Evaluation of Barriers to Telehealth Programs and Dermatological Care for American Indian Individuals in Rural Communities

Patient Learning Pathway: Identifying Patient Competencies in Teledermatology for Effective Management of Dermatological Conditions

BACKGROUND

Dermatology consultations in Québec, Canada, face accessibility challenges, with most dermatologists concentrated in urban areas. Teledermatology, offering remote diagnosis and treatment, holds promise in overcoming these limitations. However, concerns regarding patient-doctor relationships and logistical issues exist.

OBJECTIVES

This article aims to introduce a dermatology patient learning pathway (PLP) developed by the Centre of Excellence on Partnership with Patients and the Public (CEPPP), focusing on knowledge, abilities, and skills mobilized by patients and their loved ones at key moments of the life course with an illness, as well as emerging educational needs.

METHODS

The PLP development was co-developed with dermatology patient and caregiver partners, stakeholders, and the CEPPP team. The process encompassed stakeholder engagement, exploration, recruitment of patient and caregiver partners, co-development of the PLP draft, and validation through consensus building.

RESULTS

The PLP methodology led to the creation of 44 learning objectives, comprising a total of 107 subobjectives. These objectives were organized into 8 phases of the patient life course with a dermatological condition: (1) prevention and predisposition; (2) discovery, self-examination, or observation of a change; (3) first consultation; (4) wandering; (5) consultation with a dermatologist; (6) diagnosis; (7) treatments; and (8) living with it.

CONCLUSIONS

The dermatology PLP serves as a resource outlining patient competency across different stages of managing a dermatological condition throughout their life course. In the context of teledermatology, the PLP might facilitate patient and caregiver engagement by helping select appropriate information and tools to support active participation in care.

Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE- and Institute of Medicine-based recommendations

BACKGROUND

Guidance addressing atopic dermatitis (AD) management, last issued in 2012 by the American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force, requires updating as a result of new treatments and improved guideline and evidence synthesis methodology.

OBJECTIVE

To produce evidence-based guidelines that support patients, clinicians, and other decision-makers in the optimal treatment of AD.

METHODS

A multidisciplinary guideline panel consisting of patients and caregivers, AD experts (dermatology and allergy/immunology), primary care practitioners (family medicine, pediatrics, internal medicine), and allied health professionals (psychology, pharmacy, nursing) convened, prioritized equity, diversity, and inclusiveness, and implemented management strategies to minimize influence of conflicts of interest. The Evidence in Allergy Group supported guideline development by performing systematic evidence reviews, facilitating guideline processes, and holding focus groups with patient and family partners. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach informed rating the certainty of evidence and strength of recommendations. Evidence-to-decision frameworks, subjected to public comment, translated evidence to recommendations using trustworthy guideline principles.

RESULTS

The panel agreed on 25 recommendations to gain and maintain control of AD for patients with mild, moderate, and severe AD. The eAppendix provides practical information and implementation considerations in 1-2 page patient-friendly handouts.

CONCLUSION

These evidence-based recommendations address optimal use of (1) topical treatments (barrier moisturization devices, corticosteroids, calcineurin inhibitors, PDE4 inhibitors [crisaborole], topical JAK inhibitors, occlusive [wet wrap] therapy, adjunctive antimicrobials, application frequency, maintenance therapy), (2) dilute bleach baths, (3) dietary avoidance/elimination, (4) allergen immunotherapy, and (5) systemic treatments (biologics/monoclonal antibodies, small molecule immunosuppressants [cyclosporine, methotrexate, azathioprine, mycophenolate, JAK inhibitors], and systemic corticosteroids) and UV phototherapy (light therapy).

