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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 23-27

Impact of COVID on management of urological cases in a tertiary care non-COVID institute: A patient-centered study


1 Department of Urology, All India Institute of Medical Sciences, Patna, Bihar, India
2 Department of Urology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India

Date of Submission18-Jan-2021
Date of Decision08-Apr-2021
Date of Acceptance04-May-2021
Date of Web Publication12-Feb-2022

Correspondence Address:
Vipin Chandra
Department of Urology, All India Institute of Medical Sciences, Patna - 801 505, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jigims.jigims_13_21

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  Abstract 


Background: Health-care systems across the globe have been overwhelmed by coronavirus disease-19 (COVID 19). It has affected non-COVID patient management as well. While service, hospital-oriented data on effect of the pandemic on urological diseases have been published, there is scarce data on patient-centered issues in urology, particularly from India. Hence, we planned this study to determine the impact of COVID on management of urological cases.
Materials and Methods: This is a prospective observational single-center study conducted at Indira Gandhi Institute of Medical Sciences, Patna, from April 2020 to November 2020. Consecutive non-COVID adult patients presenting to the indoor, outdoor, and telemedicine services of the urology department of our institute were included. Patients who were moribund, having altered sensorium, severe cardiorespiratory illness, unable to understand and respond, and those unwilling to participate were excluded from the study. A questionnaire-based data were collected. The same interviewer explained the questionnaire to patients in their own language (English/Hindi/Bhojpuri) either in person or telephonically and recorded the findings.
Results: Two hundred consecutive patients were screened. One hundred and fifty were included in the study. Mean age of patients was 50 ± 3.2 years. One hundred and five patients were male. Thirty-eight patients had comorbid conditions. One hundred and thirty-seven patients reported delay to consult an urologist since development of the first urological symptom. The average delay was 68 ± 20 days. Thirty-two patients suffered COVID-19 disease during the urological illness. One hundred and twelve were advised for urology consultation after the first evaluation at a local health-care center. The reasons cited for delay by these patients (n = 112) were lock-down and reduced/unavailable public transport (n = 20) and fear of contacting corona infection (n = 10), both (n = 56), suffered COVID-19 (n = 18), and others (n = 8). The distance of patients' residence from the hospital was median 50 km, with interquartile range of 5–254 km. One hundred and three patients received definitive treatment and 47 were still undergoing delays due to various reasons. Sixty-two patients were advised surgery. 25 of these 62 were found to have complications due to delay.
Conclusion: Delay in all aspects of management of urological illness, including consultation, work up, and definitive treatment was observed. Of all who were advised surgery, about 40% were found to have complications due to delay in surgery.

Keywords: COVID 19, pandemic, urology


How to cite this article:
Chandra V, Bharti V, Tiwari R, Kumar V, Ahmad A, Upadhyay R, Mahmood K, Ranjan N. Impact of COVID on management of urological cases in a tertiary care non-COVID institute: A patient-centered study. J Indira Gandhi Inst Med Sci 2022;8:23-7

How to cite this URL:
Chandra V, Bharti V, Tiwari R, Kumar V, Ahmad A, Upadhyay R, Mahmood K, Ranjan N. Impact of COVID on management of urological cases in a tertiary care non-COVID institute: A patient-centered study. J Indira Gandhi Inst Med Sci [serial online] 2022 [cited 2022 Aug 19];8:23-7. Available from: http://www.jigims.co.in/text.asp?2022/8/1/23/338357




  Introduction Top


Global pandemic of coronavirus disease-19 (COVID-19) caused by the novel coronavirus is also known as severe acute respiratory syndrome coronavirus 2 began from Wuhan city of China in October 2019 and rapidly spread across national and international borders.[1] India has been facing the COVID-19 on a massive scale since February 2020. The COVID-19 disease severity can range from an asymptomatic disease to a fatal multiorgan failure. Multiple antivirals and immune-modulatory therapies of variable efficacy have been used. However, the lack of a definitive cure and effective vaccine at the time of this research has contributed to the ongoing persistence of the pandemic. Along with these major obstacles, inadequate use of preventive measures such as hand hygiene, use of face masks, and social distancing has also been contributing factors in our country. To contain the disease, the Government of India announced complete lockdown[2] to break the chain of transmission from March 2020 to June 2020. As a collateral damage, this lockdown disrupted the health-care delivery to the non-COVID patients in both private and public health-care infrastructure. While most available data are from the perspective of urologists,[3],[4] urology trainees,[5] health-care system utilization,[6] a patient-centric observation and analysis of the effect of COVID-19 pandemic on urological condition are lacking. Hence, we planned this study with the aim of determining the patient-related health-care issues among the non-COVID patients who presented to the Urology services of our institute during and after the period of lockdown while maintaining appropriate precautions and social restrictions.


