A Hybrid Clinic Model to Minimize "Face Time" in Pediatric Urologic Ambulatory Clinics
Hsin-Hsiao Scott Wang, MD, MPH, MBAn, Michael Kurtz, MD, MPH, Julie Campbell, MBA, Caleb Nelson, MD, MPH, Carlos Estrada, MD, MBA.
Boston Children's Hospital, Boston, MA, USA.
Background: In a pandemic clinicians face the unique challenge of balancing proper, timely patient care and viral spread risk reduction. This is especially difficult in ambulatory setting in which clinicians and patients are usually in a confined space rarely compliant with the 6-ft CDC guidelines. At our institution, our department initiated the hybrid outpatient model combining in-person physical exam and video consultation in the same visit aiming to minimize the face-to-face time and protecting families and staff. We sought to compare the actual face-to-face time between the "classic" and "hybrid" strategy in a pediatric urology outpatient setting.
Methods: We prospectively collected data using trained 3rd party observers from 254 "classic" pre-pandemic and 90 "hybrid" clinic MD visits during Oct-Dec 2020. Variables collected included: demographics, physician, visit date/time, new/return visit, urologic surgical history, 1st post-op visit, and diagnosis. Timestamps were recorded at patient check-in, MD in and out of room, and final check-out. The primary outcome was MD "face time", defined as the duration of MD time within the room.Univariate analysis was performed, and a multivariate regression model fitted with the main outcome (classic vs hybrid) as well as the other covariates. Surgeon was adjusted as random effect in mixed model.
Results: 346 (256 classic/90 hybrid) visits were included in the final analysis. The face-to-face time was significantly lower in hybrid visits, median 3(IQR 2-6) vs classic=10(6-17) mins, p<0.01. The in-person clinic time by visit characteristics was listed in Table 1. In univariate analysis for classic visits, longer visits were significantly associated with new patient visits (p<0.01), afternoon visits(p<0.01), decision for surgery (p=0.02), and diagnoses such as voiding dysfunction, scrotal complaints, and neurogenic bladder. Conversely, previous urologic surgery (p<0.01), 1st post-op visit (p<0.01), and diagnoses such as penile complaints, undescended testis, and hydrocele were associated with shorter visits. On the other hand, these visit characteristics were not associated with significant "face-time" difference in hybrid visits. After adjusting for new/return visit time, morning/afternoon visit time, previous surgery history, decision for surgery discussion, first post-operative visit, and diagnosis, hybrid visit remained significantly associated with shorter face-to-face time (5.7 minutes less, p <0.01).
Conclusions: Pediatric urologists’ face time with patient/family can be significantly reduced using a hybrid model. This new type of practice allows clinicians to evaluate pediatric urology conditions in-person while reducing in-person contact. Our specialty requires in-person exams for some diagnoses, and this clinic structure allows us to provide timely care while respecting local guidelines especially among the rising the more contagious COVID Delta-variant trend. 
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