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Brainard J, Crawford A, Wright B, Lim M, Everden P. Retaining dermatology patients in primary care through dialogue with secondary care providers: A service evaluation. Ann Dermatol Venereol 2024; 151:103248. [PMID: 38513422 DOI: 10.1016/j.annder.2024.103248] [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: 03/30/2023] [Revised: 06/28/2023] [Accepted: 11/07/2023] [Indexed: 03/23/2024]
Abstract
BACKGROUND There are long patient waiting lists for specialist care. A dermatology dialogue service between primary and secondary care (DDPS) was developed in eastern England. Primary care referrers uploaded patient images of skin conditions for review by and dialogue with consultant dermatologists in an attempt to retain patients in primary care rather than refer them to secondary care. METHODS Evaluation of service performance against specific targets, including reduction in secondary care waiting list growth over the period April 2021-March 2022 inclusive. Service activity was summarized in terms of speed of resolution, case numbers, and dispositions. Clinician and patient satisfaction were assessed using structured questionnaires. Actual numbers of new referrals were compared to projections based on historical data. Waiting list growth was compared to other specialties and other commissioning areas. Waiting times to initial treatment were monitored. RESULTS Over 3300 patients were enrolled and > 90% of dialogues were resolved within 36 hours. Clinician and patient satisfaction were high. Frequently asked questions and conditions were highlighted by dermatologists to design and deliver an educational event for primary care clinicians that was well received. Waiting list growth for dermatology patients in the commissioning area was smaller than for other major specialties, and generally smaller than growth for dermatology waiting lists commissioned by other NHS commissioners. There was no negative impact on the urgent priority (cancer pathway) waiting list. CONCLUSION The DDPS was satisfactory for clinicians and patients and coincided with lower growth in dermatology waiting lists than might otherwise have been expected.
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Affiliation(s)
- J Brainard
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, United Kingdom.
| | - A Crawford
- North Norfolk Primary Care, 4 Alkmaar Way, Norwich NR6 6BF, United Kingdom
| | - B Wright
- North Bristol NHS Trust, Southmead Road, Westbury-on-Trym, Bristol BS10 5NB, United Kingdom
| | - M Lim
- Norfolk and Waveney Integrated Care Board, County Hall, Martineau Lane, Norwich NR1 2DL, United Kingdom
| | - P Everden
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, United Kingdom; North Norfolk Primary Care, 4 Alkmaar Way, Norwich NR6 6BF, United Kingdom
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2
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Kling SMR, Saliba-Gustafsson EA, Winget M, Aleshin MA, Garvert DW, Amano A, Brown-Johnson CG, Kwong BY, Calugar A, El-Banna G, Shaw JG, Asch SM, Ko JM. Teledermatology to Facilitate Patient Care Transitions from Inpatient to Outpatient Dermatology: a Mixed Methods Evaluation (Preprint). J Med Internet Res 2022; 24:e38792. [PMID: 35921146 PMCID: PMC9386584 DOI: 10.2196/38792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/14/2022] [Accepted: 06/21/2022] [Indexed: 01/26/2023] Open
Abstract
Background Both clinicians and patients have increasingly turned to telemedicine to improve care access, even in physical examination–dependent specialties such as dermatology. However, little is known about whether teledermatology supports effective and timely transitions from inpatient to outpatient care, which is a common care coordination gap. Objective Using mixed methods, this study sought to retrospectively evaluate how teledermatology affected clinic capacity, scheduling efficiency, and timeliness of follow-up care for patients transitioning from inpatient to outpatient dermatology care. Methods Patient-level encounter scheduling data were used to compare the number and proportion of patients who were scheduled and received in-clinic or video dermatology follow-ups within 14 and 90 days after discharge across 3 phases: June to September 2019 (before teledermatology), June to September 2020 (early teledermatology), and February to May 2021 (sustained teledermatology). The time from discharge to scheduling and completion of patient follow-up visits for each care modality was also compared. Dermatology clinicians and schedulers were also interviewed between April and May 2021 to assess their perceptions of teledermatology for postdischarge patients. Results More patients completed follow-up within 90 days after discharge during early (n=101) and sustained (n=100) teledermatology use than at baseline (n=74). Thus, the clinic’s capacity to provide follow-up to patients transitioning from inpatient increased from baseline by 36% in the early (101 from 74) and sustained (100 from 74) teledermatology periods. During early teledermatology use, 61.4% (62/101) of the follow-ups were conducted via video. This decreased significantly to 47% (47/100) in the following year, when COVID-19–related restrictions started to lift (P=.04), indicating more targeted but still substantial use. The proportion of patients who were followed up within the recommended 14 days after discharge did not differ significantly between video and in-clinic visits during the early (33/62, 53% vs 15/39, 38%; P=.15) or sustained (26/53, 60% vs 28/47, 49%; P=.29) teledermatology periods. Interviewees agreed that teledermatology would continue to be offered. Most considered postdischarge follow-up patients to be ideal candidates for teledermatology as they had undergone a recent in-person assessment and might have difficulty attending in-clinic visits because of competing health priorities. Some reported patients needing technological support. Ultimately, most agreed that the choice of follow-up care modality should be the patient’s own. Conclusions Teledermatology could be an important tool for maintaining accessible, flexible, and convenient care for recently discharged patients needing follow-up care. Teledermatology increased clinic capacity, even during the pandemic, although the timeliness of care transitions did not improve. Ultimately, the care modality should be determined through communication with patients to incorporate their and their caregivers’ preferences.
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Affiliation(s)
- Samantha M R Kling
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Erika A Saliba-Gustafsson
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Marcy Winget
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Maria A Aleshin
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA, United States
| | - Donn W Garvert
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Alexis Amano
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Cati G Brown-Johnson
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Bernice Y Kwong
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA, United States
| | - Ana Calugar
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA, United States
| | - Ghida El-Banna
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA, United States
| | - Jonathan G Shaw
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Steven M Asch
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
- Center for Innovation to Implementation (Ci2i), Veterans Affairs Palo Alto Heath Care System, Menlo Park, CA, United States
| | - Justin M Ko
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA, United States
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On the timing and probability of Presurgical Teledermatology: how it becomes the dominant strategy. Health Care Manag Sci 2022; 25:389-405. [PMID: 35040019 DOI: 10.1007/s10729-021-09574-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/14/2021] [Indexed: 11/04/2022]
Abstract
Health level fluctuations make the outcome of any treatment option uncertain, so that decision-makers might have to wait for more information before optimally choosing treatments, especially when time spent in treatment cannot be fully recovered later in terms of health outcome. To examine whether or not, and when decision-makers should use presurgical teledermatology, a dynamic stochastic model is applied to patients waiting for dermatology surgical intervention. The theoretical model suggests that health uncertainty discourages using teledermatology. As teledermatology becomes less cost competitive, the uncertainty becomes more dominant. The results of the model were then tested empirically with the teledermatology network covering the area served by one Portuguese regional hospital, which links the primary care centers of 24 health districts with the hospital's dermatology department via the corporate intranet of the Portuguese healthcare system. Under uncertainty and irreversibility, presurgical teledermatology becomes the dominant strategy for younger patients and with lower probability of developing skin cancer.
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Zakaria A, Maurer T, Amerson E. Impact of Teledermatology Program on Dermatology Resident Experience and Education. Telemed J E Health 2021; 27:1062-1067. [DOI: 10.1089/tmj.2020.0350] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Adam Zakaria
- University of California, San Francisco (UCSF) School of Medicine, San Francisco, California, USA
| | - Toby Maurer
- Department of Dermatology, Indiana University, Indianapolis, Indiana, USA
| | - Erin Amerson
- Department of Dermatology, University of California, San Francisco (UCSF) School of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
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Teledermatology Addressing Disparities in Health Care Access: a Review. CURRENT DERMATOLOGY REPORTS 2021; 10:40-47. [PMID: 33747638 PMCID: PMC7953516 DOI: 10.1007/s13671-021-00329-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2021] [Indexed: 11/09/2022]
Abstract
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.
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Zakaria A, Miclau TA, Maurer T, Leslie KS, Amerson E. Cost Minimization Analysis of a Teledermatology Triage System in a Managed Care Setting. JAMA Dermatol 2021; 157:52-58. [PMID: 33206146 PMCID: PMC7675221 DOI: 10.1001/jamadermatol.2020.4066] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 09/19/2020] [Indexed: 11/14/2022]
Abstract
Importance Teledermatology (TD) enables remote triage and management of dermatology patients. Previous analyses of TD systems have demonstrated improved access to care but an inconsistent fiscal impact. Objective To compare the organizationwide cost of managing newly referred dermatology patients within a TD triage system vs a conventional dermatology care model at the Zuckerberg San Francisco General Hospital and Trauma Center (hereafter referred to as the ZSFG) in California. Design, Setting, and Participants A retrospective cost minimization analysis was conducted of 2098 patients referred to the dermatology department at the ZSFG between June 1 and December 31, 2017. Intervention Implementation of the TD triage system in January 2015. Main Outcomes and Measures The main outcome was mean cost to the health care organization to manage newly referred dermatology patients with or without TD triage. To estimate costs, decision-tree models were constructed to characterize possible care paths with TD triage and within a conventional dermatology care model. Costs associated with primary care visits, dermatology visits, and TD visits were then applied to the decision-tree models to estimate the mean cost of managing patients following each care path for 6 months. The mean cost for each visit type incorporated personnel costs, with the mean cost per TD consultation also incorporating software implementation and maintenance costs. Finally, ZSFG patient data were applied within the models to evaluate branch probabilities, enabling calculation of mean cost per patient within each model. Results The analysis captured 2098 patients (1154 men [55.0%]; mean [SD] age, 53.4 [16.8] years), with 1099 (52.4%) having Medi-Cal insurance and 879 (41.9%) identifying as non-White. In the decision-tree model with TD triage, the mean (SD) cost per patient to the health care organization was $559.84 ($319.29). In the decision-tree model for conventional dermatology care, the mean (SD) cost per patient was $699.96 ($390.24). Therefore, the TD model demonstrated a statistically significant mean (SE) cost savings of $140.12 ($11.01) per patient. Given an annual dermatology referral volume of 3150 patients, the analysis estimates an annual savings of $441 378. Conclusions and Relevance Implementation of a TD triage system within the dermatology department at the ZSFG was associated with cost savings, suggesting that managed health care settings may experience significant cost savings from using TD to triage and manage patients.