  Materials and Methods Top


This is a single-center prospective observational study conducted at IGIMS, Patna, from April 2020 to November 2020. IGIMS is one of the tertiary care hospitals managing non-COVID cases in the state. As a protocol, all patients undergo screening for COVID-19 and those tested positive are referred to COVID centers. For the purpose of this study, only non-COVID patients were included. All patients who presented to the emergency, outdoor and indoor, and patients referred to the urology department were screened. Adults more than 18 years of age belonging to either gender were included. Those who were moribund, having altered sensorium, severe cardiorespiratory illness, unable to understand and respond, and those unwilling to participate were excluded from the study. Patients who had severe symptoms were reassessed for inclusion after 48 h. If they satisfied the inclusion and exclusion criteria, they were enrolled. A questionnaire was provided in English and Hindi to the participants [Figure 1]. The interviewer explained the meaning of the questions in the vernacular language if the participants could not comprehend the questions fully. For the participants who were physically present in the outdoor and indoor department, the interview was taken in person. Patients who had enrolled for the telemedicine urology consultation were contacted on phone and interviewed on phone if they were eligible for enrolment. If the patient could not provide an exact number for the questions asked, an average of the numbers provided was recorded, e.g. duration of symptoms: if a patient responded to it as 5–10 days, 7.5 days was recorded as the reply. If the patient could not provide an answer to more than 5 questions, his data were not included in analysis.
Figure 1: Questionnaire provided to study participants (English version)

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Statistical analysis

For normally distributed continuous data, mean and standard deviation was calculated. For skewed data, median and interquartile range has been calculated.


  Results Top


Two hundred consecutive patients presenting to the outdoor (both in physical outdoor and through telemedicine) and indoor services of Urology department, as well as those referred to the Urology department of IGIMS, Patna, were screened. One hundred and fifty patients were included in analysis [Figure 2].
Figure 2: Flow chart of study participants

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Most of the patients were above 45 years with mean age 50 ± 13.2 years. One hundred and five patients were male and the rest are female.

Forty-six patients had comorbid conditions such as diabetes mellitus (DM) with hypertension (HTN): 12 patients, DM: 6 patients, HTN: 9 patients, renal dysfunction: 17 patients, and coronary artery disease with DM: 2 patients. Of the 17 patients with renal dysfunction, 6 were end-stage renal disease on maintenance hemodialysis.

One hundred and twenty-two patients consulted the urology department due to their urological problems and 28 patients were referred from other departments for urological consultation.

One hundred and thirty-seven patients reported that there was a delay to consult an urologist since development of the first urological symptom. The average delay was 68 ± 20 days. A total of 32 patients suffered COVID-19 disease during the symptoms and urology management were deferred. One hundred and twelve patients had consulted a local practitioner and were advised for a urology consultation. All of these patients suffered delay in getting a urology consult. The reasons cited for delay by all these patients (n = 137) were lockdown and reduced/unavailable public transport (n = 20) and fear of contacting corona infection (n = 10), both lockdown and fear of getting infected (n = 66), suffered COVID-19 (n = 18), financial (n = 15), and others (n = 8). The percentage contribution of each of these causes is shown in [Figure 3]. The distance of patients' residence from the hospital was median 50 km, with 5 to 254 km. Seventy-eight patients did not get on-time follow-up after the first urology consultation.
Figure 3: Causes of delay in urology consult after symptom onset

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One hundred and three patients received the treatment advised by a referral consultant and satisfied with the treatment although delayed. Forty-seven patients had difficulty in completing investigations, getting reports, and traveling to get definitive management on time. Their treatment was not completed at the time of answering the questionnaire. The definitive management (medical and surgical) was delayed in 116 patients, due to various reasons: both travel restrictions and fear of COVID infection (n = 42), travel restrictions alone (n = 20), fear of COVID infection alone (n = 14), delay in getting appointment (12), financial reasons (n = 24), and others (n = 4). Percentages have been shown in [Figure 4]. One hundred and thirty-four patients have delayed their medications because of lockdown situations, and the average delay was 48 ± 5.8 days. Out of 150 patients, 62 were advised some sort of intervention including major surgeries. However, all of them had delays in definitive surgery of average 48 ± 9.8 days. Out of these patients, 10 are of malignancy (bladder malignancy 7, renal malignancy 2, and prostate malignancy 1), 15 having obstructive nephropathy due to bladder outlet obstruction, 7 having ureteropelvic junction obstruction, 25 patients having stricture urethra, and 5 having bothersome lower urinary tract symptoms due to prostatomegaly unresponsive to medications. 25 patients from the 62 patients (40.3%%) who had undergone surgeries/interventions were found to have some complications/incomplete recovery due to delay in surgery, in the form of renal function deterioration, increased requirement of dialysis support, stage advancement in cases of malignancy incomplete clearance of bladder tumor, and prolonged postoperative recovery. Even after getting priority for treatment of malignant cases, the average delay was 26 ± 9.3 days.
Figure 4: Causes of delay in getting definitive treatment after urology consultation

