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Sam Chang: Hi. My name is Sam Chang. I'm a urologist in Nashville, Tennessee, at Vanderbilt University Medical Center, and we're quite fortunate to have Dr. Tracey Krupski. Dr. Krupski is the Jay Y. Gillenwater Professor of Urology at UVA, University of Virginia, and she recently presented at the SUO 2024, looking at the use of telehealth to improve access to health care to individuals throughout the country. And so we're quite fortunate to have Dr. Krupski here today to give us an overview of that presentation. So Tracey, it's always a pleasure to get to speak to a close friend and look forward to your presentation.

Tracey Krupski: Thank you, Dr. Chang. It's my pleasure to be here, and I really appreciate the opportunity to share some of our work that we have entitled "Tele-cystoscopy Improving Access to Bladder Cancer Care." We were tasked at the SUO this year to talk a little bit about areas that were resource-challenged. And so we're going to talk a little bit about defining resource-challenge, the impetus and our definition of what we term tele-cystoscopy, and just touch on the outcomes data.

So first of all, over here we have something from the AUA, our national organization that's talking about the workforce shortage. I think we are all aware of the workforce shortage, that 60% of counties don't have access to a urologist, and this is even more pronounced as you get to smaller populations, i.e., more rural areas. On the right here, you see the Wisconsin School of Medicine's Area Deprivation Index. And this is a map of my state, Virginia, and the Southwest and Southside are in the darker reds to orange.

This suggests that they have not only health insecurity, but income inequality, education inequality, health, housing inequality. So all of these things combine to make them a resource-challenged area. And we noticed this back in 2012. And here you again see the state of Virginia, if you didn't know your geography. We here in Charlottesville are at the health center in the middle to the top of the state. But we serve those areas you saw on the previous slide that were in red.

This is about six hours away. And we partnered with the Health Wagon, a free clinic. And this one, Southwest Virginia Community Health System, is 3.5 hours away. So this is our catchment area for Virginia at UVA. So we thought, well, why does everybody have to drive to see us for this 10-minute cystoscopy procedure? Why can't we take the cystoscopy to them? So we thought about training. Could we make an APP who lived and worked in that area do the cystoscopy while we watched it in Charlottesville? Is the technology adequate that we could get a good view that we could see clearly? And could we actually detect cancers or was it an adequate study?

So we've done several iterations of this. This is 10 years of work that I encapsulate down to like three minutes. But first of all, if you look a little bit, this came out this year: patient satisfaction. Patients were actually happy with it. This was a summary of 48 patients that we had done through the course of our work. We've saved them 235 miles each way and 434 minutes per visit. So in that sense, they were very appreciative. 82% lived in one of those distressed communities from the original map.

Then our penultimate paper that came out right during the pandemic, even though this work started in 2012, is where we actually took patients from those sites. We included six patients. It doesn't sound like a lot, but we actually recorded every video of what they did. So everybody had two concurrent cystoscopies. One was the in-person cystoscopy where I or Dr. Schenkman did the cystoscopy. So that's what you would consider standard of care that was recorded.

And then the nurse practitioner did a cystoscopy that was watched and interpreted by the counter urologist in Charlottesville. Both the in-person APP video, as well as the transmitted video, were also recorded. So we had six sets of videos for every patient who was enrolled, and that's what we sent out to other outside urologists who were not involved with the study to actually review them and answer a series of questions about these three things—video quality, provider proficiency, and diagnostic utility.

So for the traditional, meaning the one the urologist did in-person video they reviewed, they did say it was better. It was 92% were fluid, had very good clarity, versus 75% for the APP transmitted video. So proof of principle—you would hope that the in-person standard of care is slightly better. But the tele-cystoscopy was pretty good. The provider proficiency—they were almost virtually identical when they were talking about did you see the orifices, did you see the dome, do you feel like you did a thorough survey?

The urologist, again, on a Likert scale from 1 to 5, had a better score of being four or five versus only three to four of the APPs. But when asked, "Could you make a diagnosis?" There was an overwhelming yes. And then diagnostic utility. This is a little trickier because Sam, as a urologist who does a lot of bladder cancer, when you look in the bladder, it's not always yes, no. There can be radiation changes, there can be cystitis cystica, there can be red things.

But generally, in terms of our APP videos versus the traditional videos, 75% had 100% agreement on what they thought they saw and what action they would take from that. Whereas the rest, the other 25%, had differences in maybe they would delay the surveillance or move it up rather versus going straight to the OR or continuing surveillance. So we felt like this was pretty reassuring that we weren't harming patients with this and we were improving the access to these areas that don't have any urologist in those red stripes of my map.

So in summary, I would say the infrastructure is pretty good. I think the video quality, the clarity, the resolution is adequate for tele-cystoscopy to take off. The one limitation that I'll bring up in my work is that sustaining their skills—these are family practice APPs. They were not urologists. They were not PAs. They did not do urology on a regular basis. So if you skipped a month or two, their skills would really drop off. So maybe sending a urology APP is the more sustainable model in my mind.