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Affiliation(s)
- Adam Zakaria
- Department of Dermatology, University of California, San Francisco School of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco
| | - Theodore A. Miclau
- Department of Dermatology, University of California, San Francisco School of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Toby Maurer
- Department of Dermatology, Indiana University, Indianapolis
| | - Kieron S. Leslie
- Department of Dermatology, University of California, San Francisco School of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco
| | - Erin Amerson
- Department of Dermatology, University of California, San Francisco School of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco
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Omara S, Wen D, Ng B, Anand R, Matin RN, Taghipour K, Esdaile B. Identification of Incidental Skin Cancers Among Adults Referred to Dermatologists for Suspicious Skin Lesions. JAMA Netw Open 2020; 3:e2030107. [PMID: 33326027 PMCID: PMC7745102 DOI: 10.1001/jamanetworkopen.2020.30107] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The incidence of skin cancer is increasing and evaluation of the utility of total body skin examination (TBSE) in detecting incidental skin cancers is warranted. OBJECTIVES To evaluate the proportion and rate of incidental skin cancer detection in urgent skin cancer clinics and investigate the rate of incidental skin cancer detection in 2 groups based on the degree of clinical suspicion of the index lesion for malignancy. DESIGN, SETTING, AND PARTICIPANTS A multicenter retrospective cohort study with a case note review of consecutive secondary care consultations was conducted using data from 2 urgent suspected skin cancer screening clinics in UK National Health Service trusts. The study was performed from January 1, 2015, to March 31, 2016, and data analysis was performed from October 14, 2018, to February 1, 2019. Patients included those presenting with a skin lesion suspicious of malignancy who were referred to the urgent suspected skin cancer clinic (N = 5944) over 15 months. Patients who accepted and received a TBSE were subsequently included in the analysis. MAIN OUTCOMES AND MEASURES The proportion and rate of incidental skin cancer detection through TBSE and whether a clinically suspicious (malignant) index lesion was associated with a higher chance of having a malignant incidental lesion. RESULTS Of the 5944 patients referred to the clinic, 4726 individuals (79.5%) were evaluated. In the cohort included in the analyses, the median age was 57 years (interquartile range, 39-73 years); 2567 patients (54.3%) were women. A total of 1117 skin cancers were identified; of these, 242 lesions (21.7%) were detected incidentally through TBSE, including 197 of 570 (34.6%) basal cell carcinomas, 16 of 250 (6.4%) squamous cell carcinomas, and 25 of 215 (11.6%) melanomas. The detection rate of incidental malignant lesions was 5.1 lesions per 100 patients examined (5.1%; 95% CI, 4.5%-5.8%). There was a higher detection rate of histologically confirmed incidental malignant lesions in individuals with clinically suspicious index lesions requiring biopsy (10.9%; 95% CI, 9.5%-12.5%) compared with those presenting with clinically benign index lesions (2.0%; 95% CI, 1.6%-2.5%) (P < .001). CONCLUSIONS AND RELEVANCE The findings of this study support the use of TBSE for urgent skin cancer referrals, highlighting the potential harms of solitary lesion assessment in a subgroup. Individuals presenting with a clinically suspicious index lesion requiring biopsy are most likely to benefit from TBSE and should be counseled regarding the benefit.
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Affiliation(s)
- Sharif Omara
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef, Leiden, the Netherlands
| | - David Wen
- Department of Dermatology, Oxford University Hospitals National Health Service Foundation Trust, Churchill Hospital, Headington, Oxford, United Kingdom
| | - Benjamin Ng
- Department of Dermatology, Oxford University Hospitals National Health Service Foundation Trust, Churchill Hospital, Headington, Oxford, United Kingdom
| | - Rakesh Anand
- Department of Dermatology, Whittington Health National Health Service Foundation Trust, London, United Kingdom
| | - Rubeta N. Matin
- Department of Dermatology, Oxford University Hospitals National Health Service Foundation Trust, Churchill Hospital, Headington, Oxford, United Kingdom
| | - Kathy Taghipour
- Department of Dermatology, Whittington Health National Health Service Foundation Trust, London, United Kingdom
| | - Ben Esdaile
- Department of Dermatology, Whittington Health National Health Service Foundation Trust, London, United Kingdom
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Jew OS, Murthy AS, Danley K, McMahon PJ. Implementation of a pediatric provider-to-provider store-and-forward teledermatology system: Effectiveness, feasibility, and acceptability in a pilot study. Pediatr Dermatol 2020; 37:1106-1112. [PMID: 32869352 DOI: 10.1111/pde.14226] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND/OBJECTIVES Long wait times for in-person appointments in pediatric dermatology can lead to delays in specialty care, additional health system touchpoints, patient and family dissatisfaction, poorer outcomes, and increased overall health care costs. Store-and-forward teledermatology may address these challenges and improve access to care in pediatric dermatology. METHODS We describe a prospective, non-blinded cohort study with follow-up surveys conducted from March 1, 2018, to September 20, 2018. The study was conducted at a single center, in primary care and specialist settings. Patients included were <18 years old and received care at one of our affiliated primary care sites. Primary care providers submitted teledermatology consultations through a shared electronic medical record. A board-certified pediatric dermatologist evaluated each consultation; primary care providers conveyed recommendations to families. RESULTS Forty-three consultations for patients (23 male, 20 female; median age: 7 years [IQR: 2.4-12]) were entered by primary care providers. Median time from consult request to dermatologist initiating consult was 12.1 hours [IQR: 1.9-18.8]; median time to complete consult note was 7 minutes [IQR: 5-10.5]. Median time from primary care provider initially consulting to conveying teledermatology recommendations to families was 3 days [IQR: 1-5]. All but one consult (42/43, 98%) were completed in the intended workflow. Follow-up in-person visits with pediatric dermatologists occurred with 10/43 (23%) patients. In follow-up surveys, parents were 83% likely to recommend the service to family and friends. All primary care providers and dermatologists felt the service improved quality of care. CONCLUSIONS Provider-to-provider teledermatology consultation appears to be a feasible and acceptable method of providing care quickly and effectively to pediatric patients.
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Affiliation(s)
- Olivia S Jew
- Section of Dermatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aditi S Murthy
- Section of Dermatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Departments of Pediatrics and Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kristen Danley
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Patrick J McMahon
- Section of Dermatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Departments of Pediatrics and Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Gonçalves-Bradley DC, J Maria AR, Ricci-Cabello I, Villanueva G, Fønhus MS, Glenton C, Lewin S, Henschke N, Buckley BS, Mehl GL, Tamrat T, Shepperd S. Mobile technologies to support healthcare provider to healthcare provider communication and management of care. Cochrane Database Syst Rev 2020; 8:CD012927. [PMID: 32813281 PMCID: PMC7437392 DOI: 10.1002/14651858.cd012927.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The widespread use of mobile technologies can potentially expand the use of telemedicine approaches to facilitate communication between healthcare providers, this might increase access to specialist advice and improve patient health outcomes. OBJECTIVES To assess the effects of mobile technologies versus usual care for supporting communication and consultations between healthcare providers on healthcare providers' performance, acceptability and satisfaction, healthcare use, patient health outcomes, acceptability and satisfaction, costs, and technical difficulties. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and three other databases from 1 January 2000 to 22 July 2019. We searched clinical trials registries, checked references of relevant systematic reviews and included studies, and contacted topic experts. SELECTION CRITERIA Randomised trials comparing mobile technologies to support healthcare provider to healthcare provider communication and consultations compared with usual care. DATA COLLECTION AND ANALYSIS We followed standard methodological procedures expected by Cochrane and EPOC. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included 19 trials (5766 participants when reported), most were conducted in high-income countries. The most frequently used mobile technology was a mobile phone, often accompanied by training if it was used to transfer digital images. Trials recruited participants with different conditions, and interventions varied in delivery, components, and frequency of contact. We judged most trials to have high risk of performance bias, and approximately half had a high risk of detection, attrition, and reporting biases. Two studies reported data on technical problems, reporting few difficulties. Mobile technologies used by primary care providers to consult with hospital specialists We assessed the certainty of evidence for this group of trials as moderate to low. Mobile technologies: - probably make little or no difference to primary care providers following guidelines for people with chronic kidney disease (CKD; 1 trial, 47 general practices, 3004 participants); - probably reduce the time between presentation and management of individuals with skin conditions, people with symptoms requiring an ultrasound, or being referred for an appointment with a specialist after attending primary care (4 trials, 656 participants); - may reduce referrals and clinic visits among people with some skin conditions, and increase the likelihood of receiving retinopathy screening among people with diabetes, or an ultrasound in those referred with symptoms (9 trials, 4810 participants when reported); - probably make little or no difference to patient-reported quality of life and health-related quality of life (2 trials, 622 participants) or to clinician-assessed clinical recovery (2 trials, 769 participants) among individuals with skin conditions; - may make little or no difference to healthcare provider (2 trials, 378 participants) or participant acceptability and satisfaction (4 trials, 972 participants) when primary care providers consult with dermatologists; - may make little or no difference for total or expected costs per participant for adults with some skin conditions or CKD (6 trials, 5423 participants). Mobile technologies used by emergency physicians to consult with hospital specialists about people attending the emergency department We assessed the certainty of evidence for this group of trials as moderate. Mobile technologies: - probably slightly reduce the consultation time between emergency physicians and hospital specialists (median difference -12 minutes, 95% CI -19 to -7; 1 trial, 345 participants); - probably reduce participants' length of stay in the emergency department by a few minutes (median difference -30 minutes, 95% CI -37 to -25; 1 trial, 345 participants). We did not identify trials that reported on providers' adherence, participants' health status and well-being, healthcare provider and participant acceptability and satisfaction, or costs. Mobile technologies used by community health workers or home-care workers to consult with clinic staff We assessed the certainty of evidence for this group of trials as moderate to low. Mobile technologies: - probably make little or no difference in the number of outpatient clinic and community nurse consultations for participants with diabetes or older individuals treated with home enteral nutrition (2 trials, 370 participants) or hospitalisation of older individuals treated with home enteral nutrition (1 trial, 188 participants); - may lead to little or no difference in mortality among people living with HIV (RR 0.82, 95% CI 0.55 to 1.22) or diabetes (RR 0.94, 95% CI 0.28 to 3.12) (2 trials, 1152 participants); - may make little or no difference to participants' disease activity or health-related quality of life in participants with rheumatoid arthritis (1 trial, 85 participants); - probably make little or no difference for participant acceptability and satisfaction for participants with diabetes and participants with rheumatoid arthritis (2 trials, 178 participants). We did not identify any trials that reported on providers' adherence, time between presentation and management, healthcare provider acceptability and satisfaction, or costs. AUTHORS' CONCLUSIONS Our confidence in the effect estimates is limited. Interventions including a mobile technology component to support healthcare provider to healthcare provider communication and management of care may reduce the time between presentation and management of the health condition when primary care providers or emergency physicians use them to consult with specialists, and may increase the likelihood of receiving a clinical examination among participants with diabetes and those who required an ultrasound. They may decrease the number of people attending primary care who are referred to secondary or tertiary care in some conditions, such as some skin conditions and CKD. There was little evidence of effects on participants' health status and well-being, satisfaction, or costs.
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Affiliation(s)
| | - Ana Rita J Maria
- Nova Medical School, Faculdade de Ciências Médicas, Lisbon, Portugal
| | - Ignacio Ricci-Cabello
- Primary Care Research Unit, Instituto de Investigación Sanitaria Illes Balears, Palma de Mallorca, Spain
| | | | | | | | - Simon Lewin
- Norwegian Institute of Public Health, Oslo, Norway
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | | | - Brian S Buckley
- Department of Surgery, University of the Philippines, Manila, Philippines
| | - Garrett L Mehl
- Department of Sexual and Reproductive Health, World Health Organization, Geneva, Switzerland
| | - Tigest Tamrat
- Department of Sexual and Reproductive Health, World Health Organization, Geneva, Switzerland
| | - Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Ford B, Keay L, Angell B, Hyams S, Mitchell P, Liew G, White A. Quality and targeting of new referrals for ocular complications of diabetes from primary care to a public hospital ophthalmology service in Western Sydney, Australia. Aust J Prim Health 2020; 26:293-299. [PMID: 32659209 DOI: 10.1071/py20084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/04/2020] [Indexed: 01/03/2023]
Abstract
Patients with diabetes require regular examination for eye disease, usually in primary care settings. Guidelines recommend patients with at least moderate non-proliferative diabetic retinopathy (NPDR) be referred to an ophthalmologist for treatment; however, poorly targeted referrals lead to access blocks. The quality of new referrals associated with diabetes to a public ophthalmology service in Sydney, New South Wales, Australia, were assessed for referral completeness and targeting. A cross-sectional audit of medical records for new patients referred to Westmead Hospital Eye Clinic in 2016 was completed. Completeness of medical and ophthalmic information in referrals and subsequent patient diagnosis and management in 2016-17 was recorded. Sub-analyses were conducted by primary care referrer type (GP or optometrist). In total, 151 new retinopathy referrals were received; 12% were sent directly to a treatment clinic. Information was incomplete for diabetes status (>60%), medical (>50%) and ophthalmic indicators (>70%), including visual acuity (>60%). GP referrals better recorded medical, and optometrists (37%) ophthalmic information, but information was still largely incomplete. Imaging was rarely included (retinal photos <1%; optical coherence tomography <3%). Median appointment wait-time was 124 days; 21% of patients received treatment (laser or anti-vascular endothelial growth factor) at this or the following encounter. Targeting referrals for ocular complication of diabetes to public hospitals needs improvement. Education, feedback and collaborative care mechanisms should be considered to improve screening and referral in primary care.