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  Discussion Top


The COVID-19 pandemic has affected health care all over the world.[7] While the morbidity and mortality due to COVID-19 are well known, its impact on care for non-COVID illnesses is not exactly known. In India, a nationwide lockdown extended from March 2020 to June 2020. During this time, only emergency services for non-COVID illnesses were available, and routine outdoor and elective indoor admissions had almost stopped entirely. However, due to shutting down of transportation facilities, many even emergency cases faced enormous difficulty in getting access to treatment. In our institute to facilitate access to health care, teleconsultation was started from April 2020 and it continued for the next 3 months. Simultaneously, physical outdoor services started in a graded manner from June 2020. As detailed above, we conducted this study on patients presenting to our department during the pandemic. Literature regarding the effect of pandemic on urology services is emerging but a patient-centered analysis in urology is lacking.

We found that most patients were middle aged. Only 20 elderly patients (more than 65 years of age) presented to the institute during the study period but only 9 of these were included in the study because the rest presented with severe/critical illness. This reflects that elderly patients have probably suffered the most and presented to hospital only when they had severe symptoms. It is important to note that we excluded the ones who had critical illness or severe illness. It is likely that many of these also had significant delay in obtaining timely therapy.

More than two-thirds of the patients were evaluated by local practitioners and were referred to higher centers. This, however, is a usual pattern of urology referrals to our institute and may not be due to the pandemic situation alone. Although the previous data are not available, this is a likely effect of the pandemic. IGIMS, Patna, is a tertiary care institute and the largest government run referral institute and patients from all over the state as well as some surrounding states used to visit in pre-COVID times. However, about half the number of patients resided within a 50 km from the hospital. Although the previous data are not available, this is a likely effect of the pandemic because of which only the patients who could reach the hospital using their own transport mode could avail health-care services. Similar reasons have likely contributed to delay in follow-up consultations.

Despite the urology consultation, about a third of urology patients could not get definitive treatment. Other than the factors described above, unavailability of an accompanying person/family member, facility for accommodation, and financial shortcomings also cause delay in treatment. Majority of patients discontinued their medication for a variable period of time due to lack of timely follow-up visits. Patients who were advised surgery suffered significant delays and it resulted in complications worsening the outcomes postsurgery/intervention.

It is apparent that delay at all levels from obtaining a specialist consult, completing work up, and reporting for admission for the surgery occurred. Even though most facilities are available at subsidized rates/free for poor patients in our institute, there are a lot of inappropriate costs involved in the management of urological illnesses. Patients lose their days of work, daily wages, and have to incur expenditure of travel and accommodation, particularly those who belong to far and remote geographical areas. These are the inappropriate costs involved in treatment of urological conditions, particularly those that require indoor admission and surgery/intervention. A majority of these patients do not have any kind of medical insurance. Certain government policies have facilitated treatment-related expenses for patients having income below a threshold, however, it is the beyond treatment costs that remain uncovered. Together all these issues make it an extremely difficult task for patients of poor socioeconomic background to complete treatment. The financial impact of the pandemic, especially on the underprivileged section, has made the access to treatment even worse (owing to inappropriate costs) even in the subsidized/free health-care systems.

The functioning of all hospitals was severely affected in the pandemic and ours was no exception. In the initial phase of COVID pandemic, especially during the months March to June 2020, all departments were running with minimal staff, both doctors and nondoctors. This staggered system of duties was used to avoid mass spread of infection among health-care workers. The routine procedures were suspended for the same period of time and were gradually reinitiated. This also resulted in delay in the management of non-COVID urological illness both for consultation and definitive intervention or procedure. After reinitiation of physical outdoor gradually and telemedicine, those who required medical management alone benefited the most but those requiring surgical management continued to face delays, though not as worse as was in the absolute lockdown period.