The Social and Home Environment: Impacts of Determinants of Health on Atopic Dermatitis, Pathways Toward Solutions, and Unique Considerations for Rural and Remote North American Indigenous Populations

Disparities in environmental and social determinants of health (DOH) are associated with morbidity in atopic dermatitis (AD). The socioecological model (SEM) is a framework that can be applied to better understand how such DOH impacts patients with AD. We include a case scenario of a remote Indigenous patient reflective of real-world situations of living with AD and examine relevant impact, gaps in knowledge, and further research needs. This review highlights a variety of social and environmental exposures as important DOH which must be addressed to achieve optimal management in AD. The "rainbow model" is a modified framework to help illustrate how complex environmental and social forces impact both AD presentation and therapeutic success. However, practical applications and outcome metrics for health promotion are limited. An inter- and transdisciplinary approach is paramount to address the complex challenges associated with AD care, as well as multistakeholder approach integrating culturally-competent equitable health frameworks. This review underscores the importance of expanding the focus of AD management beyond basic science and clinical trials to recognize and address health disparities and to promote optimal health and well-being in patients with AD, and contributes a working approach to mapping the complex interventions and patient-oriented research needed using a focus on remote North American Indigenous patients affected by AD.

The benefit of early-stage diagnosis: A registry-based survey evaluating the quality of life in patients with melanoma

Background

The morbidity associated with advanced stage melanoma is an important consideration in the dialog surrounding early detection and overdiagnosis. Few studies have stratified melanoma patient quality of life (QoL) by stage at diagnosis.

Objective

We sought to investigate if melanoma stage is independently associated with changes in QoL within a large, community-based melanoma registry. Secondarily, we investigated whether demographic factors such as age, geographic location or level of education are associated with changes in QoL in the same population.

Methods

1108 melanoma patients were surveyed over a three-month period using the QoL in Adult Cancer Survivors Survey, consisting of 47 items on a 7-point frequency scale. Data were analysed using both descriptive statistical models and adjusted multivariate logistic regression.

Results

There were 677 respondents generating a 61% response rate. Overall, higher stage at diagnosis correlated with the largest decreases in QoL as it pertained to both general (p = 0.001) and Cancer-Specific stressors (p < 0.001). Education level (p = 0.020), age (p < 0.001), rural area code designation (p = 0.020) and family history of melanoma (p = 0.017) were also independently associated with changes in QoL.

Conclusion

Earlier stage at melanoma diagnosis is associated with better QoL and thus represents a crucial intervention in patient care. Given our findings and the growing body of evidence surrounding morbidity in late-stage melanoma, it is essential that QoL be included in assessing the benefits of early detection.

Scoping review of telehealth use by Indigenous populations from Australia, Canada, New Zealand, and the United States

INTRODUCTION

Telehealth has the potential to address health disparities experienced by Indigenous people, especially in remote areas. This scoping review aims to map and characterize the existing evidence on telehealth use by Indigenous people and explore the key concepts for effective use, cultural safety, and building therapeutic relationships.

METHODS

A search for published and gray literature, written in English, and published between 2000 and 2022 was completed in 17 electronic databases. Two reviewers independently screened retrieved records for eligibility. For included articles, data were extracted, categorized, and analyzed. Synthesis of findings was performed narratively.

RESULTS

A total of 321 studies were included. The most popular type of telehealth used was mHealth (44%), and the most common health focuses of the telehealth interventions were mental health (26%) and diabetes/diabetic retinopathy (13%). Frequently described barriers to effective telehealth use included concerns about privacy/confidentiality and limited internet availability; meanwhile, telehealth-usage facilitators included cultural relevance and community engagement. Although working in collaboration with Indigenous communities was the most frequently reported way to achieve cultural safety, 40% of the studies did not report Indigenous involvement. Finally, difficulty to establish trusting therapeutic relationships was a major concern raised about telehealth, and evidence suggests that having the first visit-in-person is a potential way to address this issue.

CONCLUSION

This comprehensive review identified critical factors to guide the development of culturally-informed telehealth services to meet the needs of Indigenous people and to achieve equitable access and positive health outcomes.

Dropout Rate in Digital Health Interventions for the Prevention of Skin Cancer: Systematic Review, Meta-analysis, and Metaregression

BACKGROUND

Digital strategies are innovative approaches to the prevention of skin cancer, but the attrition following this kind of intervention needs to be analyzed.

