Features associated with 90-day in-person follow-up care after virtual visits in urology

Introduction

The coronavirus disease 2019 (COVID-19) pandemic led to a paradigm shift in healthcare delivery in the United States, with a rapid increase in the utilization of telehealth appointments. By 2021, 86.5% of physicians utilized telehealth compared to just 15.4% in 2019, representing a rapid shift in how patients interacted with healthcare providers (1). This dramatic increase was similarly noted among urologists, with nearly a 7-fold increase in utilization of telehealth visits in urology from just 12% in 2019 up to 81% in 2021 (2,3). In 2022 the updated American Urological Association census data reported 65% of urologists continued to utilize telehealth during initial visits (4).

Although telehealth visits offer convenience and may improve access to care from the patient perspective, the productivity of telehealth visits and the degree to which they translate to subsequent in-person or procedural care for urologists remains underexplored. Given resource constraints on clinician time and operating room availability, it is important for institutions to understand whether telehealth visits continue to support timely delivery of surgical care for our patients, as well as to evaluate the most efficient way to deploy telehealth visits in clinical practice. One potential drawback of telehealth visits is clinics can become inundated with patients seeking expert opinions at centers where they have no intention of travelling for in-person care, inadvertently increasing wait times for patients with time-sensitive diagnoses. This challenge is compounded by the fact that over a third of urologists report experiencing professional burnout based on workload demands (5).

Therefore, given this knowledge gap, the objective of this study was to evaluate features associated with in-person encounters following an initial telehealth visit in our urology department to help understand the relationship between telehealth visits and subsequent in-person care. We present this article in accordance with the STROBE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-497/rc).

Methods

Data collection and study design

We retrospectively identified all patients seen for a telehealth appointment at Mayo Clinic Florida’s Department of Urology between January 1, 2022 and December 31, 2023. Patients with a level 2–5 visit with a new or consult billing code were included in the study cohort. Those with established or postoperative billing code types were excluded from the study. Demographic information (age, sex, race, ethnicity, travel distance, insurance type, reason for visit) and clinical data [Charlson Comorbidity Index (CCI), type of in-person visit] were collected. We further categorized patients on the basis of individual chart review according to the disease state for which they were seeking care, including the following categories: benign prostatic hyperplasia (BPH), kidney mass/cancer, bladder mass/cancer, prostate cancer, elevated prostate-specific antigen (PSA), female urinary incontinence, vasectomy, kidney stone, genitourinary reconstruction, or other.

The primary outcome was follow-up for an in-person appointment at our institution’s campus within 90 days of their telehealth appointment. These appointments were defined as an in-person visit to any department and were subdivided into office visits, surgical/procedural visits, or diagnostic testing (e.g., labs, imaging, etc.). Emergency room visits were not considered in the definition of in-person appointments because they are not elective care, and similarly preoperative visits were not marked as separate visits and instead were grouped into the procedural/surgical visit category as they were linked to a surgical episode of care. Secondary outcomes included features associated with in-person follow-up care within 90 days among the subset of patients for whom their telehealth visit was their first ever visit with our institution as identified by individual chart review, as well as features associated with likelihood of undergoing a surgical procedure within 90 days of telehealth appointment.

This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was exempted by the Institutional Review Board of Mayo Clinic (No. 24-004265) as it did not involve patient contact, and therefore, informed consent was not required.

Statistical analysis

Continuous variables were summarized using the sample mean and standard deviation. Categorical variables were summarized with number and percentage of patients.

Associations between categorical variables were analyzed using a Chi-squared test, and associations between continuous variables were analyzed using a two-sample t-test. Multivariable logistic regression was used to model the effect of various factors on whether or not patients came for an in-person visit within 90 days. BPH was used as the referent category for reason for visit as it was the most common benign reason for telehealth visit at our center. Travel distance was calculated as the distance between zip code centroids using the “zipcodeR” package, using cut points of 150 and 300 miles corresponding to 2- and 4-hour drive times. No adjustment for multiple testing was made in these exploratory analyses, and P values less than 0.05 were considered statistically significant. All statistical tests were two-sided. Statistical analyses were performed using R Statistical Software (version 4.1.2; R Foundation for Statistical Computing, Vienna, Austria).

