Build your own all-virtual multidisciplinary kidney stone clinic

Introduction

In the United States, it is estimated that 1 in 10 people will have a kidney stone event in their lifetime (1). Kidney stones represent a financial burden on society with an estimated 2.1 billion dollars spent on stone disease in 2000 (2) and significant economic stress on individual patients (3). Patients may experience a high rate of stone recurrence (4), therefore prevention is a crucial component in the management of kidney stones which includes lifestyle modifications, dietary interventions, and pharmacologic therapy (5). The multifaceted management of kidney stones lends itself well to a multidisciplinary approach, but challenges with coordination of provider schedules and obtaining a physical clinic space have limited adoption of this format.

The coronavirus disease 2019 (COVID-19) pandemic caused a significant disruption across the world and in the medical field including the dramatic rise in the use of telemedicine to deliver medical care (6). Several studies have demonstrated the feasibility and advantages of virtual clinics in the field of urology (7,8) which continue to be used despite the end of the COVID-19 health emergency in the United States.

Combining the rise of telemedicine and need for a multidisciplinary approach to managing kidney stones, our objective was to create and assess satisfaction for a totally virtual multidisciplinary kidney stone clinic at our institution and assess patient satisfaction with this novel format. We present this article in accordance with the SURGE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-24-248/rc)

Methods

The study was submitted to the Oregon Health & Science University Institutional Review Board (IRB#00023593) and determined to be exempt due to the minimal risk to the participants. Informed consent was obtained from the participants of this study. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The virtual multidisciplinary stone clinic began July 2021 and was held monthly with a morning and afternoon session. The clinic was comprised of one urologist, one nephrologist, and one dietitian. Prior to the beginning of each clinic session, the teams met virtually for 20 minutes to review and discuss a preliminary plan for the patients. Patients then log into the WebEx virtual platform (Cisco San Jose, CA, USA) and providers then joined the patient’s virtual room sequentially to review radiology, laboratory results, and dietary logs then provide counseling. Each provider is scheduled for 30 minutes. The urologist focused on symptoms, radiology review, and surgical options. Nephrologist discussed medications, labs and 24-hour urine results. The dietitian reviewed diet logs and recommended nutritional changes. A running Microsoft Teams^® group chat is used to discuss new information from the patient and/or changes in management based on their visit (Figure 1).

Figure 1 Format of the virtual multidisciplinary stone clinic. First the patients are discussed by the urologist, nephrologist, and dietitian for 20 minutes then individual providers have a virtual appointment with the patient for 30 minutes. Finally, a running group chat is utilized to discuss any changes to the patient’s plan.

After completing their clinic visit, all patients who participated in this clinic were sent a survey via electronic mail regarding their experience. The survey was created online using the Qualtrics platform. A follow-up electronic mail was sent to patients who had not completed the survey several weeks following the first email followed by a phone call requesting completion of the survey or offering to mail the survey or help fill it out over the phone (C.J.). The survey was performed over a 6 months timespan and patients were a mix of initial consults and return visits. Only patients within Oregon were seen for the telehealth visit. No incentives were provided for completing the survey. The survey was composed of twenty-five questions regarding interventions tried prior to their clinic visit, counseling during their appointment, satisfaction with the clinic, and advantages and disadvantages of the clinic. The survey was created by the practitioners of the clinic and went through several rounds of iterations until all parties agreed upon the context of the survey.

Statistical analysis

Responses were collected in free text format as well as on a 5-point Likert scale. Qualitative statistical analysis was performed. The Likert scale responses were then averaged in order to rank the potential advantages and disadvantages to the virtual clinic.

Results

A total of 122 patients were sent electronic surveys with 36 surveys started and 31 surveys completed. Only completed surveys were analyzed. Sixty-one percent of patients strongly agreed and 13% agreed that they felt comfortable using the virtual platform for their healthcare visit while only 8% disagreed and no patients strongly disagreed. When asked if they prefer the virtual platform for their visit, 69% agreed or strongly agreed while 16% disagreed or strongly disagreed.