OBJECTIVE

The aim of this paper is to assess the dropouts from studies focused on digital strategies for the prevention of skin cancer.

METHODS

We conducted this systematic review with meta-analyses and metaregression according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statements. Search terms for skin cancer, digital strategies, and prevention were combined to search PubMed, Scopus, Web of Science, CINAHL, and Cochrane Library from inception until July 2022. Randomized clinical trials that reported dropouts of participants and compared digital strategies with other interventions to prevent skin cancer in healthy or disease-free participants were included. Two independent reviewers extracted data for analysis. The Revised Cochrane Collaboration Bias tool was employed. We calculated the pooled dropout rate of participants through a meta-analysis of proportions and examined whether dropout was more or less frequent in digital interventions against comparators via an odds ratio (OR) meta-analysis. Data were pooled using a random-effects model. Subgroup meta-analyses were conducted in a meta-analysis of proportions and OR meta-analysis to assess the dropout events when data were sorted by digital interventions or control comparator. A univariate metaregression based on a random-effects model assessed possible moderators of dropout. Participants' dropout rates as pooled proportions were calculated for all groups combined, and the digital and comparator groups separately. OR>1 indicated higher dropouts for digital-based interventions. Metaregressions were performed for age, sex, length of intervention, and sample size.

RESULTS

A total of 17 studies were included. The overall pooled dropout rate was 9.5% (95% CI 5.0-17.5). The subgroup meta-analysis of proportions revealed a dropout rate of 11.6% for digital strategies (95% CI 6.8-19.0) and 10.0% for comparators (95% CI 5.5-17.7). A trend of higher dropout rates for digital strategies was observed in the overall (OR 1.16, 95% CI 0.98-1.36) and subgroup OR meta-analysis, but no significant differences were found between the groups. None of the covariates moderated the effect size in the univariate metaregression.

CONCLUSIONS

Digital strategies had a higher dropout rate compared to other prevention interventions, but the difference was not significant. Standardization is needed regarding reporting the number of and reasons for dropouts.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) CRD42022329669; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=329669.

Teledermatology in Rural, Underserved, and Isolated Environments: A Review

Purpose of Review

Recent Findings

Summary

Cancer Screening Among Rural and Urban Clinics During COVID-19: A Multistate Qualitative Study

PURPOSE

The effects of COVID-19 have been understudied in rural areas. This study sought to (1) identify cancer screening barriers and facilitators during the pandemic in rural and urban primary care practices, (2) describe implementation strategies to support cancer screening, and (3) provide recommendations.

METHODS

A qualitative study was conducted (N = 42) with primary care staff across 20 sites. Individual interviews were conducted through videoconference from August 2020 to April 2021 and recorded, transcribed, and analyzed using deductive and inductive coding (hybrid approach) in NVivo 12 Plus. Practices included federally qualified health centers, tribal health centers, rural health clinics, hospital/health system-owned clinics, and academic medical centers across 10 states including urban (55%) and rural (45%) sites. Staff included individuals serving in the dual role of health care provider and administrator (21.4%), health care administrator (23.8%), physician (19.0%), advanced practice provider (11.9%), or resident (23.8%). The interviews assessed perceptions about cancer screening barriers and facilitators, implementation strategies, and future recommendations.

RESULTS

Participants reported multilevel barriers to cancer screening including policy-level (eg, elective procedure delays), organizational (eg, backlogs), and individual (eg, patient cancellation). Several facilitators to screening were noted, such as home-based testing, using telehealth, and strong partnerships with referral sites. Practices used strategies to encourage screening, such as incentivizing patients and providers and expanding outreach. Rural clinics reported challenges with backlogs, staffing, telehealth implementation, and patient outreach.

CONCLUSION

Primary care staff used innovative strategies during the pandemic to promote cancer screening. Unresolved challenges (eg, backlogs and inability to implement telehealth) disproportionately affected rural clinics.