Results

We identified 1,079 patients who met inclusion criteria, of whom 598 (55%) sought subsequent in-person care at our facility within 90 days of a virtual appointment. For 648 (60%) patients the telehealth visit was their initial encounter with our facility, and 305 (47%) of these first-time patients were subsequently seen in-person within 90 days. Overall 413 (38%) were seen for a surgical visit within 90 days. A summary of patient characteristics and their association with visits to our campus is illustrated in Table 1. Male sex, distance from campus, first time visit to our facility, and reason for visit were significantly associated with likelihood of visiting our campus within 90 days of telehealth appointments (P<0.001 for all).

Table 2 summarizes both the univariate and multivariable logistic regression models assessing features associated with in-person care at our facility within 90 days. Among the 306 patients seen for prostate cancer, 112 (37%) followed up within 90 days of telehealth consult. Following multivariable adjustment, patients who lived more than 150 miles from our facility [adjusted odds ratio (adjOR) 0.56, 95% confidence interval (CI): 0.41–0.78, P<0.001], and those seen for prostate cancer visits (adjOR 0.4, 95% CI: 0.3–0.65, P<0.001) were significantly less likely to follow-up in-person within 90 days compared to those who lived closer or who were seeking care for BPH, respectively. CCI ≥1 (adjOR 1.4, 95% CI: 1.0–1.8, P=0.04) was associated with a significantly higher likelihood of in-person follow-up at our institution.

Next, we examined the subset of 648 patients for whom the telehealth visit was their first ever visit to our institution. Characteristics of these patients can be found in Table S1. Multivariable logistic regression (Table 3) showed patients living over 150 miles from our facility (adjOR 0.55, 95% CI: 0.36–0.84, P=0.01) and those seen for prostate cancer (adjOR 0.4, 95% CI: 0.25–0.64, P<0.001) were less likely to receive in-person care within 90 days at our facility compared to those who lived closer or who were seeking care for BPH, respectively.

We then compared the subset of 413 patients who had a surgical procedure at our facility within 90 days of their telehealth appointment to those that did not. Demographic characteristics are summarized in Table S2. Following multivariable logistic regression (Table 4), vasectomy visits (adjOR 2.7, 95% CI: 1.4–5.2, P=0.003) were significantly associated with surgical follow-up, with vasectomy patients being more likely to come for a procedure than for those seen for BPH. Patients evaluated for kidney mass/cancer (adjOR 0.41, 95% CI: 0.23–0.72, P=0.002), elevated PSA (adjOR 0.36, 95% CI: 0.23–0.56, P<0.001), and prostate cancer (adjOR 0.32, 95% CI: 0.22–0.47, P<0.001) were all less likely to have a surgical visit than patients seen for BPH.

Discussion

In the post-pandemic era, telehealth utilization remains high, and institutions are faced with the unique challenge of allocating telehealth visits in the most efficient and cost-effective manner possible. Herein, we observed that 55% of new patient telehealth visits for urologic complaints returned for in-person encounters within 90 days of their initial visit, and further that 38% came for an in-person surgical encounter during this same time period. To our knowledge, this is the first analysis to assess likelihood of in-person follow-up care after telehealth visit in urology stratified by disease process. These data may be useful to other health systems or urology practices that seek to develop disease- or procedure-specific guidelines in telehealth utilization. Goals for telehealth visits may differ by practice—for instance, some departments may view success of a telehealth visit in a surgical specialty as when it leads to surgery, while other departments may value offering convenience and reducing patient travel burden to bring second opinions into their living room—and therefore practical strategies to operationalize the observations made here will differ based on local objectives. Lastly, the potential organizational and economic implications must also be considered. Telehealth may provide an avenue to establish patients within the practice more quickly, and increase physical space in clinic for other revenue-generating activities even if patients do not pursue subsequent procedural care at the facility.