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Affiliation(s)
- Belinda Ford
- The George Institute for Global Health, UNSW Sydney, 1 King Street, Newtown, NSW 2042, Australia; and Westmead Hospital Ophthalmology Department, WSLHD, Corner Hawkesbury Road and Darcy Road, Sydney, NSW 2145, Australia; and Corresponding author.
| | - Lisa Keay
- The George Institute for Global Health, UNSW Sydney, 1 King Street, Newtown, NSW 2042, Australia; and School of Optometry and Vision Science, Faculty of Science, UNSW Sydney, Sydney, NSW 2052, Australia
| | - Blake Angell
- The George Institute for Global Health, UNSW Sydney, 1 King Street, Newtown, NSW 2042, Australia
| | - Stephanie Hyams
- Centre for Vision Research, Westmead Institute for Medical Research, 176 Hawkesbury Road Sydney, NSW 2145, Australia
| | - Paul Mitchell
- Westmead Hospital Ophthalmology Department, WSLHD, Corner Hawkesbury Road and Darcy Road, Sydney, NSW 2145, Australia; and Centre for Vision Research, Westmead Institute for Medical Research, 176 Hawkesbury Road Sydney, NSW 2145, Australia
| | - Gerald Liew
- Westmead Hospital Ophthalmology Department, WSLHD, Corner Hawkesbury Road and Darcy Road, Sydney, NSW 2145, Australia; and School of Optometry and Vision Science, Faculty of Science, UNSW Sydney, Sydney, NSW 2052, Australia; and Centre for Vision Research, Westmead Institute for Medical Research, 176 Hawkesbury Road Sydney, NSW 2145, Australia
| | - Andrew White
- Westmead Hospital Ophthalmology Department, WSLHD, Corner Hawkesbury Road and Darcy Road, Sydney, NSW 2145, Australia; and School of Optometry and Vision Science, Faculty of Science, UNSW Sydney, Sydney, NSW 2052, Australia; and Centre for Vision Research, Westmead Institute for Medical Research, 176 Hawkesbury Road Sydney, NSW 2145, Australia
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Wang RF, Trinidad J, Lawrence J, Pootrakul L, Forrest LA, Goist K, Levine E, Nair S, Rizer M, Thomas A, Wexler R, Kaffenberger BH. Improved patient access and outcomes with the integration of an eConsult program (teledermatology) within a large academic medical center. J Am Acad Dermatol 2019; 83:1633-1638. [PMID: 31678336 DOI: 10.1016/j.jaad.2019.10.053] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 10/13/2019] [Accepted: 10/22/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Insurance, racial, and socioeconomic health disparities continue to pose significant challenges for access to dermatologic care. Studies applying teledermatology to increase access to underinsured individuals and ethnic minorities are limited. OBJECTIVE To determine how the implementation of a teledermatology program affects access to health care and patient outcomes. METHODS A cross-sectional evaluation was performed of all ambulatory dermatology referrals and electronic dermatology consultations (eConsults) at Ohio State University within a 25-month period. RESULTS Compared with ambulatory referrals, eConsults served more nonwhite patients (612 of 1698 [36.0%] vs 4040 of 16,073 [25.1%]; P < .001) and more Medicaid enrollees (459 of 1698 patients [27.0%] vs 3266 of 16,073 [20.3%]; P < .001). In addition, ambulatory referral patients were significantly less likely to attend their scheduled appointment compared with eConsult patients, as either "no-shows" (246 of 2526 [9.7%] vs 3 of 62 [4.8%]) or cancellations (742 of 2526 [29.4%] vs 8 of 62 [12.9%]; P = .003). There were fewer median days to extirpation for eConsult patients compared with ambulatory referral patients (interquartile range; 80.7 ± 79.8 vs 116.9 ± 86.6 days; P = .004). CONCLUSION Integrating dermatologic care through a telemedicine system can result in improved access for underserved patients through improved efficiency outcomes.
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Affiliation(s)
- Rebecca F Wang
- Division of Dermatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - John Trinidad
- Division of Dermatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jeffrey Lawrence
- Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Llana Pootrakul
- Division of Dermatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - L Arick Forrest
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kevin Goist
- Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Edward Levine
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Shalina Nair
- Department of Family Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Milisa Rizer
- Department of Family Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Andrew Thomas
- Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Randell Wexler
- Department of Family Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Benjamin H Kaffenberger
- Division of Dermatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio.
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12
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Snoswell CL, Caffery LJ, Whitty JA, Soyer HP, Gordon LG. Cost-effectiveness of Skin Cancer Referral and Consultation Using Teledermoscopy in Australia. JAMA Dermatol 2019; 154:694-700. [PMID: 29801161 DOI: 10.1001/jamadermatol.2018.0855] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance International literature has shown that teledermoscopy referral may be a viable method for skin cancer referral; however, no economic investigations have occurred in Australia. Objective To assess the cost-effectiveness of teledermoscopy as a referral mechanism for skin cancer diagnosis and management in Australia. Design, Setting, and Participants Cost-effectiveness analysis using a decision-analytic model of Australian primary care, informed by publicly available data. Interventions We compared the costs of teledermoscopy referral (electronic referral containing digital dermoscopic images) vs usual care (a written referral letter) for specialist dermatologist review of a suspected skin cancer. Main Outcomes and Measures Cost and time in days to clinical resolution, where clinical resolution was defined as diagnosis by a dermatologist or excision by a general practitioner. Probabilistic sensitivity analysis was performed to examine the uncertainty of the main results. Results Findings from the decision-analytic model showed that the mean time to clinical resolution was 9 days (range, 1-50 days) with teledermoscopy referral compared with 35 days (range, 0-138 days) with usual care alone (difference, 26 days; 95% credible interval [CrI], 13-38 days). The estimated mean cost difference between teledermoscopy referral (A$318.39) vs usual care (A$263.75) was A$54.64 (95% CrI, A$22.69-A$97.35) per person. The incremental cost per day saved to clinical resolution was A$2.10 (95% CrI, A$0.87-A$5.29). Conclusions and Relevance Using teledermoscopy for skin cancer referral and triage in Australia would cost A$54.64 extra per case on average but would result in clinical resolution 26 days sooner than usual care. Implementation recommendations depend on the preferences of the Australian health system decision makers for either lower cost or expedited clinical resolution. Further research around the clinical significance of expedited clinical resolution and its importance for patients could inform implementation recommendations for the Australian setting.
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Affiliation(s)
| | - Liam J Caffery
- Centre for Online Health, University of Queensland, Brisbane, Australia
| | - Jennifer A Whitty
- School of Pharmacy, University of Queensland, Brisbane, Australia.,Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, England
| | - H Peter Soyer
- Dermatology Research Centre, University of Queensland, University of Queensland Diamantina Institute, Translational Research Institute, Brisbane, Australia.,Dermatology Department, Princess Alexandra Hospital, Brisbane, Australia
| | - Louisa G Gordon
- QIMR Berghofer Medical Research Institute, Brisbane, Australia.,School of Nursing, Queensland University of Technology, Brisbane, Australia.,School of Public Health, University of Queensland, Brisbane, Australia
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Impact of teledermatology on the accessibility and efficiency of dermatology care in an urban safety-net hospital: A pre-post analysis. J Am Acad Dermatol 2019; 81:1446-1452. [PMID: 31415834 DOI: 10.1016/j.jaad.2019.08.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/17/2019] [Accepted: 08/02/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Teledermatology enables dermatologists to remotely triage and evaluate dermatology patients, but previous studies have questioned whether teledermatology is clinically efficient. OBJECTIVE To determine whether implementation of a teledermatology system at the Zuckerberg San Francisco General Hospital and Trauma Center has improved the accessibility and efficiency of dermatology care delivery. METHODS Retrospective, pre-post analysis of a pre-teledermatology cohort (June 2014-December 2014) compared with a post-teledermatology cohort (June 2017-December 2017). RESULTS Our analysis captured 11,586 patients. After implementation of teledermatology, waiting times for new patients decreased significantly (84.6 days vs 6.7 days; P < .001), total cases evaluated per month increased significantly (754 vs 901; P = .008), and number of cases evaluated per dermatologist-hour increased significantly (2.27 vs 2.63; P = .010). In the post-teledermatology period, 61.8% of teledermatology consults were managed without a clinic visit. LIMITATIONS We were unable to control for changes in demand for dermatology evaluations between the 2 periods and did not have a control group with which to compare our results. CONCLUSION The dermatology service was more accessible and more efficient after implementation of teledermatology, suggesting that capitated health care settings can benefit from implementation of a teledermatology system.
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Bertrand SE, Weinstock MA, Landow SM. Teledermatology Outcomes in the Providence Veterans Health Administration. Telemed J E Health 2019; 25:1183-1188. [PMID: 30758254 DOI: 10.1089/tmj.2018.0242] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: As technology evolves, so does the integration of technology into health care delivery. Telemedicine, the use of information technology to provide remote health care, aims to improve patient access to quality care across a wide range of barriers. Introduction: Our objective was to determine whether teleconsultation leverages specialist expertise at one site within the United States' largest integrated health system. We evaluated the Providence Veterans Affairs Medical Center (PVAMC) teledermatology store-and-forward program. Materials and Methods: We evaluated 460 completed teleconsultations using retrospective chart review at the PVAMC in June-August 2016 for 12 postimaging outcomes, with no exclusion criteria. We determined outcomes using Computerized Patient Record System chart reviews. Results: Dermatologists completed 84-99% of all teleconsultations within 1 week after referral. Fifty one percent (51%) of patients required no dermatology clinic visit. Six percent (6%) of all teleconsultations were ultimately diagnosed with a biopsy-proven skin cancer. Sixty nine percent (69%) of referring providers prescribed recommended medications within 7 days. Discussion: We conclude that the PVAMC teledermatology program enables rapid access to dermatologic expertise while avoiding unnecessary clinic appointments. Conclusion: By detecting both weak links, and steps in the chain of care that successful teledermatology requires, our findings can help teledermatology systems within and outside the Veterans Affairs maximize their effectiveness.
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Affiliation(s)
- Sylvie E Bertrand
- Providence Veterans Affairs Medical Center, Dermatoepidemiology Unit, Providence, Rhode Island.,Brown University, School of Public Health, Providence, Rhode Island
| | - Martin A Weinstock
- Providence Veterans Affairs Medical Center, Dermatoepidemiology Unit, Providence, Rhode Island.,Brown University, School of Public Health, Providence, Rhode Island.,Department of Dermatology, The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Shoshana M Landow
- Providence Veterans Affairs Medical Center, Dermatoepidemiology Unit, Providence, Rhode Island.,Department of Dermatology, The Warren Alpert Medical School, Brown University, Providence, Rhode Island
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Done N, Oh DH, Weinstock MA, Whited JD, Jackson GL, King HA, Peracca SB, Elwy AR, Prentice JC. VA Telederm study: protocol for a stepped-wedge cluster randomised trial to compare access to care for a mobile app versus a workstation-based store-and-forward teledermatology process. BMJ Open 2018; 8:e022218. [PMID: 30552249 PMCID: PMC6303588 DOI: 10.1136/bmjopen-2018-022218] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Teledermatology has emerged as an important strategy to enhance access to high-quality skin care. VA Telederm is a provider-facing, web-based mobile app designed to integrate into the existing teledermatology workflow in the US Veterans Health Administration (VHA). In this study, we will conduct a systematic evaluation of VA Telederm on access outcomes in VHA facilities using a pragmatic trial guided by clinical and operational leaders. METHODS AND ANALYSIS The study is a prospective, stepped-wedge cluster randomised trial with cross-sectional exposure and outcome measurement via retrospective database analysis of administrative records. Each cluster is a VHA facility deemed eligible for the trial. We assign the intervention using a cluster-level balanced randomisation scheme based on facility size, baseline teledermatology uptake and geographic location. The trial will test whether patients receiving dermatological care at participating facilities will have better access compared with patients receiving care through the current standard process. The primary outcomes proxy for patient-level access to dermatology services, including (1) consult completion time for teledermatology consults; (2) appointment completion time for new dermatology consults; and (3) travel distance for dermatology services. As secondary outcomes, we will assess facility-level adoption outcomes, that is, the number of dermatology encounters and the proportion of teledermatology consults out of all dermatology encounters. To account for secular trends in outcomes and for correlation across individuals within clusters, we will assess the impact of the intervention using generalised linear mixed regression models. DISCUSSION Streamlining the current practice for store-and-forward teledermatology in the VHA can improve access to expert dermatological care for US veterans. The lessons learnt in this trial could validate the use of mobile technology for consultative store-and-forward dermatology in a large healthcare organisation. The results may also be of interest to other medical specialties assessing the merits of implementing mobile telehealth. PROTOCOL VERSION Version 3; 7 November 2018. TRIAL REGISTRATION NUMBER NCT03241589; Pre-results.
