards-based integration, security and data management, and scalability. Using a human-centered design methodology, care pathways will be built upon an understanding of the unmet needs of the patients to have a more enjoyable experience of care with improved clinical outcomes. To power this digital care pathway, enterprises will choose to build or partner for clinical content management to operationalize up-to-date, best-in-class pathways. With this clinical engine, this digital solution will engage with patients through multimodal communication modalities, including written, audio, photo, or video, throughout the patient journey. Leadership teams will review reporting and analytics functions to track that the digital care pathways will be iterated to improve patient experience, clinical metrics, and operational efficiency. On the backend, standards-based integration will allow this system to be built in conjunction with the electronic medical record and other data systems to provide safe and efficient use of the digital care solution. For protecting patient information and compliance, a security and data management strategy is critical to derisking breeches and preserving privacy. Finally, a framework of technical scalability will allow digital care pathways to proliferate throughout the enterprise and support the entire patient population. This framework empowers enterprise health care systems to avoid collecting a fragmented series of one-off solutions but develop a sustainable concerted roadmap to the future of proactive intelligent patient care.
The utilization of video telemedicine has dramatically increased due to the COVID-19 pandemic. However, significant social and technological barriers have led to disparities in access. We aimed to identify factors associated with patient inability to successfully initiate a video visit across a high-volume urologic practice.Video visit completion rates and patient characteristics were extracted from the electronic medical record and linked with census-level socioeconomic data. Associations between video visit failure were identified using multivariate regression modeling and random forest ensemble classification modeling.Six thousand eighty six patients and their first video visits were analyzed. On multivariate logistic regression analysis, Hispanic or Latino patients (OR 0.52, 95%CI 0.31-0.89), patients insured by Medicare (OR 0.46, 95%CI 0.26-0.79) or Medicaid (OR 0.50, 95%CI 0.29-0.87), patients of low socioeconomic status (OR 0.98, 95%CI 0.98-0.99), patients with an un-activated MyChart patient portal (OR 0.43, 95%CI 0.29-0.62), and patients unconfirmed at appointment reminder (OR 0.68, 95%CI 0.48-0.96) were significantly associated with video visit failure. Patients with primary diagnosis category of men's health (OR 47.96, 95%CI 10.24-856.35), and lower urinary tract syndromes (OR 2.69, 95%CI 1.66-4.51) were significantly associated with video visit success. Random forest analyses identified insurance status and socioeconomic status as the top predictors of video visit failure.An analysis of a urology video telemedicine cohort reveals clinical and demographic disparities in video visit completion and priorities for future interventions to ensure equity of access. Our study further suggests that specific urologic indications may play a role in success or failure of video visits.
