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Bokova E, Elhalaby I, Saylors S, Lim IIP, Rentea RM. A Systematic Review of Telehealth Utilization for Bowel Management Programs in Pediatric Colorectal Surgery. CHILDREN (BASEL, SWITZERLAND) 2024; 11:786. [PMID: 39062235 PMCID: PMC11274794 DOI: 10.3390/children11070786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Revised: 06/13/2024] [Accepted: 06/24/2024] [Indexed: 07/28/2024]
Abstract
Recent advancements in pediatric surgery have embraced telehealth (TH) modalities, transitioning from traditional in-person consultations to virtual care. This shift has broadened access to healthcare, potentially enhancing affordability, patient and caregiver satisfaction, and clinical outcomes. In pediatric colorectal surgery, telehealth has been effectively utilized to support Bowel Management Programs (BMPs) for children suffering from constipation and fecal incontinence. A systematic review was conducted to assess the effectiveness of virtual BMPs, analyzing studies from January 2010 to December 2023, sourced from MEDLINE (via PubMed), Embase, and the Cochrane Library, with five studies included. Remote BMPs, implemented through video or telephone consultations, reported satisfaction rates exceeding 75% among families, indicating a strong preference for virtual interactions over traditional visits. Significant findings from the studies include improvements in Vancouver and Baylor scores, reductions in the duration of multidisciplinary consultations, enhancements in pediatric quality of life and Cleveland scores, and decreased frequency of laxative treatments. The implementation of TH has facilitated patient-led care, enabling timely adjustments in treatment and efficient distribution of medical supplies. The findings suggest that virtual BMPs are a viable and effective alternative to conventional approaches, yielding high caregiver satisfaction and superior clinical outcomes while promoting patient independence.
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Affiliation(s)
- Elizaveta Bokova
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | - Ismael Elhalaby
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA
- Tanta University Hospital, Faculty of Medicine, Tanta University, Tanta 31527, Egypt
| | - Seth Saylors
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | - Irene Isabel P. Lim
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA
- Department of Surgery, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Rebecca M. Rentea
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA
- Department of Surgery, University of Missouri-Kansas City, Kansas City, MO 64108, USA
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Choueiki JM, Sales S, Callicott S, Ashman D, Worst K, Badillo A, Varda BK, Mayhew A, Xu TO, Levitt MA. Is Collaborative Care the Future of Medicine? Lessons Learned from the Care of Children with Colorectal Conditions. CHILDREN (BASEL, SWITZERLAND) 2024; 11:570. [PMID: 38790565 PMCID: PMC11119695 DOI: 10.3390/children11050570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/12/2024] [Accepted: 05/02/2024] [Indexed: 05/26/2024]
Abstract
The treatment of patients with colorectal disorders requires care from a wide variety of medical and surgical specialties over the course of their lifetime. This is ideally handled by a collaborative center which facilitates the assessment and development of patient care among multiple specialties which can enhance the quality and implementation of treatment plans, improve communication among different specialties, decrease morbidity, and improve patient satisfaction and outcomes. This collaborative approach can serve as a model for other parts of medicine requiring a similar multi-disciplinary and integrated method of care delivery. We describe the process, as well as the lessons learned in developing such a program.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Marc A. Levitt
- Division of Colorectal and Pelvic Reconstruction, Children’s National Hospital, Washington, DC 20010, USA; (J.M.C.); (S.S.); (S.C.); (D.A.); (K.W.); (A.B.); (B.K.V.); (T.O.X.)
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Haddad E, Hayes LC, Price D, Vallery CG, Somers M, Borer JG. Ensuring our exstrophy-epispadias complex patients and families thrive. Pediatr Nephrol 2024; 39:371-382. [PMID: 37410166 DOI: 10.1007/s00467-023-06049-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 05/17/2023] [Accepted: 06/01/2023] [Indexed: 07/07/2023]
Abstract
Individuals with bladder exstrophy-epispadias complex (EEC) need long-term integrated medical/surgical and psychosocial care. These individuals are at risk for medical and surgical complications and experience social and psychological obstacles related to their genitourinary anomaly. This care needs to be accessible, comprehensive, and coordinated. Multiple surgical interventions, reoccurring hospitalizations, urinary and fecal incontinence, extensive treatment regimens for continent diversions, genital differences, and sexual health implications affect the quality of life for the EEC patient. Interventions must include psychosocial support, medical literacy initiatives, behavioral health services, school and educational consultation, peer-to-peer opportunities, referrals to disease-specific camps, mitigation of adverse childhood events (ACEs), formal transition of care to adult providers, family and teen advisory opportunities, and clinical care coordination. The priority of long-term kidney health will necessitate strong collaboration among urology and nephrology teams. Given the rarity of these conditions, multi-center and global efforts are paramount in the trajectory of improving care for the EEC population. To achieve the highest standards of care and ensure that individuals with EEC can thrive in their environment, multidisciplinary and integrated medical/surgical and psychosocial services are imperative.
