More than a third of men seeking infertility-related care are seeing providers other than urologists, but telehealth offers an affordable, viable option for many men, according to two studies presented at the virtual American Society for Reproductive Medicine (ASRM) 2020 Scientific Congress.
"Given the high prevalence of medical comorbidity and treatable etiologies of male infertility among male partners of infertile couples, it is critical that these men undergo evaluation by a reproductive urologist," Richard Jacob Fantus, MD, an andrology fellow at Northwestern University in Chicago, Illinois, told attendees October 17 when he presented his abstract on providers seen by men for infertility.
Yet many men do not have access to reproductive urologists, which is where telemedicine can play a role, according to Alex Zhu, DO, a second-year urology resident at Michigan Medicine in Ann Arbor. In his abstract presentation on October 19, he cited a 2016 study that found that 13 states had no male reproductive urologists and that Kentucky had only one assisted reproduction center.
"Due to the lack of andrologists, patients often have to drive far distances to see a reproductive specialist or will rely on general urologists who may not have the interest or expertise in male reproduction," Zhu told attendees. "It is reasonable to assume that this geographic barrier significantly impacts the access and outcomes of assisted reproductive care. Overall, telemedicine is an invaluable resource for male infertility patients."
The retrospective cohort study presented by Fantus and colleagues involved an analysis of all visits by male patients that were included in the National Ambulatory Medical Care Survey — a dataset sponsored by the Centers for Disease Control and Prevention — from 2006 through 2016. Infertility visits by men were identified using ICD 9 and ICD 10 codes.
Of 3,410,129 for that period, 0.04% were for infertility, a total of 1513 visits. The men who made infertility visits tended to be younger (average age, 35 years) than those who made visits for other reasons (average age, 58 years; P < .05), and they were much more likely to have private insurance (89.2% vs 50.4%; P < .05).
Although most of the affected men (64.6%) who sought care because of infertility saw urologists, more than a third saw a provider other than a urologist, including 13.6% who saw gynecologists, the second most common provider type. Among those who did not see urologists, 69.4% of all the infertility diagnoses came from gynecologists. The average age of men seeing providers other than urologists was 31 years, younger than the average 36 years of those who saw urologists (P < .05). A higher proportion of those who did not see a urologist were Black (18.2%) compared with the proportion of Black patients who saw urologists (10%; P = .04).
Given the time and expense often involved in male infertility visits, telehealth has become a practical, effective option that's cost-efficient for patients, Zhu told attendees in his presentation.
"With the advent of COVID, we've all seen a rapid rise in telehealth visits," he said. At his institution, the number of telehealth visits jumped from about 400 a month prior to the COVID-19 pandemic to 30,000 – 40,000 after March 17, when the pandemic was declared a national health emergency.
Experts have estimated that 1 billion telehealth visits will be completed in 2020 in the United States, Zhu said. In addition, changes in rules and reimbursement from the Centers for Medicare & Medicaid Services (CMS) and private insurance payers have opened the door to new patients, telephone visits, and visits across state lines. In addition, during the pandemic, there is no CMS Originating Site requirement.
In their study, Zhu and colleagues analyzed a case series from a single institution to estimate the resources saved by new patients by using telehealth instead of making in-person visits before the COVID-19 pandemic made telehealth so ubiquitous. The researchers first identified all video visits between August 21, 2017, and March 17, 2020, in which a male patient saw a urologist because of concern regarding male infertility. Using chart reviews, the researchers collected information on patients' age, primary language, race, and occupation, including whether their job was blue collar or white collar.
A total of 56 patients had 70 male infertility video visits during that time. The median age was 36 years, most were White (78%), and nearly all listed English as their preferred language (96%). The median salary of the patients was $51,331; 68% held white collar jobs, and 32% held blue collar jobs, defined as manual labor.
For all but one of the patients, the video visits that were conducted during the study period were the patients' first such visits. Three visits involved non-English speakers.
The researchers used Google Maps to estimate round-trip driving distance and time. To estimate the cost of driving, they used the American Automobile Association's rate of $0.59/mile. To estimate lost wages for those who would have needed to take off a full or half day for a visit, they used Glassdoor.com.
On average, by using telehealth, patients avoided traveling a median 80 miles and taking 97 minutes to travel per visit, excluding time spent at the appointment. This amount represented $47 saved in driving costs, as well as a median $102 (half day) to $205 (full day) saved in lost wages by not needing to miss work.
The median total savings per visit was $149 for those who would have needed to take a half day off and $252 for those who would have needed to take a full day off. Combined with the savings from 11,646 miles and 12,070 minutes not driven to and from appointments, total estimated savings were $14,539 for half days off and $22,206 for full days off. These costs are likely underestimates, Zhu said, because they do not account for meals, parking fees, and other expenses related to in-person visits.
"Many of us were quick adopters of this technology due to COVID, and I think that this is more evidence that this is an excellent way to provide follow-up care, including discussion of test results, without the inconvenience for the patient of having to take off time from work," Jay Sandlow, MD, professor of urology and director of the male infertility/andrology fellowship at the Medical College of Wisconsin in Milwaukee, told Medscape Medical News. "While I feel that new patients still require an in-person exam, these virtual visits are much better than other electronic communication, such as MyChart, which is limited in its ability for discussion," continued Sandlow, who was not involved in the research but was co-moderator of the oral abstract session.
He noted that the convenience of telehealth is particularly attractive for many patients.
"Additionally, I would think that more patients would be willing to follow up if they don't have to physically come to the office," he said. "I would like to see some patient satisfaction data, although my anecdotal experience is that it has been well received. Overall, I think we are going to transition a lot of our follow-up care to telehealth."
Brooke Harnisch, MD, an assistant professor of surgery at UConn Health in Farmington, Connecticut, who was co-moderator of the session with Sandlow, echoed his interest in seeing patient satisfaction data but otherwise found the savings data compelling.
"Video visits are a reasonable option for follow-up infertility care, especially if a physical exam has been done at the initial appointment," Harnisch told Medscape Medical News. "Video visits significantly reduce driving miles, time traveled, and lost wages for patients. In the era of COVID-19, providers should continue to consider incorporation of video visits into practice."
Aside from not having patient satisfaction data, Zhu noted that other study limitations include self-selection bias from patients and variations in wage calculations.
"We likely only offered telemedicine appointments to patients we thought would be capable of using the technology in the first place," Zhu said. Even so, he added, "It's quite striking to see the total cost savings to the patients."
The presenters and those interviewed have disclosed no relevant financial relationships.
American Society for Reproductive Medicine (ASRM) 2020 Scientific Congress: Abstracts O-55 and O-144, presented October 17 and 19, 2020.
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Cite this: Telehealth Expands Access to Specialists for Male Infertility Visits - Medscape - Oct 27, 2020.
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