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Ruchika Talwar: Hi everyone. Welcome back to the UroToday Health Policy Center of Excellence. As always, my name is Ruchika Talwar and I'm a urologic oncologist in Nashville, Tennessee at Vanderbilt.

I'm really excited today to be joined by Dr. Timothy Lyon, who's going to be discussing some of his recent work looking at the experience of in-home care for urologic patients. Dr. Lyon is an associate professor of urology at Mayo Clinic in Florida, and we're really grateful that he's here to share his work with us today. Thank you so much.

Timothy Lyon: Fantastic. Thanks for having me.

Great. So I'm very excited to present our work today, which was recently published in Urology Practice, on our project titled Our Initial Experience with Inpatient Hospital Care at Home for Patients with Urologic Disease.

Hospital care at home programs have really been increasing in the past few years. And as of last year, there were more than 300 such programs in this country. However, the majority of them have been looking at patients with acute exacerbations of chronic disease. For example, patients that are admitted with something like COPD and may need a steroid taper or heart failure that needs diuresis. But the utility of these programs for patients with urologic disease really has remained unexplored. So the objective of our study was to look at our own hospital care at home program at Mayo Clinic called Advanced Care at Home and evaluate how it's being used for urologic patients currently, as well as potential opportunities for future improvement.

Our program is organized when patients are initially admitted to the hospital. We have a team screening patients for potential inclusion for Advanced Care at Home, and they have to meet several criteria. Number one, there has to be an estimated continued hospitalization of at least 48 more hours. They can't be expected to need critical care services. And we don't enroll patients who are admitted with acute mental disorders.

They then undergo some further screening, making sure that they live within a catchment area supported by our program, and they have appropriate insurance that covers the program. And when they're enrolled, they then move home along with the rest of the hospital. And we are able to provide many of the capabilities in a brick-and-mortar hospital in the patient's home. That includes things like phlebotomy, basic radiology—so X-rays and ultrasound—obviously biometric screening infusion, so IV medications, as well as daily rounds from the care team delivered virtually through a tablet.

So when the patient is brought home, we bring with them a digital technology bundle, which includes some of the things you can see on the slide here like biometric screening, a tablet through which they can communicate with us, as well as some hardware to make sure they have a reliable and secure internet connection. And then the care is provided in the home by a contracted network of nurses and paramedics, and it's overseen in our digital command centers as you can see here on the right side. So these patients are rounded on by a multidisciplinary team every day, including physicians, nurses, and advanced practice providers. Exactly the same, in fact, as what you would get in a brick-and-mortar hospital.

So for this particular study, we looked at a two-year period of our experience, and we wanted to identify patients that were admitted with urologic disease, which we defined as urinary infection, obstruction, or bleeding, or patients admitted for any reason within 90 days of urologic surgery. Primary outcome was the admitting diagnosis, reason for admission, with secondary outcomes including 30-day readmission, length of stay, and number of inpatient hospital days saved.

So over this period, we admitted 563 patients at our hospital. About 10% of them met criteria for urologic disease. So 53 admissions for patients with one of those urologic chief complaints and an additional three patients that were admitted for a non-urologic reason after urologic surgery.

Median age of our cohort was 76 with the oldest patient being 92. 54% were male, and they had a moderate comorbidity burden with a median Charlson index of 4. About half the patients, 26 patients, had had 38 previous procedures prior to admission that are outlined on the table here. You can see the vast majority of them were stone procedures, ureteral stent, ureteroscopy, nephrostomy tube.

In terms of the primary outcome, we observed that 95% of patients were admitted for general urinary infection, primarily pyelonephritis, with an additional 5% admitted with non-GU complaints including cellulitis, a CHF exacerbation, and diverticulitis. Median length of stay in the ACH program was three days. And nine patients or 16% were readmitted within 30 days. In total, 216 inpatient days were saved by enrolling these patients in the at-home program, saving the in-hospital space to care for other patients.