Patients were asked the importance of potential advantages of the virtual visit. The averaged Likert scores indicated that improved timeliness of the visit was most important (3.7) followed by ease of scheduling into the day (3.6) while avoiding exposure to infectious diseases was least important (2.8) (Figure 2). Potential disadvantages of the virtual visit including not seeing their provider in-person (−2.3), lack of physical examination (−1.9), and difficulty of logging into the virtual portal (−1.9) were most concerning. The cost of necessary telecommunication equipment was least concerning (−1.4) (Figure 2).

Figure 2 Potential advantages and disadvantages of a virtual multidisciplinary stone clinic based on average Likert scale. Green bars denote advantages and red bars denote disadvantages. The Likert scale is scored out of 5. COVID-19, coronavirus disease 2019.

When asked if patients felt like the provider thoroughly discussed the surgical treatment options with them, 76% agreed or strongly agreed while 4% of patients disagreed and 0 patients strongly disagreed. When asked if patients felt that the provider thoroughly discussed medication prevention options, 90% agreed or strongly agreed with the statement while 2% disagreed and no patients strongly disagreed. Regarding if patients felt that dietary prevention strategies were thoroughly discussed, 82% agreed or strongly agreed with the statement, and only 2% disagreed and strongly disagreed, respectively.

Overall, 83% of patients agreed or strongly agreed that the multidisciplinary stone clinic satisfied their stone related questions regarding treatment and prevention. Thirty-two percent of patients would recommend and 48% of patients would strongly recommend the multidisciplinary stone clinic to a friend or family member with kidney stones.

Discussion

We present our experience with creation and patient satisfaction of a completely virtual multidisciplinary kidney stone clinic. We found that the clinic is feasible to run monthly and that patients were satisfied with their experience. Benefits that were important to patients included improved efficiency and ability to schedule the clinic into their day, while there were few disadvantages most notably not being able to meet the provider in person. We utilized the telecommunication platform that our institution implemented during the COVID-19 pandemic which helped simplify creating the virtual clinic by reducing start-up costs and need for a complex virtual platform infrastructure.

Previous studies have demonstrated the benefits of a multidisciplinary approach to managing kidney stones. Utilization of shared medical appointments decreased wait times for appointments while increasing the number of patients seen per month (9). The subdivision of the different aspects of patient care by provider allowed for adequate time to discuss the intricacies of each by the most appropriate specialty and the pre-review and asynchronous messaging ensure alignment of the care plan. Similar to our study, patients had high satisfaction and would recommend the clinic to others (9). Multidisciplinary stone clinics have also been studied in the pediatric and underserved community populations which demonstrated decreased number of emergency department visits (10) and increased compliance with stone prevention strategies (11).

Virtual multidisciplinary clinics have been utilized in other specialties. Grogan et al. demonstrated the feasibility of converting an amyotrophic lateral sclerosis (ALS) multidisciplinary clinic to a virtual format with most patients opting for a telemedicine visit rather than waiting for the next available in person visit (12). Santoro et al. describe the experience of converting a multidisciplinary Down syndrome clinic to a virtual clinic. Similar to our experience, patients noted missing the personal connection of an in-person visit but appreciated the convenience of a virtual clinic (13). Polanco et al. described the experience of a multidisciplinary virtual pulmonary nodule clinic (14). These studies demonstrate that a virtual multidisciplinary clinic can be successfully employed in many different specialties.

The completely virtual format of the clinic can overcome limitations of a traditional clinic such as need for physical space and rooms which in turn can cut overhead costs. As the only academic hospital in the state of Oregon, patients can spend many hours traveling to the hospital for clinic visits. The virtual format eliminates not only the travel time but the economic impact of taking extended travel time off for the visit (15). In the few cases of patients that preferred an in-person encounter, they were offered visits in our separate in-person clinics

There are limitations to this study. Firstly, there is selection bias as patients who either had an overwhelming positive or negative experience are more likely to respond to the survey. Our survey questions were not validated. It is possible that patients who have technological limitations may be less likely to respond to an electronic mail survey are the same patients who have difficulty with utilizing the virtual platform which may not be accounted for in our survey results. There are limitations to the virtual clinic itself including limitations of technology literacy, coordinating timing of clinic appointments, multiple copays, and lack of physical exams.