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Affiliation(s)
- Nicolae Done
- US Department of Veterans Affairs, Center for Access Policy, Evaluation and Research, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Dennis H Oh
- Department of Research and Development, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA
| | - Martin A Weinstock
- Center for Dermatoepidemiology, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - John D Whited
- Durham Veterans Affairs Medical Centre, Duke University, Durham, North Carolina, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - George L Jackson
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - Heather A King
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - Sara B Peracca
- Department of Research and Development, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - A Rani Elwy
- Department of Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
- Department of Veterans Affairs Boston Medical Center, Center for Healthcare Organization and Implementation Research, Boston, Massachusetts, USA
| | - Julia C Prentice
- US Department of Veterans Affairs, Center for Access Policy, Evaluation and Research, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
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Chuchu N, Dinnes J, Takwoingi Y, Matin RN, Bayliss SE, Davenport C, Moreau JF, Bassett O, Godfrey K, O'Sullivan C, Walter FM, Motley R, Deeks JJ, Williams HC. Teledermatology for diagnosing skin cancer in adults. Cochrane Database Syst Rev 2018; 12:CD013193. [PMID: 30521686 PMCID: PMC6517019 DOI: 10.1002/14651858.cd013193] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Early accurate detection of all skin cancer types is essential to guide appropriate management and to improve morbidity and survival. Melanoma and squamous cell carcinoma (SCC) are high-risk skin cancers which have the potential to metastasise and ultimately lead to death, whereas basal cell carcinoma (BCC) is usually localised with potential to infiltrate and damage surrounding tissue. Anxiety around missing early curable cases needs to be balanced against inappropriate referral and unnecessary excision of benign lesions. Teledermatology provides a way for generalist clinicians to access the opinion of a specialist dermatologist for skin lesions that they consider to be suspicious without referring the patients through the normal referral pathway. Teledermatology consultations can be 'store-and-forward' with electronic digital images of a lesion sent to a dermatologist for review at a later time, or can be live and interactive consultations using videoconferencing to connect the patient, referrer and dermatologist in real time. OBJECTIVES To determine the diagnostic accuracy of teledermatology for the detection of any skin cancer (melanoma, BCC or cutaneous squamous cell carcinoma (cSCC)) in adults, and to compare its accuracy with that of in-person diagnosis. SEARCH METHODS We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, CPCI, Zetoc, Science Citation Index, US National Institutes of Health Ongoing Trials Register, NIHR Clinical Research Network Portfolio Database and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles. SELECTION CRITERIA Studies evaluating skin cancer diagnosis for teledermatology alone, or in comparison with face-to-face diagnosis by a specialist clinician, compared with a reference standard of histological confirmation or clinical follow-up and expert opinion. We also included studies evaluating the referral accuracy of teledermatology compared with a reference standard of face-to-face diagnosis by a specialist clinician. DATA COLLECTION AND ANALYSIS Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where there were information related to the target condition of any skin cancer missing. Data permitting, we estimated summary sensitivities and specificities using the bivariate hierarchical model. Due to the scarcity of data, we undertook no covariate investigations for this review. For illustrative purposes, we plotted estimates of sensitivity and specificity on coupled forest plots for diagnostic threshold and target condition under consideration. MAIN RESULTS The review included 22 studies reporting diagnostic accuracy data for 4057 lesions and 879 malignant cases (16 studies) and referral accuracy data for reported data for 1449 lesions and 270 'positive' cases as determined by the reference standard face-to-face decision (six studies). Methodological quality was variable with poor reporting hindering assessment. The overall risk of bias was high or unclear for participant selection, reference standard, and participant flow and timing in at least half of all studies; the majority were at low risk of bias for the index test. The applicability of study findings were of high or unclear concern for most studies in all domains assessed due to the recruitment of participants from secondary care settings or specialist clinics rather than from primary or community-based settings in which teledermatology is more likely to be used and due to the acquisition of lesion images by dermatologists or in specialist imaging units rather than by primary care clinicians.Seven studies provided data for the primary target condition of any skin cancer (1588 lesions and 638 malignancies). For the correct diagnosis of lesions as malignant using photographic images, summary sensitivity was 94.9% (95% confidence interval (CI) 90.1% to 97.4%) and summary specificity was 84.3% (95% CI 48.5% to 96.8%) (from four studies). Individual study estimates using dermoscopic images or a combination of photographic and dermoscopic images generally suggested similarly high sensitivities with highly variable specificities. Limited comparative data suggested similar diagnostic accuracy between teledermatology assessment and in-person diagnosis by a dermatologist; however, data were too scarce to draw firm conclusions. For the detection of invasive melanoma or atypical intraepidermal melanocytic variants both sensitivities and specificities were more variable. Sensitivities ranged from 59% (95% CI 42% to 74%) to 100% (95% CI 48% to 100%) and specificities from 30% (95% CI 22% to 40%) to 100% (95% CI 93% to 100%), with reported diagnostic thresholds including the correct diagnosis of melanoma, classification of lesions as 'atypical' or 'typical, and the decision to refer or to excise a lesion.Referral accuracy data comparing teledermatology against a face-to-face reference standard suggested good agreement for lesions considered to require some positive action by face-to-face assessment (sensitivities of over 90%). For lesions considered of less concern when assessed face-to-face (e.g. for lesions not recommended for excision or referral), agreement was more variable with teledermatology specificities ranging from 57% (95% CI 39% to 73%) to 100% (95% CI 86% to 100%), suggesting that remote assessment is more likely recommend excision, referral or follow-up compared to in-person decisions. AUTHORS' CONCLUSIONS Studies were generally small and heterogeneous and methodological quality was difficult to judge due to poor reporting. Bearing in mind concerns regarding the applicability of study participants and of lesion image acquisition in specialist settings, our results suggest that teledermatology can correctly identify the majority of malignant lesions. Using a more widely defined threshold to identify 'possibly' malignant cases or lesions that should be considered for excision is likely to appropriately triage those lesions requiring face-to-face assessment by a specialist. Despite the increasing use of teledermatology on an international level, the evidence base to support its ability to accurately diagnose lesions and to triage lesions from primary to secondary care is lacking and further prospective and pragmatic evaluation is needed.
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Affiliation(s)
- Naomi Chuchu
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Jacqueline Dinnes
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Yemisi Takwoingi
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Rubeta N Matin
- Churchill HospitalDepartment of DermatologyOld RoadHeadingtonOxfordUKOX3 7LE
| | - Susan E Bayliss
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Clare Davenport
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Jacqueline F Moreau
- University of Pittsburgh Medical CenterInternal MedicineDepartment of Medicine, Office of EducationUPMC Montefiore Hospital, N715PittsburghUSAPA, 15213
| | - Oliver Bassett
- Addenbrooke's HospitalPlastic SurgeryHills RoadCambridgeUKCB2 0QQ
| | - Kathie Godfrey
- The University of Nottinghamc/o Cochrane Skin GroupNottinghamUK
| | | | - Fiona M Walter
- University of CambridgePublic Health & Primary CareStrangeways Research Laboratory, Worts CausewayCambridgeUKCB1 8RN
| | - Richard Motley
- University Hospital of WalesWelsh Institute of DermatologyHeath ParkCardiffUKCF14 4XW
| | - Jonathan J Deeks
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Hywel C Williams
- University of NottinghamCentre of Evidence Based DermatologyQueen's Medical CentreDerby RoadNottinghamUKNG7 2UH
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Augustin M, Wimmer J, Biedermann T, Blaga R, Dierks C, Djamei V, Elmer A, Elsner P, Enk A, Gass S, Henningsen M, Hofman-Wellenhof R, von Kiedrowski R, Kunz HD, Liebram C, Navarini A, Otten M, Reusch M, Schüller C, Zink A, Strömer K. Praxis der Teledermatologie. J Dtsch Dermatol Ges 2018; 16 Suppl 5:6-57. [DOI: 10.1111/ddg.13512] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Matthias Augustin
- Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP); Universitätsklinikum Hamburg-Eppendorf (UKE), Hamburg
| | - Johannes Wimmer
- Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP); Universitätsklinikum Hamburg-Eppendorf (UKE), Hamburg
| | - Tilo Biedermann
- Hautklinik Campus Biederstein; Technische Universität München, München
| | - Rolf Blaga
- Psoriasis Selbsthilfe Arbeitsgemeinschaft e. V.; Berlin
| | | | | | - Arno Elmer
- Hochschule für Ökonomie und Management Berlin, Berlin
| | - Peter Elsner
- Klinik für Hautkrankheiten; Universitätsklinikum Jena, Jena
| | - Alexander Enk
- Hautklinik; Universitätsklinikum Heidelberg, Heidelberg
| | | | - Maike Henningsen
- Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP); Universitätsklinikum Hamburg-Eppendorf (UKE), Hamburg
| | | | | | | | | | | | - Marina Otten
- Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP); Universitätsklinikum Hamburg-Eppendorf (UKE), Hamburg
| | | | | | - Alexander Zink
- Dermatologischen Universitätsklinik; Technischen Universität München, München
| | - Klaus Strömer
- Gemeinschaftspraxis für Dermatologie und Allergologie; Mönchengladbach
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Abstract
Telemedicine is slowly transforming the way in which healthcare is delivered and has the potential to improve access to subspecialty expertise, reduce healthcare costs, and improve the overall quality of care. While many subspecialty fields within medicine today have either experimented with or begun to implement telemedicine platforms to enable remote consultation and care, dermatology is particularly suited for this care system as skin disorders are uniquely visible to the human eye. Through teledermatology, diagnostic images of skin disorders with accompanying clinical histories can be remotely reviewed by teledermatologists by any number of modalities, such as photographic clinical images or live video teleconferencing. Diagnoses and treatment recommendations can then be rendered and implemented remotely. The evidence to date supports both its diagnostic and treatment accuracy and its cost effectiveness. Administrative, regulatory, privacy, and reimbursement policies surrounding this dynamic field continue to evolve. In this review, we examine the history, evidence, and administrative landscape surrounding teledermatology and discuss current practice guidelines and ongoing controversies.
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Affiliation(s)
- Jonathan J Lee
- Department of Dermatology, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Joseph C English
- Department of Dermatology, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA.
- Teledermatology, UPMC North Hills Dermatology, 9000 Brooktree Rd Suite 200, Wexford, PA, 15044, USA.
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Naka F, Lu J, Porto A, Villagra J, Wu ZH, Anderson D. Impact of dermatology eConsults on access to care and skin cancer screening in underserved populations: A model for teledermatology services in community health centers. J Am Acad Dermatol 2018; 78:293-302. [DOI: 10.1016/j.jaad.2017.09.017] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 08/29/2017] [Accepted: 09/06/2017] [Indexed: 11/16/2022]
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Telemedicine: A systematic review of economic evaluations. Med J Islam Repub Iran 2017; 31:113. [PMID: 29951414 PMCID: PMC6014807 DOI: 10.14196/mjiri.31.113] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Indexed: 01/18/2023] Open
Abstract
Background: Telemedicine is an expanded term in health information technology that comprises procedures for transmitting medical
information electronically to improve patients’ health status. The objective of this research is to evaluate the cost-effectiveness of
telemedicine interventions in various specialty areas.