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Affiliation(s)
- Emily Haddad
- Cook Children's Health Care System, Fort Worth, TX, USA.
| | - Lillian C Hayes
- Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Diane Price
- Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christina G Vallery
- Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael Somers
- Department of Nephrology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph G Borer
- Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Caruso AM, Bommarito D, Girgenti V, Amato G, Calabrese U, Figuccia A, Baldanza F, Grasso F, Giglione E, Casuccio A, Milazzo MPM, Di Pace MR. Evaluation of Anal Sphincter with High Resolution Anorectal Manometry and 3D Reconstruction in Patients with Anorectal Malformation. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1037. [PMID: 37371268 DOI: 10.3390/children10061037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 05/27/2023] [Accepted: 06/01/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Patients with anorectal malformation (ARM) need long-term follow-up, in order to evaluate fecal continence; the main predictors of longer-term success are the type of ARM, associated anomalies and sacral integrity. Three-Dimensional High Resolution Anorectal Manometry (3D-HRAM) gives detailed information on pressure on the anal complex profile. Our objective was to analyze anal sphincter activity in ARM patients with 3D-HRAM establishing the correlation between manometric and clinical data. METHODS Forty ARM patients were submitted to 3D-HRAM: manometric, anatomical and clinical scores were correlated with each other and with the bowel management response (BM). RESULTS A positive correlation between all scores and types of ARM was found: in high ARM and in patients with spinal anomalies (regardless to ARM type) lower scores were reported and even after BM they did not achieve good continence. CONCLUSIONS 3D-HRAM gives detailed data on the functional activity of the anal sphincter complex. Our study revealed a correlation between manometric parameters and clinical outcomes, confirming spinal malformations and ARM type as the most important prognostic risk factors for a bad outcome. Specific sphincteric defects can also be explored with manometry, allowing for tailored bowel management strategies.
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Affiliation(s)
- Anna Maria Caruso
- Pediatric Surgical Unit, Children's Hospital 'G. di Cristina', ARNAS Civico, 90100 Palermo, Italy
| | - Denisia Bommarito
- Pediatric Surgical Unit, Children's Hospital 'G. di Cristina', ARNAS Civico, 90100 Palermo, Italy
| | - Vincenza Girgenti
- Pediatric Surgical Unit, Children's Hospital 'G. di Cristina', ARNAS Civico, 90100 Palermo, Italy
| | - Glenda Amato
- Pediatric Surgical Unit, Children's Hospital 'G. di Cristina', ARNAS Civico, 90100 Palermo, Italy
| | - Ugo Calabrese
- Pediatric Surgical Unit, Children's Hospital 'G. di Cristina', ARNAS Civico, 90100 Palermo, Italy
| | - Adele Figuccia
- Pediatric Surgical Unit, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialities, University of Palermo, 90100 Palermo, Italy
| | - Fabio Baldanza
- Pediatric Surgical Unit, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialities, University of Palermo, 90100 Palermo, Italy
| | - Francesco Grasso
- Pediatric Surgical Unit, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialities, University of Palermo, 90100 Palermo, Italy
| | - Emanuela Giglione
- Pediatric Surgery Division, Women's and Children's Health Department, University of Padua, 35100 Padua, Italy
| | - Alessandra Casuccio
- Pediatric Surgical Unit, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialities, University of Palermo, 90100 Palermo, Italy
| | | | - Maria Rita Di Pace
- Pediatric Surgical Unit, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialities, University of Palermo, 90100 Palermo, Italy
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Bokova E, Svetanoff WJ, Levitt MA, Rentea RM. Pediatric Bowel Management Options and Organizational Aspects. CHILDREN 2023; 10:children10040633. [PMID: 37189882 DOI: 10.3390/children10040633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 03/30/2023]
Abstract