So in conclusion, we observed that our Advanced Care at Home program seemed feasible and effective in caring for patients with genitourinary infections. However, there is still much to learn about this process. And future work is planned to look at patient satisfaction, cost of care, as well as seeing whether we can expand inclusion of urologic patients in this program who may need drain or Foley catheter care. Thanks very much and happy to continue the discussion.

Ruchika Talwar: Great. This is such exciting work to see in the urologic surgery space. There's been a big emphasis on shifting care from the inpatient setting to home. I don't say the outpatient setting because, again, it's still a high acuity, but we're able to deliver that care at home. And it really helps us, particularly in an era where we are in the healthcare system extremely resource-strained, whether it's beds, whether it's equipment, whether it's staffing issues. So very excited to see you all leading the way in urologic care.

Logically, it makes sense to me that a lot of the infections can be treated at home given the fact that it's often the IV antibiotic requirement that keeps people in the hospital.

Timothy Lyon: Correct.

Ruchika Talwar: Or if it's some sort of need to stay broad while we await final cultures, et cetera. But based on your initial experience here, I was hoping you could potentially give us a look into the future and how this might look in the post-operative space, particularly after a major surgery.

Timothy Lyon: Yeah, great question. So we are lucky in urology that many of our patients, even post-operatively, don't require very long hospitalizations. So I think there's probably not much role for people that are undergoing laparoscopic or robotic extirpative procedures that either have no hospital stay or very short one.

We're very interested in looking at things that have a longer hospital stay such as radical cystectomy. I think it is unlikely that a program like this can completely replace inpatient hospitalization just because of the high need for things like CT scans, maybe percutaneous drain placement, consultations from other departments. But I think there is a potential role to shorten the hospital stay.

In our program currently, we can provide things like nasogastric suction, and we may be able to identify patients maybe one or two days after cystectomy that appear to be doing well, send them home, continue their convalescence at home, which may accomplish dual goals—put a patient in an environment they're more comfortable in as well as preserve some of our hospital space for other patients.

Ruchika Talwar: Absolutely. I'm curious from the patient perspective, did your team ever face any hesitation where patients were nervous about leaving the brick-and-mortar hospital and transitioning their care at home potentially could have been due to a perceived lack of support or something like that? And if that did occur, how did your team handle those situations?

Timothy Lyon: Yeah. So ultimately it's voluntary, right? So if a patient has a huge reservation, they don't need to enroll on the program. But our team has become very experienced now. We've been doing this for over three years and across all of our clinical sites have enrolled more than 3,000 patients. So they lead with all of the support that's provided. And it's not unheard of that patients may need to be transported back to the brick-and-mortar hospital. So I think when patients hear that, it puts them at ease a little bit, that we're not setting them off to sail, to convalesce on their own, but they still receive all the same type of support they'd get if they were physically here.

Ruchika Talwar: Yeah, great point. And on the flip side of that, what about hesitation from physicians? The hospital-at-home programs are expanding at medical centers across the country. What is your advice to urologists who may be a bit hesitant themselves to enroll their patients in this sort of program?

Timothy Lyon: Yeah, I mean, at first I would say we need to embrace this. Obviously, this is something patients want. And we need to meet our patients where they are and help provide the care that gives them the most comfort to recover and convalesce.

When approaching it with hesitation, which I think is normal and appropriate with anything new, I think the next piece of advice is to start small, right? This is one of the sweet spots, I think, for this care in patients with infections where they're really not doing much in the hospital except receiving IV antibiotics and waiting for their cultures to speciate. And this is, I think, the right patient population to start with. And as you see how it unfolds, what the patient experiences, how they do, then you can expand it to more acute patients with different needs.

Ruchika Talwar: Yeah, I think that's absolutely right. Well, Dr. Lyon, really exciting work. We need urologists to, as you mentioned, embrace this and lead the way on what these programs may look like while we still have the ability to retain some of that control, because I think change is coming. There's a big emphasis at the federal level and within our own health systems to try to optimize resource utilization. So kudos to you and your group for this work. And we appreciate you taking the time to share it with our UroToday audience.

Timothy Lyon: Thanks very much for having me. I appreciate the opportunity.

Ruchika Talwar: And again, as always, to our audience, thank you for joining us. We'll see you next time.