Application and implementation of telehealth services designed for the elderly population during the COVID-19 pandemic: A systematic review

BACKGROUND

Telehealth has many benefits, in routine care and especially during times of epidemics in which restrictions to direct patient/healthcare-provider interaction exist.

OBJECTIVE

To explore the availability, application, and implementation of telehealth services during the Covid-19 era, designed for the aged population (age 65 and more).

METHODS

This systematic review/analysis was conducted by searching the most popular databases including PubMed, Embase, and Web of Science. We included studies that clearly defined any use of telemedicine services in any aspect of healthcare during the COVID-19 pandemic, aimed at the elderly population, published in peer-reviewed journals. We independently assessed search results, extracted the relevant studies, and assessed their quality.

RESULTS

3225 articles were identified after removing duplicates. After reading the full texts of 40 articles, 11 articles were finally included. Among the telehealth services, there were services aimed for triage and control during the outbreak of the COVID-19 pandemic, remote monitoring and treatment, follow-ups online meetings for patients residing in health centers, and application of online services.

CONCLUSIONS

Although the elderly population may benefit the most from telehealth services, especially during pandemics and social distancing restrictions, not enough services were developed and implemented to satisfy the needs of this population.

Melanoma: How and When to Consider Clinical Diagnostic Technologies

In response to rising rates of melanoma worldwide, novel non-invasive melanoma detection techniques are emerging to facilitate the early detection of melanoma and decrease unnecessary biopsies of benign pigmented lesions. Because they often report similar study findings, it may be difficult to determine how best to incorporate these technologies into clinical practice based on their supporting studies alone. As an expansion of the recent article by Fried et al.¹, which reviewed the clinical data supporting these non-invasive melanoma detection techniques, the first article in this continuing medical education series provides practical advice on how and when to use various non-invasive melanoma detection techniques into clinical practice.

Atopic dermatitis and skin infections are a poorly documented crisis in Canada's Indigenous pediatric population: It's time to start the conversation

Canadian Indigenous youth continue to face higher rates of health disparities than their non-Indigenous counterparts. In dermatology, this includes a high burden of atopic dermatitis, as well as secondary skin and soft tissue infections. Unfortunately, numerous barriers to treatment exist, including systemic and institutional racism, poverty, crowded housing conditions on reserves, access and cost of basic skin care regimens, and clean water access. As per the Truth and Reconciliation Commission, Canadian dermatologists have been called upon to train more First Nations, Metis, and Inuit physicians to ensure we are providing high-quality, anti-racist, culturally appropriate care to Indigenous peoples.

Barriers to healthcare access in pediatric dermatology: A systematic review

Barriers to healthcare access are healthcare inequities that have been widely studied across different medical specialties. No studies have previously evaluated the state of barriers to healthcare access research in pediatric dermatology. A systematic review was conducted to examine the types of barriers identified within pediatric dermatology literature. Relevant information was extracted and categorized into the themes of systemic, sociocultural, or individual barriers. The systemic barriers we found include finances, wait times, and geography. The sociocultural barriers included culture beliefs and communication. Patient beliefs and health knowledge were found as individual barriers. The small number and limited scope of studies we identified suggest that barriers to healthcare access in pediatric dermatology remain an understudied topic. Additional research is needed to further characterize these barriers to dermatologic care, as well as the impact of any interventions designed to overcome them.

Challenges faced by doctors and nurses in wound care management during the COVID-19 pandemic in Turkey and their views on telehealth

Aim

This study aimed to determine the problems faced by physicians and nurses dealing with chronic wound care during the COVID-19 pandemic and their views on telehealth.

Materials and methods

A descriptive and cross-sectional design was used in this study. The sample comprised physicians (n = 74) and nurses (n = 271) interested in chronic wound care. Data were collected through a questionnaire form consisting of open- and closed-ended questions.