A bowel management program (BMP) to treat fecal incontinence and severe constipation is utilized for patients with anorectal malformations, Hirschsprung disease, spinal anomalies, and functional constipation, decreasing the rate of emergency department visits, and hospital admissions. This review is part of a manuscript series and focuses on updates in the use of antegrade flushes for bowel management, as well as organizational aspects, collaborative approach, telemedicine, the importance of family education, and one-year outcomes of the bowel management program. Implementation of a multidisciplinary program involving physicians, nurses, advanced practice providers, coordinators, psychologists, and social workers leads to rapid center growth and enhances surgical referrals. Education of the families is crucial for postoperative outcomes, prevention, and early detection of complications, especially Hirschsprung-associated enterocolitis. Telemedicine can be proposed to patients with a defined anatomy and is associated with high parent satisfaction and decreased patient stress in comparison to in-person visits. The BMP has proved to be effective in all groups of colorectal patients at a 1- and 2-year follow-up with social continence achieved in 70–72% and 78% of patients, respectively, and an improvement in the patients’ quality of life. A transitional care to adult program is essential to maintain the same quality of care, and continuity of care and to achieve desired long-term outcomes as the patient reaches adult age.
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Short SS, Durham MM, Rollins MD. Hirschsprung disease outcomes. Semin Pediatr Surg 2022; 31:151160. [PMID: 35690462 DOI: 10.1016/j.sempedsurg.2022.151160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hirschsprung disease (HD) is a complex surgical and medical problem that appears to have varied health and social outcomes with the age and neurodevelopmental state of patients. In general, long-term outcomes are thought to be good for the majority of patients despite recognized problems with constipation and/or fecal incontinence. However, there are no universally accepted pathways regarding post-operative bowel management programs nor clearly defined follow-up pathways making the current outcome measures difficult to interpret. Further, other factors that may influence outcome including age at the time of procedure and procedure type continue to lack consensus. Improved support of children in resource limited environments and during periods of transition into the adult medical care environment are needed to improve outcome. Recent proliferation of multidisciplinary care teams and consortia may help to better understand outcomes and address current knowledge gaps. Continuing these collaborations will be imperative to continuing improvements in care which may ultimately impact outcome.
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Affiliation(s)
- Scott S Short
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, 100N. Mario Capecchi Drive, Suite 3800, Salt Lake City, UT 84113, United States.
| | - Megan M Durham
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Room B206 1364 Clifton Road, NE, Atlanta, GA 30322, Georgia
| | - Michael D Rollins
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, 100N. Mario Capecchi Drive, Suite 3800, Salt Lake City, UT 84113, United States
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The utilization of botulinum toxin for Hirschsprung disease. Semin Pediatr Surg 2022; 31:151161. [PMID: 35690464 DOI: 10.1016/j.sempedsurg.2022.151161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Patients with Hirschsprung disease (HD) can struggle with persistent obstructive symptoms even after a successful pull-through. These symptoms lead to stasis of stool and can result in Hirschsprung associated enterocolitis (HAEC). Recurrent episodes of HAEC warrant further workup; if there are no signs of mechanical obstruction or an aganglionic pull-through, the use of botulinum toxin injections to the internal anal sphincter has been utilized to relieve these symptoms. In this review, we describe the variations in botulinum toxin injection use and describe ongoing studies to prevent obstructive symptoms and Hirschsprung-associated enterocolitis (HAEC). Botulinum toxin injection utilization has been described for obstructive symptoms after HD pull-through, in the setting of active HAEC, and has been proposed to be part of the treatment algorithm for prevention of HAEC after pull-through. Dosing utilized for the injections, along with the complications, are also described. Prospective, multi-institutional trials are needed to identify the effectiveness of botulinum toxin injections in the outpatient/prophylactic setting as current data suggest some benefits in preventing future obstructive symptoms; however, other studies have conflicting results.
