COVID Pandemic Impact on Healthcare Provision and Patient Psychosocial Distress: A Multi-National Cross-Sectional Survey among Asia-Pacific Countries

The coronavirus (COVID) global pandemic has significantly affected the delivery and maintenance of healthcare system with many clinicians tasked to make difficult decisions to balance between providing optimal and high-quality urological care to their patients, and utilising the increasingly burdened healthcare resources. In hospitals which are tasked to manage COVID patients, various surgical departments have been instructed to minimise (or suspend) all non-urgent elective surgeries to cope with the number of COVID admissions and near-deaths that are consuming precious resources such as ventilators, intensive care unit beds and theatre sessions. Many urological societies have released various position statements and clinical guidelines advocating for a tier healthcare system that prioritise surgeries based on the degree of urgency so that critical patients continue to receive appropriate clinical care [1, 2, 3, 4, 5, 6].

To date, most countries are facing second (or third) waves of COVID infection and worldwide, it is estimated that more than 110 million people have been infected with 2.5 million reported deaths [7]. While several COVID vaccines have been approved, delivered and administered across many countries and continents, this COVID pandemic will likely remain a threat for the considerable future. Healthcare system remains under duress and constraint with rapidly depleted resources have increased mental and physical stress to healthcare personnel and patients. In the climate of social restrictive measures and a need for an accurate update on healthcare information, the digital healthcare system has become the new norm [1, 2, 5]. Telemedicine and digital health interventions, which allow many clinical activities to be carried out effectively and safely, have been instituted promptly to address some of the limitations in the current healthcare system.

Considering the above-mentioned, we conducted a multi-national survey to study the impact of COVID pandemic on andro-urological services across countries in Asia-Pacific. The objectives of this study are to evaluate the impact of COVID pandemic on the provision of clinical care and digital healthcare interventions in each centre, as well as patient distress and acceptance of the telehealth services.

The COVID pandemic has significantly altered the way various healthcare systems manage personnel and patients worldwide. Various governmental policies and contingency plans have been implemented to ensure strict social measures to limit COVID contagion and redirect the healthcare system with prioritisation to more critical areas [2, 5, 14]. Many urological departments and urologists are forced to make difficult and at times, extraordinary decisions to balance between providing optimal and timely urological care to their patients, while meeting the strict guidelines on safety and social measures to patients and healthcare workers. In hospitals that cater for managing COVID patients, valued healthcare resources are diverted to cope to emergency frontline services with adjustment, suspension or cancellation of non-critical and elective services to cope with the devastating increment of COVID-19 cases. Both outpatient clinics and operating theatres are regularly adjusted, sometimes on a daily to weekly basis, based on the directions by the governmental agencies.

The integration of digital telemedicine in the healthcare system has been significantly accelerated in this COVID pandemic. Government policymakers and healthcare providers strongly advocate the incorporation of various digital interventions to maximise clinical interface and effectively streamline many clinical activities within a safe environment [15, 16]. In our study, the use and integration of telemedicine has resulted in more than 50% reduction in the out-patient services in most centres with conversion to telehealth consultations although physical attendance to clinic remained possible if patients fulfilled certain criteria. This was associated with more phone calls and emails correspondence with the patients. The decrease in the number of new referrals was likely a result of fewer patients seeing their primary care physician during the social restriction period or perhaps relating to the fear of contracting COVID with exposure to medical centres and hospitals, although we did not collect data on this aspect.

Telehealth practise has expanded beyond traditional activities to include out-patient consultations, medical education, videoconferencing to coordinate clinical care and remote monitoring on patient's well-being [17]. Furthermore, these telemedicine and educational webinars conducted through internet-based platforms have been shown to improve healthcare access with greater convenience and efficiency [18, 19, 20] with the additional advantages in terms of cost and time saving, as well as environmental pollution prevention [21]. Boehm et al [22] showed that most patients (63.2%) were judged suitable for telemedicine and preferred telemedicine consultations to a face-to-face consultation, with no difference in preference between those with oncological or benign conditions, or patients with COVID-19 risks factors. In our study, most of the patients (85.7%) found telehealth service to be relatively straightforward and reported a score of 1 (very easy) or 2 (easy). We reported a significant increase in the number of educational webinars for patients and colleagues to promote health awareness and clinical management during this pandemic.