Results

Of the participants, 21.4% (n = 74) were physicians and 78.6% (n = 271) were nurses. Of the physicians, 45.9% (n = 34) were obliged to work in another unit during the COVID-19 period, while 43.2% continued their service related to chronic wound care, and only 17.0% (n = 18) in the wound care service before the pandemic. These rates are 51.3% (n = 139), 51.6% (n = 157) and 36.8% (n = 128) for nurses, respectively. 40.7% of the physicians (n = 33) and 34.9% of the nurses (n = 106) stated that their time had been reduced for chronic wound care. When the telehealth experiences were examined, 32.4% (n = 24) of the physicians utilized telehealth, 29.7% (n = 22) used e-visit, 77.0% (n = 57) stated that they thought telehealth was a good option, 47.3% (n = 35) utilized it for wound evaluation and treatment, and 31.9% (n = 59) used smart phones. These rates for nurses were 16.6% (n = 45), 14.0% (n = 38), 72.7% (n = 197), 33.9% (n = 92), and 27.0% (n = 182), respectively.

Conclusions

The COVID-19 pandemic negatively affected the manner of delivery, duration, and quality of service regarding wound management. During this period, face-to-face contact times with patients were reduced, some diagnosis and treatment attempts were not performed, and wound care services were suspended temporarily or permanently. On the other hand, a positive result was achieved in that the physicians and nurses gave positive feedback for the telehealth experience.

Use of Video Telehealth Tablets to Increase Access for Veterans Experiencing Homelessness

BACKGROUND

Veterans experiencing homelessness face substantial barriers to accessing health and social services. In 2016, the Veterans Affairs (VA) healthcare system launched a unique program to distribute video-enabled tablets to Veterans with access barriers.

OBJECTIVE

Evaluate the use of VA-issued video telehealth tablets among Veterans experiencing homelessness in the VA system.

DESIGN

Guided by the RE-AIM framework, we first evaluated the adoption of tablets among Veterans experiencing homelessness and housed Veterans. We then analyzed health record and tablet utilization data to compare characteristics of both subpopulations, and used multivariable logistic regression to identify factors associated with tablet use among Veterans experiencing homelessness.

PATIENTS

In total, 12,148 VA patients receiving tablets between October 2017 and March 2019, focusing on the 1470 VA Veterans experiencing homelessness receiving tablets (12.1%).

MAIN MEASURES

Tablet use within 6 months of receipt for mental health, primary or specialty care.

KEY RESULTS

Nearly half (45.9%) of Veterans experiencing homelessness who received a tablet had a video visit within 6 months of receipt, most frequently for telemental health. Tablet use was more common among Veterans experiencing homelessness who were younger (AOR = 2.77; P <.001); middle-aged (AOR = 2.28; P <.001); in rural settings (AOR = 1.46; P =.005); and those with post-traumatic stress disorder (AOR = 1.64; P <.001), and less common among those who were Black (AOR = 0.43; P <.001) and those with a substance use disorder (AOR = 0.59; P <.001) or persistent housing instability (AOR = 0.75; P = .023).

CONCLUSIONS

Telehealth care and connection for vulnerable populations are particularly salient during the COVID-19 pandemic but also beyond. VA's distribution of video telehealth tablets offers healthcare access to Veterans experiencing homelessness; however, barriers remain for subpopulations. Tailored training and support for these patients may be needed to optimize telehealth tablet use and effectiveness.

Teledermatology Addressing Disparities in Health Care Access: a Review

Purpose of Review

Dermatologists have been at the forefront of researching telemedicine to expand access to care. The current COVID-19 pandemic has prompted even greater expansion and implementation of teledermatology. This review discusses the research examining the potential impact of teledermatology addressing disparities in care.

Recent Findings

Teledermatology appears to increase access to dermatology given expanded means to deliver care. Specifically, recent studies have found increased access among Medicaid-insured, resource-poor urban and rural, and elderly populations. Teledermatology implementation also facilitates education among providers at different levels of training. Still, as some patients have inconsistent access to the required technology, increased reliance on telemedicine may also potentially increase disparities for some populations.