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Abstract
PURPOSE Pediatric colorectal conditions require complex medical care and can require lifelong support. Caregivers often seek medical information on the internet. The aim of this study was to characterize the use of three social media platforms for information sharing about pediatric colorectal conditions. METHODS A systematic study of Instagram, Facebook, and Twitter was performed using standardized search terms. Accounts with activity within the last year were included. Quantitative data were collected. Accounts were qualitatively assessed and assigned a functional category. Group differences were tested via Kruskal-Wallis test and Fisher's exact tests for continuous and categorical variables, respectively. RESULTS A total of 96 Instagram accounts, 57 Twitter accounts, 49 Facebook pages, and 45 Facebook groups were identified. Accounts originated from 24 countries and the greatest number of accounts was created in 2013. The most common source of information on Instagram was from personal accounts (74.0%), on Facebook was from support groups (45.7%), and on Twitter was from health care providers (35.1%), (p < 0.001). The most common functional categories on Instagram were personal story (69.8%), on Twitter were scientific information/medical research (57.9%), and on Facebook were supportive/story sharing (47.8%), (p < 0.001). CONCLUSIONS Social media serves as a source for medical information and allows for supportive communities for pediatric colorectal patients and their families to exist.
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Svetanoff WJ, Briggs K, Fraser JA, Lopez J, Fraser JD, Juang D, Aguayo P, Hendrickson RJ, Snyder CL, Oyetunji TA, St Peter SD, Rentea RM. Outpatient Botulinum Injections for Early Obstructive Symptoms in Patients with Hirschsprung Disease. J Surg Res 2021; 269:201-206. [PMID: 34587522 DOI: 10.1016/j.jss.2021.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 06/23/2021] [Accepted: 07/22/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Botulinum toxin (BT) injections may play a role in preventing Hirschsprung associated enterocolitis (HAEC) episodes related to internal anal sphincter (IAS dysfunction). Our aim was to determine the association of outpatient BT injections for early obstructive symptoms on the development of HAEC. METHODS A retrospective review of children who underwent definitive surgery for Hirschsprung disease (HSCR) from July 2010 - July 2020 was performed. The timing from pull-through to first HAEC episode and to first BT injection was recorded. Primary analysis focused on the rate of HAEC episodes and timing between episodes in patients who did and did not receive BT injections. RESULTS Eighty patients were included. Sixty patients (75%) were male, 15 (19%) were diagnosed with trisomy 21, and 58 (72.5%) had short-segment disease. The median time to pull-through was 150 days (IQR 16, 132). Eight patients (10%) had neither an episode of HAEC or BT injections and were not included in further analysis. Forty-six patients (64%) experienced at least one episode of HAEC, while 64 patients (89%) had at least one outpatient BT injection. Compared to patients who never received BT injections (n = 9) and those who developed HAEC prior to BT injections (n = 35), significantly fewer patients who received BT injections first (n = 28) developed enterocolitis (P < 0.001), with no patient developing more than one HAEC episode. CONCLUSION Outpatient BT is associated with decreased episodes of HAEC and increased interval between HAEC episodes requiring inpatient treatment. Scheduling outpatient BT injections to manage obstructive symptoms may be beneficial after pull-through for HSCR.
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Affiliation(s)
| | - Kayla Briggs
- Department of Surgery, Children's Mercy Hospital; Kansas City, Missouri
| | - James A Fraser
- Department of Surgery, Children's Mercy Hospital; Kansas City, Missouri
| | - Joseph Lopez
- Department of Surgery, Children's Mercy Hospital; Kansas City, Missouri
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Hospital; Kansas City, Missouri; University of Missouri-Kansas City School of Medicine; Kansas City, Missouri
| | - David Juang
- Department of Surgery, Children's Mercy Hospital; Kansas City, Missouri; University of Missouri-Kansas City School of Medicine; Kansas City, Missouri
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy Hospital; Kansas City, Missouri; University of Missouri-Kansas City School of Medicine; Kansas City, Missouri
| | - Richard J Hendrickson
- Department of Surgery, Children's Mercy Hospital; Kansas City, Missouri; University of Missouri-Kansas City School of Medicine; Kansas City, Missouri
| | - Charles L Snyder
- Department of Surgery, Children's Mercy Hospital; Kansas City, Missouri; University of Missouri-Kansas City School of Medicine; Kansas City, Missouri
| | - Tolulope A Oyetunji
- Department of Surgery, Children's Mercy Hospital; Kansas City, Missouri; University of Missouri-Kansas City School of Medicine; Kansas City, Missouri
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital; Kansas City, Missouri; University of Missouri-Kansas City School of Medicine; Kansas City, Missouri
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital; Kansas City, Missouri; University of Missouri-Kansas City School of Medicine; Kansas City, Missouri.