Methods: The Cochrane Library and Centre for Review and Dissemination were searched up to February 2013 using Mesh. Studies
that compared any kind of telemedicine with any other routine care technique and used cost per health utility unit’s outcomes were
included.
Results: Twenty-one articles were included. According to the included studies, it seems that using telemedicine in cardiology can be
effective and cost-effective enough but pre-hospital telemedicine diagnostics program are likely to have little impact on acute myocardial
infarction fatality. In pulmonary, telemedicine can be a cost-effective strategy for delivering outpatient pulmonary care to rural
populations which have limited access to specialized services, but telemedicine is not cost- effective in asthma and airways cancer. In
ophthalmology, especially in the diagnosis of diabetic retinopathy, the use of telemedicine is a cost-effective tool. In dermatology,
telemedicine is not cost-effective enough in comparison of conventional cares. In other fields such as physical activity and diet, eating
disorder, tele-ICU, psychotherapy for depression and telemedicine on ships, telemedicine can be used as a cost-effective tool for treatments
or cares.
Conclusion: Most of the included studies confirmed that telemedicine is cost-effective for applying in major medical fields such as
cardiology; but in dermatology, papers could not confirm the positive capability of telemedicine.
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Trettel A, Eissing L, Augustin M. Telemedicine in dermatology: findings and experiences worldwide - a systematic literature review. J Eur Acad Dermatol Venereol 2017; 32:215-224. [PMID: 28516492 DOI: 10.1111/jdv.14341] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 03/29/2017] [Indexed: 01/28/2023]
Abstract
Telemedicine has become an important element of health care in many countries and profited from the technological progress of the last two decades. Due to the visual character of the dermatological specialty, teledermatology in particular participated in that development and is becoming a major tool in dermatological consultation. The objective of this article was to identify the use of teledermatology across the world based on published original articles. A systematic literature search of the MEDLINE and Embase databases for eligible publications (predefined inclusion and exclusion criteria) and a cross-validation search were conducted. Search results were reviewed systematically. The search resulted in 204 publications meeting the inclusion criteria for analysis. The highest number of published studies on teledermatology was performed in the United States, followed by the United Kingdom, Spain, the Netherlands, Italy and Austria. The majority of dermatological indications for telemedical consultations were not specified or included various kinds of skin diseases, followed by skin cancer and wounds. Research questions predominantly focused on concordance, effectiveness and cost-effectiveness to determine the value. Teledermatology proved to be a reliable consultation tool in the majority of studies. If specified, telemedicine was used in daily dermatological routine for patient management purposes, to consult patients in peripheral locations, or for medical support in nursing homes or home care settings. The application of teledermatology worldwide is highest in North American and European countries, while countries with poor geographical distribution of physicians seem to be under-represented in teledermatological use, as concluded from publication output. Regarding indications, comparison with classic consultation and area of application, most studies were of general nature. For precise determination of the value, systematic studies would be needed. However, teledermatology is already accepted as a valid tool.
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Affiliation(s)
- A Trettel
- Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - L Eissing
- Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - M Augustin
- Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
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Choosing a Model for eConsult Specialist Remuneration: Factors to Consider. INFORMATICS-BASEL 2016. [DOI: 10.3390/informatics3020008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Liddy C, Drosinis P, Keely E. Electronic consultation systems: worldwide prevalence and their impact on patient care-a systematic review. Fam Pract 2016; 33:274-85. [PMID: 27075028 DOI: 10.1093/fampra/cmw024] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Many health organizations are exploring the potential of electronic consultation (eConsult) services to address excessive wait times for specialist care. OBJECTIVE To understand the effectiveness, population impact and costs associated with implementation of eConsult services. METHODS We conducted a systematic review using a narrative synthesis approach. We searched Medline and Embase from inception to August 2014 (English/French). Included studies focused on communication between primary care providers and specialist physicians through an asynchronous, directed communication over a secure electronic medium. We assessed study quality with a modified version of the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. We synthesized the results using the Triple Aim framework. RESULTS A total of 36 studies were included. Most were set in the USA and focused on single-specialty services (most commonly dermatology). Population health outcomes included patient populations, adoption/utilization and provider attitudes. Providers cited timely advice from specialists, good medical care, confirmation of diagnoses and educational benefits. No clinical outcomes were reported. Patient experience of care was generally positive, with quick specialist response times (4.6 hours to 3.9 days), avoided referrals (12-84%) and satisfaction ranging from 78% to 93%. System costs were reported in only seven studies using different outcome measures and settings, limiting comparability. CONCLUSION Though eConsult systems are highly acceptable for patients and providers and deliver improved access to specialist advice, gaps remain regarding eConsult's impact on population health and system costs. To achieve optimized health system performance, eConsult services must include specialty services as determined by community needs and further explore cost-effectiveness.
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Affiliation(s)
- Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Department of Family Medicine and
| | - Paul Drosinis
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, Ontario and Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, Ontario, Canada
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Batalla A, Suh-Oh HJ, Salgado-Boquete L, Abalde T, de la Torre C. Teledermatología. Capacidad para reducir consultas presenciales según el grupo de enfermedad. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.piel.2015.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Vedire K, Joselow AL, Markham CM, Raugi GJ. Teledermatology-directed surgical care is safe and reduces travel. J Telemed Telecare 2016; 22:121-6. [PMID: 26116856 DOI: 10.1177/1357633x15589861] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 04/16/2015] [Indexed: 11/16/2022]
Abstract
METHODS We conducted a retrospective chart review and identified 186 Veterans in the VA Corporate Data Warehouse as having malignant melanomas or severely dysplastic nevi during the four-year period of observation from 1 July 2009 to 30 June 2013 and met inclusion and exclusion criteria for analysis. RESULTS Three hundred and sixty-six surgical procedures were performed for diagnosis and treatment of these conditions including biopsy and wide-local excision, of which 189 carefully selected cases were performed by primary care clinicians with 2.0% biopsy complication rate and a 7.7% wide-local excision complication rate. Cases not performed by primary care providers were referred to specialists (e.g. dermatologists, general surgeons or specialty surgeons) who had a 2.5% complication rate in biopsies and wide-local excision complication rate of 13.5% in severely dysplastic nevi and pTis and pT1a lesions and a 10.7% complication rate for lesions pT1b and greater. DISCUSSION These results show that a significant fraction of surgical procedures for diagnosis and treatment of malignant melanoma and severely dysplastic nevi can be safely performed in rural clinics by trained primary care providers.
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Affiliation(s)
- Kirtana Vedire
- VA Puget Sound Health Care System, Seattle Division, USA
| | - Andrew L Joselow
- VA Puget Sound Health Care System, Seattle Division, USA Tulane University School of Medicine, New Orleans, USA
| | | | - Gregory J Raugi
- VA Puget Sound Health Care System, Seattle Division, USA University of Washington, Department of Medicine (Dermatology), Seattle, USA
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Impact of store-and-forward (SAF) teledermatology on outpatient dermatologic care: A prospective study in an underserved urban primary care setting. J Am Acad Dermatol 2015; 74:484-90.e1. [PMID: 26679528 DOI: 10.1016/j.jaad.2015.09.058] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 09/24/2015] [Accepted: 09/28/2015] [Indexed: 01/04/2023]
Abstract
BACKGROUND The clinical value of teledermatology in the primary care setting remains relatively unknown. OBJECTIVE We sought to determine the impact of teledermatology on outpatient diagnosis, management, and access to dermatologic care in a resource-poor primary care setting. METHODS We performed a prospective study of store-and-forward teledermatology consults submitted between January and November 2013 from 11 underserved clinics in Philadelphia to the University of Pennsylvania using mobile devices and the Internet. We assessed diagnostic and management concordance between primary care providers and dermatologists, time to consult completion, anticipated level of dermatology input in the absence of teledermatology, and number of consults managed with teledermatology alone. RESULTS The study included 196 consults encompassing 206 dermatologic conditions. Diagnoses and management plans of primary care providers and dermatologists were fully concordant for 22% and 23% of conditions, respectively. The median time to consult completion was 14 (interquartile range 3-28) hours. At least 61% of consults would not otherwise have received dermatology input, and 77% of consults were managed with teledermatology alone. LIMITATIONS Lack of a diagnostic gold standard, limited patient follow-up, and uncertain generalizability are limitations. CONCLUSION Teledermatology is an innovative and impactful modality for delivering dermatologic care to outpatients in resource-poor primary care settings.
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Abstract
This article provides an overview of teledermatology with an emphasis on the evidence most relevant to referring clinicians, who are often primary care clinicians. Discussion includes the different modalities used for teledermatology and their diagnostic reliability, diagnostic accuracy, impact on in-person dermatology visits, clinical outcomes, and user satisfaction.
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Affiliation(s)
- John D Whited
- Research and Development, Durham Veterans Affairs Medical Center, Research and Development (151), 508 Fulton Street, Durham, NC 27705, USA; Division of General Internal Medicine, Duke University School of Medicine, 411 West Chapel Hill Street, Suite 500, Durham, NC 27701, USA.
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Kummerow Broman K, Oyefule OO, Phillips SE, Baucom RB, Holzman MD, Sharp KW, Pierce RA, Nealon WH, Poulose BK. Postoperative Care Using a Secure Online Patient Portal: Changing the (Inter)Face of General Surgery. J Am Coll Surg 2015; 221:1057-66. [PMID: 26453260 DOI: 10.1016/j.jamcollsurg.2015.08.429] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Revised: 08/14/2015] [Accepted: 08/14/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Many patients seek greater accessibility to health care. Meanwhile, surgeons face increasing time constraints due to workforce shortages and elevated performance demands. Online postoperative care may improve patient access while increasing surgeon efficiency. We aimed to evaluate patient and surgeon acceptance of online postoperative care after elective general surgical operations. STUDY DESIGN A prospective pilot study within an academic general surgery service compared online and in-person postoperative visits from May to December 2014. Included patients underwent elective laparoscopic cholecystectomy, laparoscopic ventral hernia repair, umbilical hernia repair, or inguinal hernia repair by 1 of 5 surgeons. Patients submitted symptom surveys and wound pictures, then corresponded with their surgeons using an online patient portal. The primary outcome was patient-reported acceptance of online visits in lieu of in-person visits. Secondary outcomes included detection of complications via online visits, surgeon-reported effectiveness, and visit times. RESULTS Fifty patients completed both online and in-person visits. Online visits were acceptable to most patients as their only follow-up (76%). For 68% of patients, surgeons reported that both visit types were equally effective, while clinic visits were more effective in 24% and online visits in 8%. No complications were missed via online visits, which took significantly less time for patients (15 vs 103 minutes, p < 0.01) and surgeons (5 vs 10 minutes, p < 0.01). CONCLUSIONS In this population, online postoperative visits were accepted by patients and surgeons, took less time, and effectively identified patients who required further care. Further evaluation is needed to establish the safety and potential benefit of online postoperative visits in specific populations.