Whilst various alternative strategies may have been put in place as temporary measures as directed by government policy and hospital administrations each patient's condition must be weighted appropriately and individualised. The volumes of publication on the changes in urological care and urology providers have highlighted considerable cut-down of urological services and patients with benign conditions faced longer delayed in clinical management than those with malignant conditions [5, 14]. Nonetheless, urgent (or semiurgent) cases remain eligible on a case-by-case basis and can continue to be performed by adhering to local institution guideline. In our cohort, many out-patient services were reduced or postponed by adhering to new hospital policy and regulation during the COVID pandemic. As expected, all the non-urgent elective theatre cases were postponed while the number of urgent cases was reduced by at least 50% in all the hospitals.

Despite constant media awareness campaigns and efforts, many patients are faced with uncertainty and expressed some degree of psychosocial distress as a result of this pandemic [23, 24, 25]. In our study, we found that most of the patients were reasonably happy and accepted the current clinical arrangements under this COVID situation, although some patients expressed dissatisfaction (35.7%) and hold a pessimistic view on the current healthcare system (28.5%). Psychometric validated questionnaire measures such as DASS and DES were scored in a relatively positive manner although most patients (85.7%) indicated their preferences for more detailed information on healthcare provision with a score of above 5 out of 10. A shared decision making with open communication, based on clinical evidence that balances risks, expected outcomes and available resources with patient preferences and expectations, are necessary to minimise psychological distress. In this rapidly-evolving pandemic, prompt and up-to-date precautionary measures based on local data with the provision of pragmatic evidence-based clinical care should be implemented by various institutions while governmental policies will need to be modified and adapted to provide, support, and treat patients safely and efficiently.

We acknowledged several limitations in our study such as the relatively small sample size and that data was collected in a single cross-sectional timeline amid the pandemic. Furthermore, reporting and selection biases may arise since our cohort consists of key leaders in highly specialised centres may not be representative of the general population. Our sample size also precludes the ability to provide more granular data analysis beyond individual hospital centres. The impact on other subspecialty care as a result of government shutdown policies or hospital directives are not covered by our study too. Nonetheless, the relative homogeneity of responses across various centres in our study highlights several generalised observations regarding the management strategies adopted by various centres and are in keeping with current evidence-based best practice. In our study, all surveyed healthcare systems are proactive in COVID management in terms of resource allocation, service optimisation and patient well-being. However, the longer-term impact of telemedicine and some of the delays in surgical management will require future study.

The clinical and regulatory framework for the implementation of telehealth service is rapidly evolving and will likely be different across institutions, healthcare systems, cities and countries. While numerous studies including a recent systematic review [15] have shown that electronic-based health-related interventions can be effective and safe, other aspects of telemedicine, especially with regard to maintaining clinical professionalism, confidentiality, quality data transmission, and adequate comprehension by patients must be adhered and uphold [26]. Furthermore, many clinicians have to adapt to the rapidly changing landscape of digital information without affecting the quality of their work [14, 27]. The role of telesurgery and telementoring are an emerging field that will require further studies and refinements too. Long-term data including health-economic cost-analysis assessments and patient-reported psychometric measures are needed to understand the economic implications and the impact of telehealth applications on patient well-being and quality of care.

The COVID pandemic has significantly changed the way healthcare systems manage personnel and patients worldwide. Telemedicine and digital healthcare interventions have been adopted to provide more efficient and safe healthcare services while adhering to strict social measures to limit viral contagion. Despite what technology might enable us to do in the now and in the future, it will be critical to develop standardised systems with real time tracking and appropriate backup protocols to facilitate efficient and safe delivery of high-quality evidence-based healthcare. Our study showed telehealth services have been integrated early and successfully during the COVID pandemic and patients are generally receptive to this arrangement with minimal psychosocial distress.