Our findings also highlight the impact of COVID-19 on outcomes of non-COVID urological conditions. In some cases, the impact of treatment delays is insignificant, but in cases such as obstructive uropathy/nephropathy and malignancies, the impact may be significant and is likely to have a long-term impact both in terms of morbidity and mortality.

On a brighter note, the inception of telemedicine has improved access to health care. While it is not suitable for severe or emergency situations, it reduced the delays in access to treatment in our institute for clinically stable patients. The utility of telemedicine and its potential in urology has been reported from other countries as well.[8],[9]

There are two glaring questions that the pandemic has put forth, one is regarding our preparedness for a pandemic and the second, equally or more vital is the question of equitable access to health care. A developing country like India is still struggling to provide basic health care to all sections of the society.[10] In such scenario how can we expect a good pandemic PREPAREDNESS with the current infrastructure when even the much more developed countries are failing to de so. The existing health-care system, particularly the district and subdivisional hospitals, can be strengthened to provide preliminary treatment of each specialty as well as superspecialty. Telemedicine in the form of doctor-to-doctor discussions can also go a long way in providing specialist care at peripheral level and may obviate the need of travel (even in nonpandemic period) for a significant number of patients, if not all. This shall also reduce the burden on tertiary care hospitals that are at present the sole centers of specialist and super-specialist care, to some extent.

The strengths of the study include analysis of patient-centered issues in urological management, an area where data are scarce. The interviewer was the same for the study so as to avoid interviewer bias. The study period includes both data pertaining to during and after lockdown period. Limitations of the study include relatively small number of patients and unavailability of baseline data for direct statistical comparison. The survey is based on recall and ability of patients to convey the details accurately which are subjective. Very ill patients were excluded from the study, and hence, these data are applicable only to noncritical urology illness.


  Conclusion Top


COVID-19 pandemic has affected all aspects of urology care for non-COVID patients. Elderly patients and those residing far from the institute did not represent adequately in the study suggesting a huge impact on this patient population. Among all included patients, delay in obtaining urology consult after onset of symptoms, getting investigations done, definitive treatment, and continuing treatment were observed variably in a majority of patients. About 42% patients who needed surgery/intervention suffered complications due to delay.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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WHO weekly update on COVID19 as on 11 october, 2020 10 am CEST. Available from: https://apps.who.int/iris/bitstream/handle/10665/336034/nCoV-weekly-sitrep11Oct20-eng.pdf. [Last accessed on 2020 Dec 24].  Back to cited text no. 1
    
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Jin P, Park H, Jung S, Kim J. Challenges in Urology during the COVID-19 Pandemic. Urol Int 2021;105:3-16.  Back to cited text no. 3
    
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Navriya SC, Ranjan SK, Kumar S, Kandari AK, Narain TA, Mammen KJ. Strategies to deliver urology services in the times of COVID-19 pandemic based on current literature. Clin Surg 2020;5;2907.  Back to cited text no. 4
    
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Chan MC, Yeo SEK, Chong YL, Lee YM. Stepping forward: Urologists' efforts during the COVID-19 outbreak in Singapore. Eur Urol 2020;78:e38-e39.  Back to cited text no. 5
    
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Naspro R, Da Pozzo LF. Urology in the time of corona. Nat Rev Urol 2020;17:251-3.  Back to cited text no. 6
    
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Hick JL, Biddinger PD. Novel coronavirus and old lessons-Preparing the health system for the pandemic. N Engl J Med 2020;382:e55.  Back to cited text no. 7
    
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Leibar Tamayo A, Linares Espinós E, Ríos González E, Trelles Guzmán C, Álvarez-Maestro M, de Castro Guerín C, et al. Evaluation of teleconsultation system in the urological patient during the COVID-19 pandemic. Actas Urol Esp 2020;44:617-22.  Back to cited text no. 8
    
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Novara G, Checcucci E, Crestani A, Abrate A, Esperto F, Pavan N, et al. Telehealth in urology: A systematic review of the literature. How much can telemedicine be useful during and after the COVID-19 pandemic? Eur Urol 2020;78:786-811.  Back to cited text no. 9
    
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Lal A, Ashworth HC, Dada S, Hoemeke L, Tambo E. Optimizing pandemic preparedness and response through health information systems: Lessons learned from Ebola to COVID-19 [published online ahead of print, 2020 Oct 2]. Disaster Med Public Health Prep 2020;1-8.  Back to cited text no. 10
    


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