Perhaps unsurprisingly, we observed that patients who lived further away from our center were less likely to be seen in person following a telehealth encounter. The implication of this finding, particularly regarding whether a geographic radius should be implemented for new virtual visits, remains unclear. The lower translation to in-person care may reflect a number of patient factors that could not be clearly elucidated in this study. Lee et al. reported travel patterns for patients undergoing radical cystectomy and found patients with fewer local providers and more disadvantaged physical environments were least likely to travel more than 50 miles for surgery, suggesting patients of lower socioeconomic status may find travel to be either too financially burdensome or logistically challenging (6). Indeed, financial toxicity is common among patients with urological cancers and can be exacerbated by distance on account of travel-related expenses (7). For these patients, telehealth may not adequately bridge the access gap as the resources required to actually travel for procedural care could not be overcome. Previous evidence has suggested that for urologic cancer patients who are already at risk of suffering worse oncologic outcomes, telehealth has the potential to exacerbate disparities (8,9). Conversely, it is also possible that patients who sought virtual visits who lived further from our center simply elected to proceed with care locally, thereby explaining the finding that these patients were less likely to pursue in person care with us within 90 days. It is likely that both of these factors may have played into patient decision-making regarding setting in which they sought in-person care, and future work is needed to more clearly delineate the relative contributions of these and other factors in the decision to pursue subsequent in-person care following initial virtual visit.

Vasectomy was the only visit reason significantly associated with higher odds of returning for a procedural visit than BPH, whereas oncologic visits were associated with a lower likelihood of patients returning for surgery. This discrepancy may reflect fundamental differences in the decision-making process for seeking healthcare for benign and malignant conditions. Telehealth lowers the barrier to accessing medical opinions, allowing patients to seek second or third consultations before proceeding with treatment (10). Thus, some patients may elect to seek care closer to home or proceed with neoadjuvant therapy following a virtual opinion that does not translate into short-term procedural care. In contrast, patients pursuing vasectomy are seeking a more discrete episode of care than those with cancer, which may account for the higher likelihood of in-person procedural care seen after virtual visit herein. Indeed, previous work at several other centers has demonstrated there is no difference in the rate of vasectomy completion between patients seen for initial vasectomy visit in person versus virtually (11,12). On the basis of these observations, we plan to continue to provide telehealth visits for patients seeking vasectomy in our practice.

Our data revealed that prostate cancer visits were the least likely to translate into in-person visits at our center within 90 days of initial telehealth visit. Notably, this was inclusive of visits for advanced imaging, visits with other service lines, prostate biopsy, or definitive therapy with surgery or radiation. However, we would caution that this observation should not necessarily be taken as evidence that these visits were of low value. Given the variety of treatment modalities available for prostate cancer, patients must be well-informed to actively participate in shared decision-making regarding the decision for active treatment and for treatment modality (13-15). Supporting this, Radhakrishnan et al. found that over 40% of prostate cancer patients sought second opinions, with most citing a desire for more information about their diagnosis (16). While telehealth visits for prostate cancer may not always lead to short-term in-person follow-up care, they can still provide significant value by facilitating access to expert opinions at potentially lower costs, and this may be particularly true for patients who elect to pursue active surveillance for low- or very-low risk prostate cancer (10). Indeed, multidisciplinary visits for prostate cancer have been shown to increase uptake of active surveillance, which would not have translated to a 90-day follow-up visit in the current study (17,18). Previous work has demonstrated telehealth allows for high-quality care for urologic cancer patients regardless of location and is well-received by patients during initial visits (10,19). These benefits are not urology specific, and have been observed in other surgical specialties, such as orthopedics, where telehealth consultations have shown high patient and provider satisfaction, cost-effectiveness, reduced wait times, and improved access (20). This further underscores how telehealth may enable timely expert opinions, facilitate second opinions, and reduce both economic and organizational burdens, offering value to patients and health systems despite not resulting in surgical intervention. To further examine these intangible features, future work will focus on longer-term follow-up after telehealth visits for patients with prostate cancer to further investigate their impact.