Conclusions

A virtual multidisciplinary kidney stone clinic is a feasible clinic that can be implemented in multi-specialty centers with advantages of cost saving, flexibility, low start up requirements, and high patient satisfaction scores. There are few disadvantages to using the platform.

Acknowledgments

Manuscript was previously presented as a podium presentation at Western Section American Urological Association 2023 meeting and Northwest Urological Society 2024 meeting.

Funding: None.

Footnote

Reporting Checklist: The authors have completed the SURGE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-24-248/rc

Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-24-248/dss

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-24-248/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-24-248/coif). I.M. reports consulting fees from Sonomotion (reimbursement for DSMB work) and Cambria (advisory board). The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was submitted to the Oregon Health & Science University Institutional Review Board (IRB#00023593) and determined to be exempt due to the minimal risk to the participants. Informed consent was obtained from the participants of this study.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Abufaraj M, Xu T, Cao C, et al. Prevalence and Trends in Kidney Stone Among Adults in the USA: Analyses of National Health and Nutrition Examination Survey 2007-2018 Data. Eur Urol Focus 2021;7:1468-75. [Crossref] [PubMed]
2. Pearle MS, Calhoun EA, Curhan GC, et al. Urologic diseases in America project: urolithiasis. J Urol 2005;173:848-57. [Crossref] [PubMed]
3. Green BW, Labagnara K, Feiertag N, et al. Financial Toxicity of Nephrolithiasis: The First Assessment of the Economic Stresses of Kidney Stone Treatment. Urology 2022;170:46-52. [Crossref] [PubMed]
4. Siener R. Nutrition and Kidney Stone Disease. Nutrients 2021;13:1917. [Crossref] [PubMed]
5. Gul Z, Monga M. Medical and dietary therapy for kidney stone prevention. Korean J Urol 2014;55:775-9. [Crossref] [PubMed]
6. Mann DM, Chen J, Chunara R, et al. COVID-19 transforms health care through telemedicine: Evidence from the field. J Am Med Inform Assoc 2020;27:1132-5. [Crossref] [PubMed]
7. Boehm K, Ziewers S, Brandt MP, et al. Telemedicine Online Visits in Urology During the COVID-19 Pandemic-Potential, Risk Factors, and Patients' Perspective. Eur Urol 2020;78:16-20. [Crossref] [PubMed]
8. Gan Z, Lee SY, Weiss DA, et al. Single institution experience with telemedicine for pediatric urology outpatient visits: Adapting to COVID-19 restrictions, patient satisfaction, and future utilization. J Pediatr Urol 2021;17:480.e1-7. [Crossref] [PubMed]
9. Jhagroo RA, Nakada SY, Penniston KL. Shared medical appointments for patients with kidney stones new to medical management decrease appointment wait time and increase patient knowledge. J Urol 2013;190:1778-84. [Crossref] [PubMed]
10. Ming JM, Lopes RI, Harvey EA, et al. Cost Effectiveness and Impact in Quality of Care of a Pediatric Multidisciplinary Stone Clinic. Pediatr Qual Saf 2021;6:e474. [Crossref] [PubMed]
11. Stout M, Mcnamara M, Posid T, et al. Improving Access and Quality of Care for Kidney Stone Patients in an Underserved Community. J Endourol 2023;37:467-73. [Crossref] [PubMed]
12. Grogan J, Walsh S, Haulman A, et al. Rapid Conversion to a Completely Virtual Multidisciplinary ALS Clinic in Response to the COVID-19 Pandemic: Implications for Future Care Delivery. J Clin Neuromuscul Dis 2023;24:207-13. [Crossref] [PubMed]
13. Santoro SL, Donelan K, Haugen K, et al. Transition to virtual clinic: Experience in a multidisciplinary clinic for Down syndrome. Am J Med Genet C Semin Med Genet 2021;187:70-82. [Crossref] [PubMed]
14. Polanco D, González J, Gracia-Lavedan E, et al. Multidisciplinary virtual management of pulmonary nodules. Pulmonology 2024;30:239-46. [Crossref] [PubMed]
15. Gadzinski AJ, Ellimoottil C. Telehealth in urology after the COVID-19 pandemic. Nat Rev Urol 2020;17:363-4. [Crossref] [PubMed]