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Affiliation(s)
- Kristy Kummerow Broman
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education, and Clinical Center, Tennessee Valley Health care System, Veterans Affairs Medical Center, Nashville, TN.
| | | | - Sharon E Phillips
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Rebeccah B Baucom
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Michael D Holzman
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Kenneth W Sharp
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Richard A Pierce
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - William H Nealon
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Benjamin K Poulose
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
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Sharma P, Kovarik CL, Lipoff JB. Teledermatology as a means to improve access to inpatient dermatology care. J Telemed Telecare 2015; 22:304-10. [DOI: 10.1177/1357633x15603298] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 08/07/2015] [Indexed: 11/16/2022]
Abstract
Many hospitals have limited inpatient dermatology consultation access. Most dermatologists are outpatient-based and may find the distance and time to complete inpatient consultations prohibitive. Teledermatology may improve access to inpatient dermatology care by reducing barriers of distance and time. We conducted a prospective two-phase pilot study at two academic hospitals comparing time needed to complete inpatient consultations after resident dermatologists initially evaluated patients, called average handling time (AHT), and time needed to respond to the primary team, called time to response (TTR), with and without teledermatology with surveys to capture changes in dermatologist opinion on teledermatology. Teledermatology was only used in the study phase, and patients were seen in-person in both study phases. Teledermatology alone sufficiently answered consultations in 10 of 25 study consultations. The mean AHT in the study phase (sAHT) was 26.9 min compared to the baseline phase (bAHT) of 43.5 min, a 16.6 min reduction ( p = 0.004). The 10 study cases where teledermatology alone was sufficient had mean study TTR (sTTR) of 273.3 min compared to a baseline TTR (bTTR) of 405.7 min, a 132.4 min reduction ( p = 0.032). Teledermatology reduces the time required for an attending dermatologist to respond and the time required for a primary team to receive a response for an inpatient dermatology consultation in a subset of cases. These findings suggest teledermatology can be used as a tool to improve access to inpatient dermatology care.
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Affiliation(s)
- Priyank Sharma
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Carrie L Kovarik
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jules B Lipoff
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Chu S, Boxer R, Madison P, Kleinman L, Skolarus T, Altman L, Bennett C, Shelton J. Veterans Affairs Telemedicine: Bringing Urologic Care to Remote Clinics. Urology 2015; 86:255-60. [PMID: 26168998 DOI: 10.1016/j.urology.2015.04.038] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 03/24/2015] [Accepted: 04/08/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To report the use of telemedicine to deliver general urologic care to remote locations within the Veterans Affairs Greater Los Angeles Healthcare System. We describe the diagnoses managed, patient satisfaction, safety, and benefit to patients in terms of saved travel time and expense. METHODS We conducted a retrospective chart review examining care delivered through urology telemedicine clinics over a 6-month period. We examined the urologic conditions, patient satisfaction, and emergency department visits within 30 days of the visit. We estimated patient benefit by calculating travel distance and time and the saved travel-associated costs using Google Maps and US Census income data. RESULTS Ninety-seven unique telemedicine visits were conducted and a total of 171 urologic diseases were assessed. The most common conditions were lower urinary tract symptoms (35%), elevated prostate-specific antigen level (15%), and prostate cancer (14%). One patient was seen in the emergency department within 30 days with an unpreventable urologic complaint. Patient satisfaction was "very good" to "excellent" in 95% of cases, and 97% would refer another veteran to the urology telemedicine clinic. Patients saved an average of 277 travel miles, 290 minutes of travel time, $67 in travel expenses, and $126 in lost opportunity cost. CONCLUSION Telemedicine was successfully and safely used to evaluate and treat a wide range of urologic conditions within the Veterans Affairs Greater Los Angeles Healthcare System, and saves patients nearly 5 hours and up to $193 per visit. Further investigation of the potential of telemedicine for the delivery of urologic care in a cost-effective manner is warranted.
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Affiliation(s)
- Stephanie Chu
- Department of Urology, University of California, Los Angeles, CA.
| | - Richard Boxer
- Department of Urology, University of California, Los Angeles, CA; Veterans Affairs Greater Los Angeles, Los Angeles, CA
| | | | | | - Ted Skolarus
- Department of Urology, University of Michigan, Ann Arbor, MI; HSR&D Center for Health Communications Research, Veterans Affairs Ann Arbor, Ann Arbor, MI
| | - Lisa Altman
- Veterans Affairs Greater Los Angeles, Los Angeles, CA
| | - Carol Bennett
- Department of Urology, University of California, Los Angeles, CA; Veterans Affairs Greater Los Angeles, Los Angeles, CA
| | - Jeremy Shelton
- Department of Urology, University of California, Los Angeles, CA; Veterans Affairs Greater Los Angeles, Los Angeles, CA
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Coates SJ, Kvedar J, Granstein RD. Teledermatology: from historical perspective to emerging techniques of the modern era: part I: History, rationale, and current practice. J Am Acad Dermatol 2015; 72:563-74; quiz 575-6. [PMID: 25773407 DOI: 10.1016/j.jaad.2014.07.061] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 07/21/2014] [Accepted: 07/27/2014] [Indexed: 11/30/2022]
Abstract
Telemedicine is the use of telecommunications technology to support health care at a distance. Technological advances have progressively increased the ability of clinicians to care for diverse patient populations in need of skin expertise. Dermatology relies on visual cues that are easily captured by imaging technologies, making it ideally suited for this care model. Moreover, there is a shortage of medical dermatologists in the United States, where skin disorders account for 1 in 8 primary care visits and specialists tend to congregate in urban areas. Even in regions where dermatologic expertise is readily accessible, teledermatology may serve as an alternative that streamlines health care delivery by triaging chief complaints and reducing unnecessary in-person visits. In addition, many patients in the developing world have no access to dermatologic expertise, rendering it possible for teledermatologists to make a significant contribution to patient health outcomes. Teledermatology also affords educational benefits to primary care providers and dermatologists, and enables patients to play a more active role in the health care process by promoting direct communication with dermatologists.
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Affiliation(s)
- Sarah J Coates
- Department of Dermatology, Weill Cornell Medical College, New York, New York
| | - Joseph Kvedar
- Department of Dermatology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Richard D Granstein
- Department of Dermatology, Weill Cornell Medical College, New York, New York.
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Blank L, Baxter S, Woods HB, Goyder E, Lee A, Payne N, Rimmer M. What is the evidence on interventions to manage referral from primary to specialist non-emergency care? A systematic review and logic model synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03240] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BackgroundDemand management describes any method used to monitor, direct or regulate patient referrals. Several strategies have been developed to manage the referral of patients to secondary care, with interventions targeting primary care, specialist services, or infrastructure.ObjectiveThis research aimed to conduct an inclusive systematic review and logic model synthesis in order to better understand factors impacting on the effectiveness of interventions targeting referral between primary and secondary medical health care.DesignThe approach combined systematic review with logic modelling synthesis techniques to develop an evidence-based framework of factors influencing the pathway between interventions and system-wide changes.SettingPrimary health care.Main outcome measuresReferral from primary to secondary care.Review methodsSystematic searches were undertaken to identify recent, relevant studies. Quality of individual studies was appraised, with consideration of overall strength of evidence. A narrative synthesis and logic model summary of the data was completed.ResultsFrom a database of 8327 unique papers, 290 were included in the review. The intervention studies were grouped into four categories of education interventions (n = 50); process change interventions (n = 49); system change interventions (n = 38); and patient-focused interventions (n = 3). Effectiveness was assessed variously in these papers; however, there was a gap regarding the mechanisms whereby these interventions lead to demand management impacts. The findings suggest that, although individual-level interventions may be popular, the stronger evidence relates only to peer-review and feedback interventions. Process change interventions appeared to be more effective when the change resulted in the specialist being provided with more or better quality information about the patient. System changes including the community provision of specialist services by general practitioners, outreach provision by specialists and the return of inappropriate referrals appeared to have evidence of effect. The pathway whereby interventions might lead to service-wide impact was complex, with multiple factors potentially acting as barriers or facilitators to the change process. Factors related, first, to the doctor (including knowledge, attitudes and beliefs, and previous experiences of a service), second, to the patient (including condition and social factors) and, third, to the influence of the doctor–patient relationship. We also identified a number of potentially influential factors at a local level, such as perceived waiting times and the availability of a specialist. These elements are key factors in the pathway between an intervention and intended demand management outcomes influencing both applicability and effectiveness.ConclusionsThe findings highlight the complexity of the referral process and multiple elements that will impact on intervention outcomes and applicability to a local area. Any interventions seeking to change referral practice need to address factors relating to the individual practitioner, the patient and also the situation in which the referral is taking place. These conclusions apply especially to referral management in a UK context where this whole range of factors/issues lies well within the remit of the NHS. This work highlights that intermediate outcomes are important in the referral pathway. It is recommended that researchers include measure of these intermediate outcomes in their evaluation of intervention effectiveness in order to determine where blocks to or facilitators of system-wide impact may be occurring.Study registrationThe study is registered as PROSPERO CRD42013004037.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Lindsay Blank
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Susan Baxter
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Helen Buckley Woods
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Goyder
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Lee
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Nick Payne
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Melanie Rimmer
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Brunett PH, DiPiero A, Flores C, Choi D, Kum H, Girard DE. Use of a voice and video internet technology as an alternative to in-person urgent care clinic visits. J Telemed Telecare 2015; 21:219-26. [PMID: 25697491 DOI: 10.1177/1357633x15571649] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 12/09/2014] [Indexed: 11/16/2022]
Abstract
This study aimed to determine the feasibility of patient-initiated online Internet urgent care visits, and to describe patient characteristics, scope of care, provider adherence to protocols, and diagnostic and therapeutic utilization. A total of 456 unique patients were seen via Internet-based technology during the study period, generating 478 consecutive total patient visits. Of the 82 patients referred for an in-person evaluation, 75 patients (91.5%) reported to the clinic as instructed. None of the 82 patients recommended for in-person evaluation required an emergency department referral, hospital admission or urgent consultative referral. We conclude that real-time online primary and urgent care visits are feasible, safe and potentially beneficial in increasing convenient access to urgent and primary care.
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Affiliation(s)
- Patrick H Brunett
- Division of Graduate Medical Education, Oregon Health & Science University, Portland, OR, USA
| | - Albert DiPiero
- Division of General Internal Medicine & Geriatrics, Oregon Health & Science University, Portland, OR, USA ZoomCare, Portland, OR, USA
| | - Christine Flores
- Division of Graduate Medical Education, Oregon Health & Science University, Portland, OR, USA
| | - Dongseok Choi
- Division of Graduate Medical Education, Oregon Health & Science University, Portland, OR, USA
| | | | - Donald E Girard
- Division of Graduate Medical Education, Oregon Health & Science University, Portland, OR, USA Division of General Internal Medicine & Geriatrics, Oregon Health & Science University, Portland, OR, USA
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Blank L, Baxter S, Woods HB, Goyder E, Lee A, Payne N, Rimmer M. Referral interventions from primary to specialist care: a systematic review of international evidence. Br J Gen Pract 2014; 64:e765-74. [PMID: 25452541 PMCID: PMC4240149 DOI: 10.3399/bjgp14x682837] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 06/11/2014] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Demand management defines any method used to monitor, direct, or regulate patient referrals. Strategies have been developed to manage the referral of patients to secondary care, with interventions that target primary care, specialist services, or infrastructure. AIM To review the international evidence on interventions to manage referral from primary to specialist care. DESIGN AND SETTING Systematic review. METHOD Iterative, systematic searches of published and unpublished sources public health, health management, management, and grey literature databases from health care and other industries were undertaken to identify recent, relevant studies. A narrative synthesis of the data was completed to structure the evidence into groups of similar interventions. RESULTS The searches generated 8327 unique results, of which 140 studies were included. Interventions were grouped into four intervention categories: GP education (n = 50); process change (n = 49); system change (n = 38); and patient-focused (n = 3). It is clear that there is no 'magic bullet' to managing demand for secondary care services: although some groups of interventions may have greater potential for development, given the existing evidence that they can be effective in specific contexts. CONCLUSIONS To tackle demand management of primary care services, the focus cannot be on primary care alone; a whole-systems approach is needed because the introduction of interventions in primary care is often just the starting point of the referral process. In addition, more research is needed to develop and evaluate interventions that acknowledge the role of the patient in the referral decision.