Several limitations of this study are important to acknowledge. The retrospective design introduces the potential for measurement bias. Allocation of patients to either an in-person or telehealth visit was by patient decision and as such, this nonrandomized allocation predisposes to selection bias. We elected to assess a 90-day window for follow-up care as 90 days is the longest window considered as a single episode of care by the Center for Medicare and Medicaid services, but we acknowledge that this definition may have failed to capture patients who returned for a surgical procedure beyond that time period, for instance patients receiving neoadjuvant systemic therapy for cancer or who delayed an elective procedure until a more convenient time (21). We acknowledge that a 90-day follow-up window is a short time period for oncologic cases, and that different results could be observed with longer follow-up. Nevertheless, a 90-day window is a standard timeframe for rolling financial forecasting at a departmental level, which is why it was chosen, and future work is needed to understand the potential impact of telehealth visits on follow-up at longer intervals. Though the sample size is not especially small, the possibility of a type II error (i.e., a false-negative finding) is important to consider, and we cannot conclude no true association exists simply due to the occurrence of a non-significant P value. Lastly, our study was conducted in a single department at a tertiary medical center in the southeastern United States, and the results may not be generalizable to other practice settings. Indeed, hospitals in other regions of the United States, publicly funded hospitals, or those within an integrated regional health system may experience different rates of conversion from telehealth consultations to in-person care.

Future studies can build upon the findings reported here by including additional centers and geographic regions to assess whether differences exist across the United States. Another potential avenue for investigation is to assess the time taken for each telehealth visit, which would strengthen our understanding of the time burden for these visits as well as whether time spent with patients is associated with in-person follow-up. Unfortunately, duration of visit data was not available in the current study. Another way to improve upon our understanding of follow-up after telehealth encounters would be to administer surveys following virtual visits to identify factors patients cite as reasons important to them in determining location of follow-up care.

Conclusions

Herein, we observed that patients with a shorter travel distance, and those being seen for a vasectomy were more likely to pursue in-person care within 90 days after a virtual visit than those seen for oncologic indications. These findings may be useful to other urology departments as they seek to more efficiently integrate virtual and in-person visits in resource-constrained practice environments.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-497/rc

Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-497/dss

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-497/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-497/coif). C.D.D. is a course director and faculty for Boston Scientific/Lumenis and Cook Medical. D.D.T is currently employed by an institution that has received funds through participation in the Grail grant, is the current secretary of the Southeastern section of the Americal Urologic Association and has received travel support, and is a shareholder of an industry startup. T.D.L. is an investigator for NIH grant UL1 TR02377, Casey DeSantis Cancer foundation grant, industry funded clinical trials with immunityBio, Protara Therapeutics, CG Oncology, Merck Sharp & Dohme, Janssen, and has served on the advisory board for ImmunityBio, UroGen Pharma and enGene. 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. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was exempted by the Institutional Review Board of Mayo Clinic (No. 24-004265) as it did not involve patient contact, and therefore, informed consent was not required.