Summary

Teledermatology may serve to reduce disparities in health care access in many underserved and marginalized communities. Future research should continue to study implementation, especially given the expansion during the COVID-19 pandemic. Ultimately, teledermatology may play an important role in ensuring equitable care access for all.

The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence

BACKGROUND

The outbreak of coronavirus disease-19 (COVID-19) is a public health emergency of international concern. Telehealth is an effective option to fight the outbreak of COVID-19. The aim of this systematic review was to identify the role of telehealth services in preventing, diagnosing, treating, and controlling diseases during COVID-19 outbreak.

METHODS

This systematic review was conducted through searching five databases including PubMed, Scopus, Embase, Web of Science, and Science Direct. Inclusion criteria included studies clearly defining any use of telehealth services in all aspects of health care during COVID-19 outbreak, published from December 31, 2019, written in English language and published in peer reviewed journals. Two reviewers independently assessed search results, extracted data, and assessed the quality of the included studies. Quality assessment was based on the Critical Appraisal Skills Program (CASP) checklist. Narrative synthesis was undertaken to summarize and report the findings.

RESULTS

Eight studies met the inclusion out of the 142 search results. Currently, healthcare providers and patients who are self-isolating, telehealth is certainly appropriate in minimizing the risk of COVID-19 transmission. This solution has the potential to prevent any sort of direct physical contact, provide continuous care to the community, and finally reduce morbidity and mortality in COVID-19 outbreak.

CONCLUSIONS

The use of telehealth improves the provision of health services. Therefore, telehealth should be an important tool in caring services while keeping patients and health providers safe during COVID-19 outbreak.

Telehealth Availability in US Hospitals in the Face of the COVID-19 Pandemic

BACKGROUND

Telehealth is likely to play a crucial role in treating COVID-19 patients. However, not all US hospitals possess telehealth capabilities. This brief report was designed to explore US hospitals' readiness with respect to telehealth availability. We hope to gain deeper insight into the factors affecting possession of these valuable capabilities, and how this varies between rural and urban areas.

METHODS

Based on 2017 data from the American Hospital Association survey, Area Health Resource Files and Medicare cost reports, we used logistic regression models to identify predictors of telehealth and eICU capabilities in US hospitals.

RESULTS

We found that larger hospitals (OR(telehealth) = 1.013; P < .01) and system members (OR(telehealth) = 1.55; P < .01) (OR(eICU) = 1.65; P < .01) had higher odds of possessing telehealth and eICU capabilities. We also found evidence suggesting that telehealth and eICU capabilities are concentrated in particular regions; the West North Central region was the most likely to possess capabilities, given that these hospitals had higher odds of possessing telehealth (OR = 1.49; P < .10) and eICU capabilities (OR = 2.15; P < .05). Rural hospitals had higher odds of possessing telehealth capabilities as compared to their urban counterparts, although this relationship was marginally significant (OR = 1.34, P < .10).

CONCLUSIONS

US hospitals vary in their preparation to use telehealth to aid in the COVID-19 battle, among other issues. Hospitals' odds of possessing the capability to provide such services vary largely by region; overall, rural hospitals have more widespread telehealth capabilities than urban hospitals. There is still great potential to expand these capabilities further, especially in areas that have been hard hit by COVID-19.

Clinical effectiveness and cost-effectiveness of teledermatology: Where are we now, and what are the barriers to adoption?

There has been rapid growth in teledermatology over the past decade, and teledermatology services are increasingly being used to support patient care across a variety of care settings. Teledermatology has the potential to increase access to high-quality dermatologic care while maintaining clinical efficacy and cost-effectiveness. Recent expansions in telemedicine reimbursement from the Centers for Medicare & Medicaid Services (CMS) ensure that teledermatology will play an increasingly prominent role in patient care. Therefore, it is important that dermatologists be well informed of both the promises of teledermatology and the potential practice challenges a continuously evolving mode of care delivery brings. In this article, we will review the evidence on the clinical and cost-effectiveness of teledermatology and we will discuss system-level and practice-level barriers to successful teledermatology implementation as well as potential implications for dermatologists.