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Ruchika Talwar: Hi everyone and welcome back to UroToday's Health Policy Center of Excellence. My name is Ruchika Talwar, and today I'm joined by Dr. Emily Clennon, who's a resident at the Oregon Health Sciences University School of Medicine.

Emily Clennon: Hello.

Ruchika Talwar: Thanks for being here with us today.

Emily Clennon: Of course, my pleasure.

Ruchika Talwar: So Dr. Clennon will be discussing a recent area of research that she's published in surrounding a big quality and policy issue, the transfer of pediatric torsion patients to pediatric hospitals.

Emily Clennon: I published this article with Dr. Duty and Dr. Seideman also at OHSU because we wanted to really start a conversation about the issue of transferring pediatric patients from rural communities where they present with testicular torsion to tertiary pediatric centers. We have noticed over the last couple of years at our institution that there's been a gradual increase in the number of pediatric patients, particularly adolescent patients transferred for torsion and in discussion with colleagues in pediatric urology across the country, we're not alone in this finding. So we evaluated our own institutional data and we'll have an article published hopefully in the next couple of months with particularly those data. But this article was really meant to address not the problem per se, which we all know that transferring patients from one center to another takes time. We know that a lot of pediatric patients who present, present a little bit late and we're not able to save the testicle.

But there are a subset of patients who if we act quickly with testicular torsion, we can save their gonad. And transferring those patients and causing delays in care on the health system end or the institutional end is really not acceptable for those patients because we could be contributing to gonadal loss for adolescents. And in looking at our own data, we identified that there were a number of different health systems factors that were creating pressure on urologists and local emergency care docs to transfer patients from their institution up to a tertiary care center. So as I said, our data to be published later will address some of the problems and our actual findings within Oregon, but sometimes in the articles in the regular literature, we get really caught up in identifying the problem. So we wrote this piece for JU Forum to identify some of the solutions that we identified in Oregon, which can sometimes be overlooked in other types of articles.

So we discuss a couple of different barriers at different health systems levels in the article. The first being at the individual provider level concerns about liability and taking care of pediatric patients or limitations in malpractice coverage for patients who are less than 18 years old. At the institutional level, we found that actually the number one driving factor of transfer in Oregon was institutional policies that prevent the care of pediatric patients. So this one, institutions typically either have never had or removed recommendations or requirements for their staff to be certified in the care of pediatric patients, particularly like nurses or support staff. They then create these policies that say we aren't necessarily going to have people certified at all hours of the day. And so patients who come in the middle of the night, we're just going to transfer all those pediatric patients to different centers.

And then on a broader scale between institutions, there are a lot of hospitals and a lot of areas in Oregon that just have no urology call coverage whatsoever. And then a lot of institutions that have really intermittent call coverage. So there may be times when they could have local care and then other times when they would have to be transferred somewhere else to be cared for. So how do we address some of these problems? Well, first of all, the American Board of Urology in 2013 addressed liability concerns to some degree. This was put out in a newsletter statement sent to urologists where they certified or verified that urologists who are certified for the practice of urology are certified to practice for all areas of urology. So any board certification is adequate to treat pediatric patients. And the board particularly said that they do not support urologists on call deferring routine pediatric care to some specialty certified colleagues.

So this isn't necessarily adequate to totally assuage all concerns about individual providers' liability and malpractice coverage. But it is a step in that direction to sort of affirm the standard of care. In Oregon, to address some of these institutional issues, our colleagues at Kaiser Permanente Northwest, just in the last few years, have adapted their institutional policy that required the transfer of pediatric patients to allow treatment of patients up to 12 years old at Kaiser institutions, unless they require specialty anesthetic care, have other medical problems. And then in Eugene, there's a group of pediatric surgeons who decided on their own volition that they needed to address some of the gaps in care in that area and so they started covering testicular torsions, trained up, got comfortable with the procedure, and they cover these. And that prevents two hours of transfer time for patients in the Eugene area up to Portland, which before, all of those patients were being transferred.

And then to address some of the urology call coverage issues, this doesn't necessarily fix the problem, but we created a map and are going to be distributing this to all institutions in the state that outlines what the call coverage situations are for different hospitals across the state. So whether they have 24/7 coverage, limited coverage, or none. And this will ideally allow places that need to transfer patients to minimize the transfer distance, so maybe from a place near Eugene, just send them there rather than sending them several extra hours up to the pediatric tertiary center.