And then I think this is an attractive alternative to improve access. I'm not going to claim that it's better, but these are patients who otherwise may not see a urologist at all. So in that sense, I think it's more feasible. This was pure research. The next step is going to be adoption and reimbursement. And we know that the 2024 telehealth benefits are maybe being rolled back by Congress. So that's going to be a policy issue going forward. But thank you for the chance to talk about this. It's been really important to me to do this work.

Sam Chang: Tracey, that was great. I just want to ask some logistic questions. In terms of the scopes themselves, were these disposable scopes? How did you go through the initial training with the APPs? How did you initiate the program?

Tracey Krupski: So this is a great question. And we did look at data of experience when we first started that infrastructure piece of my triangle. We didn't have Ambu or disposable scopes back in 2014 when we started this, so we compared two short scopes. We ended up going with the C-view Telepak scope, and we also then later did it over again with a Wolf scope. And that's a really good point you bring up because one of the problems was having these off-site places take care of this very expensive scope. So I'm in the process of—

Sam Chang: Exactly what I was trying to think about, yeah.

Tracey Krupski: We broke one and it was $8,000 of grant money to fix it. So yeah, we had one fantastic nurse, LaDonna, that had done surgery a long time ago and she was really good at doing the first few. It was high-level sterilization. Of course, they didn't have a Sterrad or anything. So I do think it does work. We're testing it now with the Ambu scope, but it could be any scope. And then the training piece is another good question. We adopted it from the British Association of Urologic Nursing.

So they had a kind of a whole program laid out. And we have several papers on that. But I didn't have time to show all those things. We had a Thiel cadaver lab, so it's a living cadaver lab, so the tissue is elastic. And that was a great benefit to these APPs coming to UVA to train on those cadavers because they could practice with the scopes over and over without being in the OR extending OR time like they did in Britain. Or having the tension of like being a live patient that's watching you, "practice." And then there's a urogynecology cystoscopy checklist, which is a validated instrument, which is how we checked them off on it.

Sam Chang: Fantastic. So you got actually a model mechanism to make this more widespread for sure. As you did these, do you envision doing a number of these, taping them and then batching—do that again.

Tracey Krupski: No. We don't have time for that. That's the advantage of this. This is why this is different than Australia and Britain. You can be in your clinic, they come grab you and say, Dr. Chang, they're ready to do that cysto in Knoxville. And you just tune in and you say, look a little bit more there. Take a still shot of that. Yeah, that's nothing. That's squamous metaplasia. And you don't have to do something after hours. You don't have to work with that.

Sam Chang: That's how I was wondering—is the real-time capability. No, you're exactly right because you can imagine you getting a taped video and it's like, oh, I didn't see that one area. But being able to do that real-time, having that built in. But I agree with you totally regarding that continuous performance of this procedure. And if you go 6 months, you go 3 months, you're going to get that drop-off just as you described. So, Tracey, where do we go next with the research? Where are we going to go next?

Tracey Krupski: So I think we have to really lobby. This was an AUA summit issue last year, and I expect it will be again. We have to extend—right now supervised APP work is included in the telehealth benefits packaging right now. That may go away at the end of 2024, which means there would be no reimbursement for something like this. You can petition for what I've called as a G code, as how I understand it, to actually be reimbursed for the professional fee.

And then hopefully the facility fee could go to the place that's performing it. There's a company who's been in contact with me, and I don't want to promote some specific companies, but it is being operationalized to have a remote cystoscopy. So I think it could be being taken into the medical device thing outside of just research by me.

Sam Chang: Yeah, I think that's a great point being able to—just as you described at your last slide of making that next step from research and to actually implementing it into policy and real-world activity. And I think it really does emphasize the continued increasing role of our APPs.

Tracey Krupski: Absolutely. And I think we do have—not to be negative, or I know everyone in America worries about medicolegal, and that had been one of the hurdles APPs doing procedures through the last couple decades that you and I have been practicing. But I think you have to remember when you see that other study, 2.5 hours of driving each way or five hours each way, even if it's not perfect, if it's very good or not inferior, I think it's an option we have to consider. If 60% of counties have no urologist, how is that going to work?

Sam Chang: Huge, huge point. And then your last article regarding the patient satisfaction just further confirms the benefit that this type of model would have for so many patients who are currently—would honestly probably not get any type of standardized care.

Tracey Krupski: 100 percent. They don't.

Sam Chang: Yeah. So, Tracey, thanks so much for spending some time with us. And we look forward to your continued role in leadership in this because I think there's no question that we're going to have to improve access to care.

Tracey Krupski: Absolutely. Thank you so much for the opportunity. I really appreciate it.