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Affiliation(s)
- Lindsay Blank
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Susan Baxter
- School of Health and Related Research, University of Sheffield, Sheffield
| | | | - Elizabeth Goyder
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Andrew Lee
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Nick Payne
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Melanie Rimmer
- School of Health and Related Research, University of Sheffield, Sheffield
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Kirsh SR, Ho PM, Aron DC. Providing specialty consultant expertise to primary care: an expanding spectrum of modalities. Mayo Clin Proc 2014; 89:1416-26. [PMID: 24889514 DOI: 10.1016/j.mayocp.2014.04.016] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 04/11/2014] [Accepted: 04/16/2014] [Indexed: 01/18/2023]
Abstract
In most models of health care delivery, the bulk of services are provided in primary care and there is frequent request for the input of specialty consultants. A critical issue for current and future health care systems is the effective and efficient delivery of specialist expertise for clinicians and patients. Input on a patient's care from specialty consultants usually requires a face-to-face visit between the patient and the consultant. New and complementary models of knowledge sharing have emerged. We describe a framework assessment of a spectrum of knowledge-sharing methods in the context of a patient-centered medical home. This framework is based on our experience in the Veterans Health Administration and a purposive review of the literature. These newer modes of specialty consultation include electronic consultation, secure text messaging, telemedicine of various types, and population preemptive consults. In addition to describing these modes of consultation, our framework points to several important areas in which further research is needed to optimize effectiveness.
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Affiliation(s)
- Susan R Kirsh
- Office of Specialty Care, Veterans Health Administration, Washington, DC; Office of Specialty Care/VA HSR&D QUERI Evaluation Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH; Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, OH
| | - P Michael Ho
- Office of Specialty Care/VA HSR&D QUERI Evaluation Center, Eastern Colorado Health Care System Medical Center, Aurora, CO; Department of Medicine, School of Medicine, University of Colorado Denver, Aurora, CO
| | - David C Aron
- Office of Specialty Care/VA HSR&D QUERI Evaluation Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH; Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, OH; Department of Organizational Behavior, Weatherhead School of Management, Cleveland, OH.
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Goudie C, Lunt D, Reid S, Sanders R. Ophthalmic digital image transfer: benefits to triage, patient care and resource. Ophthalmic Physiol Opt 2014; 34:628-35. [PMID: 25223370 DOI: 10.1111/opo.12154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 08/13/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE Hospital capacity in the UK is currently significantly challenged due to new treatments, targets and resource limitations. There have been significant improvements in training, equipment and shared care services in community primary care optometry services. Despite this the challenges to ophthalmic service delivery are considerable. One area of potential benefit is the effect on outcome when a clinical image is attached to a referral. We aimed to quantify the effect of attaching digital images to ophthalmic referrals. METHODS Retrospective analysis of 358 consecutive optometry referrals to the Hospital Eye Service in Dunfermline, Scotland using electronic referral with digital images. All images were screened by consultant ophthalmologists. RESULTS The patients were aged between 9 and 100 years (mean age 63.6 years). Sixty four (18%) referrals were deemed urgent (requiring appointment within 24-60 h), with the majority, 28 (8%) being wet macular degeneration. One hundred and seventy (48%) were deemed routine (appointment within 2-6 weeks), with categories including macular disease, glaucoma, cataract, optic disc and retinal abnormalities. Twenty seven (8%) patients were already attending the hospital eye service, or had been referred previously for the same condition. Categories were mainly glaucoma, diabetic retinopathy and cataract. Ninety-five (25%) were 'e-diagnosed' based on image and referral information (i.e. with no secondary eye care appointment). Diagnosis included glaucoma suspect (22, 6%), macular pathology (12, 3%), abnormal looking discs (9, 2.5%) and cataract (9, 2.5%). The overall 'did not attend' rate for those patients seen in the hospital eye service (254) was <1% (two patients). CONCLUSIONS The attachment of digital images improved the quality of referral triaging from optometry to secondary eye care in the hospital eye service. It allowed detection of sight threatening disease early and more appropriate allocation of patients to specific specialist clinics at first visit. They allowed safe and speedy 'e-diagnosis' of a subgroup, saving hospital capacity and minimising patient inconvenience. Indirectly the service also reduced the 'did not attend' rate. With recent improvements in camera and internet technology digital images will have an ever increasing role in secondary eye care as it continues to adapt to meet modern demands.
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Affiliation(s)
- Colin Goudie
- Department of Ophthalmology, Queen Margaret Hospital, Dunfermline, Scotland, UK
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Teledermatology: Key factors associated with reducing face-to-face dermatology visits. J Am Acad Dermatol 2014; 71:570-6. [DOI: 10.1016/j.jaad.2014.02.021] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 02/15/2014] [Accepted: 02/18/2014] [Indexed: 11/24/2022]
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Askari A, Khodaie M, Bahaadinbeigy K. The 60 most highly cited articles published in the Journal of Telemedicine and Telecare and Telemedicine Journal and E-health. J Telemed Telecare 2014; 20:35-43. [DOI: 10.1177/1357633x13519899] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Summary We analysed the most highly cited articles in two specialist telemedicine journals, the Journal of Telemedicine and Telecare (JTT) and Telemedicine Journal and E-health (TJEH). Articles were extracted from the Science Citation Index Expanded in September 2012. A total of 1810 articles were listed for the JTT and 1550 for TJEH. In the JTT, the mean number of citations was 43 (SD 13); in TJEH the mean number of citations was 30 (SD 11). The average number of citations for the JTT was significantly higher than for TJEH ( P < 0.001). In each journal, the 60 articles which had the most citations were identified as highly cited publications (HCPs). The 60 HCPs in the JTT originated from 16 countries; the 60 HCPs in TJEH originated from 10 countries. Considering both journals together, the majority of HCPs came from the US, UK, Australia and Canada. In the JTT, the mean number of authors for each HCP was 4.6 (SD = 3.1); in TJEH, the mean number of authors for each HCP was 4.5 (SD = 2.3). There was no difference between the two journals ( P = 0.84) and the characteristics of the HCPs published in the JTT and TJEH were broadly similar. Although HCPs are not a direct method of measuring quality, they are an indicator of the scientific impact of the articles.
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Affiliation(s)
- Azam Askari
- Medical Informatics Research Centre, Institute of Futures Studies in Health, Kerman University of Medical Science, Kerman, Iran
| | - Mahdieh Khodaie
- Medical Informatics Research Centre, Institute of Futures Studies in Health, Kerman University of Medical Science, Kerman, Iran
| | - Kambiz Bahaadinbeigy
- Research Center for Modelling in Health, Institute of Future Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
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Philp JC, Frieden IJ, Cordoro KM. Pediatric teledermatology consultations: relationship between provided data and diagnosis. Pediatr Dermatol 2013; 30:561-7. [PMID: 23889079 DOI: 10.1111/pde.12180] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
There is a shortage of pediatric dermatologists. Teledermatology has emerged as a tool to facilitate access to dermatologists. Many questions remain regarding how to optimize consultations in order to provide the best diagnosis and management recommendations. The aim of this retrospective cohort study was to categorize the historical data and judge the adequacy of photographs sent by referring providers to our academic pediatric teledermatology practice at the University of California, San Francisco, and to evaluate the relationship of these data to our ability to render a diagnosis. A diagnosis was rendered in 75% of cases. The only historical data associated with receiving a diagnosis was prior treatment (OR 2.01, CI 1.01, 4, p < 0.05). Appropriate image distance from the target was associated with receiving a diagnosis for rashes (OR 2.69, CI 1.07, 6.8, p = 0.04) and growths (OR 4.16, CI 1.04, 16.6, p = 0.04). A lack of diagnosis was significantly associated with a recommendation for referral for biopsy (OR 0.03, CI 0.01, 0.10, p < 0.0001) or for in-person consultation (OR 0.19, CI 0.05, 0.66, p < 0.001). In conclusion, pediatric teledermatologists are able to make a diagnosis most of the time, regardless of historical information provided or image quality. The rate of diagnosis may be improved with the use of standardized templates for historical information. Similarly, photography training could minimize the need for in-person consultation. Specific information regarding prior treatments could also help in providing useful management recommendations.
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Affiliation(s)
- Julie C Philp
- Department of Dermatology, University of California, San Francisco, San Francisco, California
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Whited JD, Warshaw EM, Kapur K, Edison KE, Thottapurathu L, Raju S, Cook B, Engasser H, Pullen S, Moritz TE, Datta SK, Marty L, Foman NA, Suwattee P, Ward DS, Reda DJ. Clinical Course Outcomes for Store and Forward Teledermatology Versus Conventional Consultation: A Randomized Trial. J Telemed Telecare 2013; 19:197-204. [DOI: 10.1177/1357633x13487116] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We assessed the clinical course of patients after store and forward teledermatology in comparison with conventional consultations. Patients being referred from primary care to dermatology clinics were randomly assigned to teledermatology or a conventional consultation. A total of 392 patients were randomized; 261 patients completed the study and were included in the analysis. Their clinical course was rated on a five-point scale by a panel of three dermatologists, blinded to study assignment, who reviewed serial digital image sets. The clinical course was assessed by comparing images sets between baseline and first clinic visit (if one occurred) and between baseline and nine months. There was no evidence to suggest a difference between the two groups in either clinical course between baseline and nine months post-referral ( P = 0.88) or between baseline and the first dermatology clinic visit ( P = 0.65). Among teledermatology referrals, subsequent presentation for an in-person dermatology clinic visit was significantly correlated with clinical course ( P = 0.023). Store and forward teledermatology did not result in a significant difference in clinical course at either of two post-referral time periods.
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Affiliation(s)
- John D Whited
- Durham Veterans Affairs Medical Center, Durham, North Carolina, USA (current affiliation)
- Harry S Truman Memorial Veterans’ Hospital, Columbia, Missouri, USA
| | - Erin M Warshaw
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
- Department of Dermatology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kush Kapur
- Department of Dermatology, University of Missouri Columbia, Missouri, USA
| | - Karen E Edison
- Cooperative Studies Program Coordinating Center, Edward Hines Jr Veterans Affairs Hospital, Hines, Illinois
| | - Lizy Thottapurathu
- Department of Dermatology, University of Missouri Columbia, Missouri, USA
| | - Srihari Raju
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Bethany Cook
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Holly Engasser
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Samantha Pullen
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Thomas E Moritz
- Department of Dermatology, University of Missouri Columbia, Missouri, USA
| | - Santanu K Datta
- Durham Veterans Affairs Medical Center, Division of General Internal Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Lucinda Marty
- Saint Cloud Veterans Affairs Healthcare System, Saint Cloud, Minnesota, USA
| | - Neal A Foman
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
- Department of Dermatology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Pitiporn Suwattee
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
- Department of Dermatology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Dana S Ward
- Cooperative Studies Program Coordinating Center, Edward Hines Jr Veterans Affairs Hospital, Hines, Illinois
| | - Domenic J Reda
- Department of Dermatology, University of Missouri Columbia, Missouri, USA
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Borooah S, Grant B, Blaikie A, Styles C, Sutherland S, Forrest G, Curry P, Legg J, Walker A, Sanders R. Using electronic referral with digital imaging between primary and secondary ophthalmic services: a long term prospective analysis of regional service redesign. Eye (Lond) 2012; 27:392-7. [PMID: 23258310 DOI: 10.1038/eye.2012.278] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Demands on publicly funded ophthalmic services worldwide continue to increase with new treatments, waiting time targets, working time limits, and restricted budgets. These highlight the necessity to develop innovative ways of utilising existing capacity more effectively. METHOD A new regional, fully electronic ophthalmic-referral service with digital imaging was trialled using existing information-technology (IT) infrastructure. Following successful pilot study, the service was rolled out regionally. Service delivery data was prospectively collated for all the attendances in the year prior to (2006) and the year following (2008) introduction. RESULTS Comparing 2006 against 2008, median waiting times reduced (14 vs 4 weeks), and fewer new patients were observed (8714 vs 7462 P<0.0001), with 1359 referrals receiving electronic diagnosis (e-diagnosis). New patient did not arrive (635 vs 503 P<0.0001) and emergencies also reduced (2671 v 1984 P<0.0001). DISCUSSION Novel use of existing IT infrastructure improves communication between primary and secondary care. This promotes more effective use of limited outpatient capacity by retaining patients with non-progressive, asymptomatic pathology in the community, whilst fast-tracking patients with sight-threatening disease. Resultant significant, sustained improvements in regional service delivery point to a simple model that could easily be adopted by other providers of universal healthcare globally.