And we go on to make some recommendations for readers to consider these different options and different ways to address this problem in their states and at different health systems levels, since these barriers exist at multiple levels that we can address. So, at the individual practice level, we can, as urologists, educate our local partners. So, particularly pediatric urologists who are sort of dealing with the brunt of these transfers, can educate local urologists, local pediatric surgeons, talk to the pediatric surgeons and the general surgeons about them potentially covering these cases, and just see where we can eliminate gaps and how we can get patients the fastest care with the network of providers that we have. At the hospital and hospital system level, if you are in an institution that has one of these policies that limits, totally prevents the care of pediatric patients, you can petition your leadership to adapt those policies because, as we know, most transfer patients are adolescents, they're healthy, they don't have a lot of comorbidities that a lot of our adult patients who require urgent surgery do.

And these are quick, pretty easy surgeries to do. And so, we've seen that at Kaiser, it is possible in some systems to change those policies. So we would recommend that you at least start those conversations with your leadership. At the state level, we can educate the local providers, so, similar to the individual level, go to local urological association or surgical association meetings and start this conversation to figure out how we can bridge these gaps. You can also create and share maps of urologic call coverage, as we have in Oregon, and just share those and try to create sort of a central hub so everyone's on the same page about when transfer is necessary, making it the shortest time possible.

And then to try to further address the liability concerns, we can request statements from our state medical boards to either set or affirm the standard of care being the local provision of care for these patients rather than transfer to a pediatric center. And similarly, at the national level, we can call for similar statements from the Society for Pediatric Urology or the AUA at large, rather than just the American Board of Urology, to set or affirm the standard of locally provided care. So, we hope that these are helpful for you and you consider addressing this area of pediatric urology policy issue.

Ruchika Talwar: Thank you, Dr. Clennon. I think the topic that you just presented on is a great example of an actionable area of quality improvement that both improves the quality of care for our patients' outcomes, as well as reduces some of that excess process's cost, certainly of transferring a patient, and undue burden within the health system in dealing with pediatric torsions. So, tell me, of the different solutions that you all at OHSU have identified and potentially are in the midst of implementing, which have you so far found to be the most effective?

Emily Clennon: We haven't analyzed data from other institutions yet, so it's hard to say in an evidence-based way what's been the most effective. But, because the institutional policies that have been identified as the number one factor leading to transfer, and most of our transfers in Portland, are in Oregon, actually come within the Portland metropolitan area. So, it's not a very long distance to transfer. Working with our local institutions and sort of cross-communicating and causing these, or creating these, new policy changes to allow the care of pediatric patients at these institutions in the metro area, I think will be by far the most effective. And I think that there have been a number of cases at Kaiser already that would've been transferred, and they've avoided that and avoided probably at least an hour delay in getting that patient to the operating room.

Ruchika Talwar: And in addition to the time delays, there are other costs that physicians, I think, don't always recognize, such as, despite it being a short ambulance ride up to like 10, 15, 20 minutes, a lot of those times the ambulance companies are actually out of network for patients and they're not covered by insurance. And insurance can easily deny that coverage and those ambulance rides can be pretty burdensome from a financial perspective on families. Have you all thought about any of the health system cost implications that this may have, other than just transportation?

Emily Clennon: Yeah, so in our upcoming analysis of our data, we have looked at cost, and just to sort of give a general preview, we found that an estimate of the cost burden to the patient and the healthcare system, depending on what their insurance coverage is and sort of how they're billed, the cost is about double for any patient who's transferred overall, compared to patients who are treated locally. There were a lot of duplicated emergency room costs. Even though we're not necessarily getting new imaging, most of the workup has already been done before they're transported. We found that the emergency room costs were not significantly different than the patients who just arrived to OHSU primarily. And the costs, as you said, are falling to the patients in a lot of these settings.

And in addition to just the cost issues, the fact that we have a lot of patients who are being transported, maybe just across the city, but sometimes from hours away, they're being transported often without their family members, and then the family has to come up hours later. Sometimes they're getting hotel rooms and having to spend the night in Portland, and picking up medications here. We didn't necessarily evaluate all those costs in our data, but we're very aware, in communicating with our patients, that this is a huge burden that just doesn't need to happen clinically.

Ruchika Talwar: Yeah. Well, congratulations on exploring this really important area. I look forward to seeing your upcoming data with the multi-institutional outcomes and cost considerations here. But still, I think it's really great that you all got the conversation going by publishing this JU Forum piece, and we're so grateful you spent some time with us discussing this topic today.

Emily Clennon: Of course. Thank you for having me.

Ruchika Talwar: To our audience, we'll see you next time.