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. Myrick KL, Mahar M, DeFrances CJ. Telemedicine Use Among Physicians by Physician Specialty: United States, 2021. NCHS Data Brief 2024;1-8. [Crossref] [PubMed]
2. American Urologic Association. The State of the Urology Workforce and Practice in the United States. AUA 2019. Accessed May 3, 2025. Available online: https://www.auanet.org/research-and-data/aua-census/census-results
3. American Urologic Association. The State of the Urology Workforce and Practice in the United States. AUA 2021. Accessed May 3, 2025. Available online: https://www.auanet.org/research-and-data/aua-census/census-results
4. American Urologic Association. The State of the Urology Workforce and Practice in the United States. AUA 2022. Accessed May 3, 2025. Available online: https://www.auanet.org/research-and-data/aua-census/census-results
5. American Urologic Association. The State of the Urology Workforce and Practice in the United States. AUA 2023. Accessed May 3, 2025. Available online: https://www.auanet.org/research-and-data/aua-census/census-results
6. Lee YS, Schommer J, Borkar S, et al. Features associated with travel distance for radical cystectomy in Florida: Implications for access to care. Urol Oncol 2023;41:485.e9-485.e16. [Crossref] [PubMed]
7. Bhanvadia SK, Psutka SP, Burg ML, et al. Financial Toxicity Among Patients with Prostate, Bladder, and Kidney Cancer: A Systematic Review and Call to Action. Eur Urol Oncol 2021;4:396-404. [Crossref] [PubMed]
8. Gul ZG, Sharbaugh DR, Ellimoottil C, et al. Telemedicine in urologic oncology care: Will telemedicine exacerbate disparities? Urol Oncol 2024;42:28.e1-7. [Crossref] [PubMed]
9. Odukoya EJ, Andino J, Ng S, et al. Predictors of Video versus Audio-Only Telehealth Use among Urological Patients. Urol Pract 2022;9:198-204. [Crossref] [PubMed]
10. Carson DS, Simpson S, Gadzinski AJ, et al. Telehealth visit type and patient-reported outcomes among patients with cancer. Urol Oncol 2024;42:448.e17-22. [Crossref] [PubMed]
11. White J, Rahman F, Petrella F, et al. Telehealth Sterilization Consultation Does Not Impact Likelihood of Vasectomy: A Retrospective Institutional Analysis. Urology 2023;176:79-81. [Crossref] [PubMed]
12. Hernandez H, Bernstein AP, Zhu E, et al. No Detectable Association Between Virtual Setting for Vasectomy Consultation and Vasectomy Completion Rate. Urol Pract 2023; Epub ahead of print. [Crossref] [PubMed]
13. Eastham JA, Auffenberg GB, Barocas DA, et al. Clinically Localized Prostate Cancer: AUA/ASTRO Guideline, Part I: Introduction, Risk Assessment, Staging, and Risk-Based Management. J Urol 2022;208:10-8. [Crossref] [PubMed]
14. Eastham JA, Auffenberg GB, Barocas DA, et al. Clinically Localized Prostate Cancer: AUA/ASTRO Guideline, Part II: Principles of Active Surveillance, Principles of Surgery, and Follow-Up. J Urol 2022;208:19-25. [Crossref] [PubMed]
15. Eastham JA, Auffenberg GB, Barocas DA, et al. Clinically Localized Prostate Cancer: AUA/ASTRO Guideline. Part III: Principles of Radiation and Future Directions. J Urol 2022;208:26-33. [Crossref] [PubMed]
16. Radhakrishnan A, Grande D, Mitra N, et al. Second opinions from urologists for prostate cancer: Who gets them, why, and their link to treatment. Cancer 2017;123:1027-34. [Crossref] [PubMed]
17. Aizer AA, Paly JJ, Zietman AL, et al. Models of care and NCCN guideline adherence in very-low-risk prostate cancer. J Natl Compr Canc Netw 2013;11:1364-72. [Crossref] [PubMed]
18. Hussein AA, Shabir U, Mahmood AW, et al. The impact of NCCN-compliant multidisciplinary conference on the uptake of active surveillance among eligible patients with localized prostate cancer. Urol Oncol 2023;41:483.e21-6. [Crossref] [PubMed]
19. Chen LW, Usinger DS, Katz AJ. Telehealth use and perceptions among prostate cancer survivors. Cancer Med 2023;12:17308-12. [Crossref] [PubMed]
20. Ajrawat P, Young Shin D, Dryan D, et al. The Use of Telehealth for Orthopedic Consultations and Assessments: A Systematic Review. Orthopedics 2021;44:198-206. [Crossref] [PubMed]
21. Bundled payments for care improvement (BPCI) initiative: General information. CMS.gov. April 12, 2021. Accessed March 22, 2025. Available online: https://www.cms.gov/priorities/innovation/innovation-models/bundled-payments