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Lopez JJ, Svetanoff WJ, Rosen JM, Carrasco A, Rentea RM. Leveraging Collaboration in Pediatric Multidisciplinary Colorectal Care Using a Telehealth Platform. Am Surg 2021; 88:2320-2326. [PMID: 34105388 DOI: 10.1177/00031348211023428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE Pediatric colorectal problems often require complex multidisciplinary care (MDC), which has been affected by the SARS-CoV-2-2019 (COVID-19) pandemic. We describe our utilization and implementation of telehealth (TH) for pediatric colorectal surgery MDC visits and collate patient satisfaction using TH compared to in-person (IP) visits. METHODS Implementation of a single-institution MDC TH platform to perform patient visits on February 1, 2020 was studied. Following 6 months of implementation, TH visits' characteristics were compared with IP visits in the 3 months before implementation by patient volume, length of clinic visits, and patient satisfaction survey results. RESULTS Before implementation, 152 (100%) of clinic visits were IP. During the implementation, 87 (37.7%) were TH visits. Seventy-four (49%) were MDC visits, 17 (23%) of these using the TH platform. Each TH visit's median length was 25 minutes (IQR 15-30), while the median length of IP visits was 45 minutes (IQR 30-45). Pre-implementation satisfaction scores were 88.6% positive, while satisfaction scores after implementation were 96.8% positive. None of the patients who utilized the TH platform had an unplanned hospital admission within 24 hours of being seen. CONCLUSION Our experience demonstrates that the TH platform can provide an efficient avenue for established patients and families to receive highly complex multidisciplinary follow-up care. High levels of patient satisfaction indicated that TH should become part of the routine care plan for patients who require long-term or consistent follow-up.
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Affiliation(s)
- Joseph J Lopez
- Comprehensive Colorectal Center, 4204Children's Mercy Hospital, University of Missouri Kansas City, Kansas City, MO, USA.,Department of Pediatric Surgery, 4204Children's Mercy Hospital, University of Missouri Kansas City, Kansas City, MO, USA
| | - Wendy Jo Svetanoff
- Comprehensive Colorectal Center, 4204Children's Mercy Hospital, University of Missouri Kansas City, Kansas City, MO, USA.,Department of Pediatric Surgery, 4204Children's Mercy Hospital, University of Missouri Kansas City, Kansas City, MO, USA
| | - John M Rosen
- Department of Pediatric Gastroenterology, 4204Children's Mercy Hospital, University of Missouri Kansas City, Kansas City, MO, USA
| | - Alonso Carrasco
- Department of Pediatric Urology, 4204Children's Mercy Hospital, University of Missouri Kansas City, Kansas City, MO, USA
| | - Rebecca M Rentea
- Comprehensive Colorectal Center, 4204Children's Mercy Hospital, University of Missouri Kansas City, Kansas City, MO, USA.,Department of Pediatric Surgery, 4204Children's Mercy Hospital, University of Missouri Kansas City, Kansas City, MO, USA
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Shepherd C, Cookson M, Shore N. The Growth of Integrated Care Models in Urology. Urol Clin North Am 2021; 48:223-232. [PMID: 33795056 DOI: 10.1016/j.ucl.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
With heightened awareness of health care outcomes and efficiencies and reimbursement-based metrics, it is ever more important that urologists consider the effects of integrated care models on physicians/staff/clinics fulfillment and patient outcomes, and whether and how to optimally implement these models within their unique practice settings. Despite growing evidence that integrating care improves outcomes, uncertainty persists regarding which approach is most efficient and achievable in terms of specialty considerations and financial resources. In this article, we discuss strategies for integrating urologic care and its impact on current and future health care delivery.
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Affiliation(s)
- Caitlin Shepherd
- University of Oklahoma, 920 Stanton L. Young Boulevard, WP 2140, Oklahoma City, OK 73104, USA.
| | - Michael Cookson
- Department of Urology, University of Oklahoma, 920 Stanton L. Young Boulevard, WP 2140, Oklahoma City, OK, USA
| | - Neal Shore
- CPI, Carolina Research Center, 823 82nd Parkway, Myrtle Beach, SC 29572, USA
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