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Affiliation(s)
- S Borooah
- Princess Alexandra Eye Pavilion, Edinburgh, UK.
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Palen TE, Price D, Shetterly S, Wallace KB. Comparing virtual consults to traditional consults using an electronic health record: an observational case-control study. BMC Med Inform Decis Mak 2012; 12:65. [PMID: 22769592 PMCID: PMC3502437 DOI: 10.1186/1472-6947-12-65] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 06/25/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients have typically received health care through face-to-face encounters. However, expansion of electronic communication and electronic health records (EHRs) provide alternative means for patient and physicians to interact. Electronic consultations may complement regular healthcare by providing "better, faster, cheaper" processes for diagnosing, treating, and monitoring health conditions. Virtual consultation between physicians may provide a method of streamlining care, potentially saving patients the time and expense of added visits. The purpose of this study was to compare physician usage and patient satisfaction with virtual consultations (VCs) with traditional consultations (TCs) facilitated within an EHR. METHODS We conducted an observational case-control survey study within Kaiser Permanente, Colorado. A sample of patients who had VCs requested by physicians (N = 270) were matched with patients who had TCs requested by physicians (N = 270), by patient age, gender, reason for the consult, and specialty department. These patients (VC and TC), were invited to participate in a satisfaction survey. In addition, 205 primary care physicians who submitted a VC or TC were surveyed. RESULTS During the study period, 58,146 VC or TC were requested (TC = 96.3%). Patients who completed a satisfaction survey (267 out of 540 patients, 49.4% response rate) indicated they were satisfied with their care, irrespective of the kind of consult (mean 10-point Likert score of 8.5). 88 of 205 primary care physicians surveyed (42.9%) returned at least one survey; VC and TC survey response rates and consulted departments were comparable (p = 0.13). More TCs than VCs requested transfer of patient care (p = 0.03), assistance with diagnosis (p = 0.04) or initiating treatment (p =0.04). Within 3 weeks of the consultation request, 72.1% of respondents reported receiving information from VCs, compared with 33.9% of the TCs (p < 0.001). Utility of information provided by consultants and satisfaction with consultations did not differ between VCs and TCs. CONCLUSIONS Referring physicians received information from consultants more quickly from VCs compared with TCs, but the value and application of information from both types of consultations were similar. VCs may decrease the need for face-to-face specialty encounters without a decrease in the patient's perception of care.
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Affiliation(s)
- Ted E Palen
- Department of Internal Medicine, Colorado Permanente Medical Group, Institute for Health Research, Kaiser Permanente, Denver, CO, USA.
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Kehle SM, Greer N, Rutks I, Wilt T. Interventions to improve veterans' access to care: a systematic review of the literature. J Gen Intern Med 2011; 26 Suppl 2:689-96. [PMID: 21989623 PMCID: PMC3191217 DOI: 10.1007/s11606-011-1849-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To conduct a systematic review to address the following key questions: (1) what interventions have been successful in improving access for veterans with reduced health care access? (2) Have interventions that have improved health care access led to improvements in process and clinical outcomes? DATA SOURCES OVID MEDLINE, CINAHL, PsychINFO. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS English language articles published in peer-reviewed journals from 1990 to June 2010. All interventions designed to improve access to health care for US veterans that reported the impact of the intervention on perceived (e.g., satisfaction with access) or objective (e.g., travel time, wait time) access were included. APPRAISAL AND SYNTHESIS METHODS: Investigators abstracted data on study design, study quality, intervention, and impact of the intervention on access, process outcomes, and clinical outcomes. RESULTS Nineteen articles (16 unique studies) met the inclusion criteria. While there were a small number of studies in support of any one intervention, all showed a positive impact on either perceived or objective measures of access. Implementation of Community Based Outpatient Clinics (n = 5 articles), use of Telemedicine (n = 5 articles), and Primary Care Mental Health Integration (n = 6 articles) improved access. All 16 unique studies reported process outcomes, most often satisfaction with care and utilization. Four studies reported clinical outcomes; three found no differences. LIMITATIONS Included studies were largely of poor to fair methodological quality. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Interventions can improve access to health care for veterans. Increased access was consistently linked to increased primary care utilization. There was a lack of data regarding the link between access and clinical outcomes; however, the limited data suggest that increased access may not improve clinical outcomes. Future research should focus on the quality and appropriateness of care and clinical outcomes.
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Affiliation(s)
- Shannon M Kehle
- Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, USA.
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Duursma F, Schers HJ, Vissers KC, Hasselaar J. Study protocol: optimization of complex palliative care at home via telemedicine. A cluster randomized controlled trial. BMC Palliat Care 2011; 10:13. [PMID: 21827696 PMCID: PMC3176474 DOI: 10.1186/1472-684x-10-13] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 08/09/2011] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Due to the growing number of elderly with advanced chronic conditions, healthcare services will come under increasing pressure. Teleconsultation is an innovative approach to deliver quality of care for palliative patients at home. Quantitative studies assessing the effect of teleconsultation on clinical outcomes are scarce. The aim of this present study is to investigate the effectiveness of teleconsultation in complex palliative homecare. METHODS/DESIGN During a 2-year recruitment period, GPs are invited to participate in this cluster randomized controlled trial. When a GP refers an eligible patient for the study, the GP is randomized to the intervention group or the control group. Patients in the intervention group have a weekly teleconsultation with a nurse practitioner and/or a physician of the palliative consultation team. The nurse practitioner, in cooperation with the palliative care specialist of the palliative consultation team, advises the GP on treatment policy of the patient. The primary outcome of patient symptom burden is assessed at baseline and weekly using the Edmonton Symptom Assessment Scale (ESAS) and at baseline and every four weeks using the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes are self-perceived burden from informal care (EDIZ), patient experienced continuity of medical care (NCQ), patient and caregiver satisfaction with the teleconsultation (PSQ), the experienced problems and needs in palliative care (PNPC-sv) and the number of hospital admissions. DISCUSSION This is one of the first randomized controlled trials in palliative telecare. Our data will verify whether telemedicine positively affects palliative homecare. TRIAL REGISTRATION The Netherlands National Trial Register NTR2817.
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Affiliation(s)
- Froukje Duursma
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
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Estimating travel reduction associated with the use of telemedicine by patients and healthcare professionals: proposal for quantitative synthesis in a systematic review. BMC Health Serv Res 2011; 11:185. [PMID: 21824388 PMCID: PMC3178488 DOI: 10.1186/1472-6963-11-185] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Accepted: 08/08/2011] [Indexed: 11/15/2022] Open
Abstract
Background A major benefit offered by telemedicine is the avoidance of travel, by patients, their carers and health care professionals. Unfortunately, there is very little published information about the extent of avoided travel. We propose to undertake a systematic review of literature which reports credible data on the reductions in travel associated with the use of telemedicine. Method The conventional approach to quantitative synthesis of the results from multiple studies is to conduct a meta analysis. However, too much heterogeneity exists between available studies to allow a meaningful meta analysis of the avoided travel when telemedicine is used across all possible settings. We propose instead to consider all credible evidence on avoided travel through telemedicine by fitting a linear model which takes into account the relevant factors in the circumstances of the studies performed. We propose the use of stepwise multiple regression to identify which factors are significant. Discussion Our proposed approach is illustrated by the example of teledermatology. In a preliminary review of the literature we found 20 studies in which the percentage of avoided travel through telemedicine could be inferred (a total of 5199 patients). The mean percentage avoided travel reported in the 12 store-and-forward studies was 43%. In the 7 real-time studies and in a single study with a hybrid technique, 70% of the patients avoided travel. A simplified model based on the modality of telemedicine employed (i.e. real-time or store and forward) explained 29% of the variance. The use of store and forward teledermatology alone was associated with 43% of avoided travel. The increase in the proportion of patients who avoided travel (25%) when real-time telemedicine was employed was significant (P = 0.014). Service planners can use this information to weigh up the costs and benefits of the two approaches.
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Colven R, Shim MHM, Brock D, Todd G. Dermatological diagnostic acumen improves with use of a simple telemedicine system for underserved areas of South Africa. Telemed J E Health 2011; 17:363-9. [PMID: 21599529 DOI: 10.1089/tmj.2010.0163] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Telemedicine holds promise as a tool for improving the delivery of specialty care, especially in underserved regions, including those in South Africa. However, data that demonstrate the extent of its sustainable benefits to referring providers are currently insufficient. This study investigates whether utilization of a teledermatology network enhances the diagnostic acumen of primary care providers (PCPs) in underserved areas of South Africa. MATERIALS AND METHODS A longitudinal descriptive pilot study was conducted after establishing a telemedicine network linking University of Cape Town dermatology consultants to six providers from five underserved primary care sites using store-and-forward technology between October 2004 and January 2007. Of 120 total referrals, trend analysis was performed using 72 sets of patient histories, digital images, and corresponding consultant responses to evaluate the diagnostic concordance between six PCPs and teleconsultants over 12 consecutive referrals. RESULTS Strong positive Spearman rank-order correlations were observed between the number of referrals sent per PCP and proportion of primary diagnostic agreement with teledermatologists, rs=0.86 (p <0.001). The mean primary diagnostic concordance trend that started at 13% for the first four referrals increased nearly fourfold after referring as few as nine patients to the network. CONCLUSIONS If a simple and inexpensive teledermatology solution is carefully implemented in a resource-limited setting, an improvement of PCP diagnostic acumen can be achieved with a relatively small number of referrals. This educational benefit to referring PCPs could be sustainable and would ultimately enhance the quality of dermatological care in these underserved regions.
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Affiliation(s)
- Roy Colven
- Division of Dermatology, University of Washington School of Medicine, Seattle, WA, USA.
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Warshaw EM, Hillman YJ, Greer NL, Hagel EM, MacDonald R, Rutks IR, Wilt TJ. Teledermatology for diagnosis and management of skin conditions: A systematic review. J Am Acad Dermatol 2011; 64:759-72. [PMID: 21036419 DOI: 10.1016/j.jaad.2010.08.026] [Citation(s) in RCA: 182] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Revised: 08/04/2010] [Accepted: 08/21/2010] [Indexed: 01/08/2023]
Affiliation(s)
- Erin M Warshaw
- Minneapolis Veterans Affairs Medical Center, Center for Chronic Disease Outcomes Research, Minneapolis, Minnesota 55417, USA.
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Herce J, Lozano R, Salazar CI, Rollon A, Mayorga F, Gallana S. Management of Impacted Third Molars Based on Telemedicine: A Pilot Study. J Oral Maxillofac Surg 2011; 69:471-5. [DOI: 10.1016/j.joms.2010.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Revised: 07/26/2010] [Accepted: 09/22/2010] [Indexed: 10/18/2022]
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Edison KE, Chance L, Martin K, Braudis K, Whited JD. Users and Nonusers of University-Based Dermatology Services Following a Teledermatology Encounter: A Retrospective Descriptive Analysis. Telemed J E Health 2011; 17:14-8. [DOI: 10.1089/tmj.2010.0098] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Karen E. Edison
- Department of Dermatology, University of Missouri School of Medicine, Columbia, Missouri
| | - Louanne Chance
- Department of Dermatology, University of Missouri School of Medicine, Columbia, Missouri
| | - Kari Martin
- Department of Dermatology, University of Missouri School of Medicine, Columbia, Missouri
| | - Kara Braudis
- Department of Dermatology, University of Missouri School of Medicine, Columbia, Missouri
| | - John D. Whited
- Research Service, Departments of Medicine and Dermatology, Harry S. Truman Memorial Veterans' Hospital, University of Missouri School of Medicine, Columbia, Missouri
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