A Review of the Use of Telemedicine in Dermatologic Surgery

Coronavirus Disease 2019 in Kidney Transplantation - A 2024 Update

The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 has led to the death of about 7 million people worldwide. When infected, older individuals and those with diabetes, hypertension, cardiovascular disease, and compromised immune system are at higher risk for unfavorable outcomes. These comorbidities are prevalent in kidney transplant candidates and recipients making them inherently vulnerable to severe acute respiratory syndrome coronavirus 2 infection, hence, the significant burden the pandemic has exerted on kidney transplant programs. With the swift discovery and wide-scale availability of vaccines and therapeutics against severe acute respiratory syndrome coronavirus 2, the pandemic is currently behind us allowing transplant programs to relieve their restrictions and resume normal pre-COVID-19 operations. In the aftermath of the pandemic, we discuss the implications for immunosuppression and vaccination, COVID-19-induced kidney injury phenotypes and long COVID-19 symptoms. We also discuss some of the operational aspects the pandemic brought about - mainly the utilization of telemedicine - that are now here to stay.

A Post-COVID Population-Based Analysis of Mohs Micrographic Surgeon Distribution in the United States

BACKGROUND

Policy changes to Mohs micrographic surgery board certification eligibility and population shifts in the wake of the COVID-19 pandemic have significant implications for the accessibility of Mohs micrographic surgeons across the United States.

OBJECTIVE

To examine the geographic distribution of micrographic surgery providers considering recent population trends and assess the impact of certification eligibility changes and population shifts on accessibility.

METHODS AND MATERIALS

Medicare claims data were utilized to identify micrographic surgery providers. Surgeon densities were calculated per 100,000 people by county and state. Population changes were analyzed using US census data.

RESULTS

Practicing micrographic surgeons were concentrated in metropolitan and nonmetropolitan areas. Overall, 80.4% of counties lacked micrographic surgery providers, with rural areas being the most underserved. Population changes varied among states.

CONCLUSION

Shifts in micrographic surgery certification requirements, US population distribution, and micrographic surgeon location emphasize challenges in accessibility, especially in rural areas across the United States.

From diagnosis to intervention: a review of telemedicine's role in skin cancer care

Skin cancer treatment is a core aspect of dermatology that relies on accurate diagnosis and timely interventions. Teledermatology has emerged as a valuable asset across various stages of skin cancer care including triage, diagnosis, management, and surgical consultation. With the integration of traditional dermoscopy and store-and-forward technology, teledermatology facilitates the swift sharing of high-resolution images of suspicious skin lesions with consulting dermatologists all-over. Both live video conference and store-and-forward formats have played a pivotal role in bridging the care access gap between geographically isolated patients and dermatology providers. Notably, teledermatology demonstrates diagnostic accuracy rates that are often comparable to those achieved through traditional face-to-face consultations, underscoring its robust clinical utility. Technological advancements like artificial intelligence and reflectance confocal microscopy continue to enhance image quality and hold potential for increasing the diagnostic accuracy of virtual dermatologic care. While teledermatology serves as a valuable clinical tool for all patient populations including pediatric patients, it is not intended to fully replace in-person procedures like Mohs surgery and other necessary interventions. Nevertheless, its role in facilitating the evaluation of skin malignancies is gaining recognition within the dermatologic community and fostering high approval rates from patients due to its practicality and ability to provide timely access to specialized care.

Factors Associated With Comfort Using Telemedicine for Upper Limb Specialty Care

PURPOSE

There is a growing interest in diagnosis and treatment through telemedicine because of its convenience, accessibility, and lower costs. There are clinician and patient barriers to wider adoption of telemedicine. To support the effective and equitable use of telemedicine, we investigated the patient, illness, and surgeon factors associated with the specialist level of comfort in providing upper limb care via telemedicine.

METHODS

Seventy-five upper-extremity musculoskeletal specialists completed an online survey-based experiment in which they viewed 12 patient scenarios with randomized patient age, gender, diagnosis, pain intensity, and patient preference for surgical treatment (yes or no) and rated their comfort with telemedicine from 0, no comfort, to 10, complete comfort. The participants were able to provide a rationale for their stance in open text boxes. We recorded the following specialist factors: gender, location of practice, years in practice, subspecialty, the supervision of trainees, and surgeon-rated importance of a physical examination.

RESULTS

In a multivariable analysis, greater surgeon comfort using telemedicine was associated with nontrauma conditions, four specific diagnoses, and patients who did not have severe pain. Lower surgeon comfort with telemedicine was associated with the higher clinician-rated importance of a hands-on physical examination and supervising trainees. Text-based reasons provided for relative comfort with telemedicine included nonsurgical treatment and facility of diagnosis based on interviews alone. Text-based reasons for relative discomfort with telemedicine included a perceived need for a hands-on physical examination and a preference for an in-person conversation for specific discussions, including scheduling surgery.

CONCLUSIONS

Greater specialist enthusiasm for telemedicine is associated with personal preferences regarding the upper-extremity condition, patients with less severe pain, and a willingness to forego a hands-on examination.

CLINICAL RELEVANCE

Utilization of telemedicine for upper-extremity specialty care may be facilitated by diagnosis-specific care strategies and strategies for video examination, with a focus on tactics that are effective for people with more intense symptoms.

The impact of COVID-19 on kidney transplant care

The SARS-CoV-2 virus precipitated the coronavirus 2019 (COVID-19) pandemic, which placed considerable strain on healthcare systems and necessitated immediate and rapid alterations in the delivery of healthcare. In the transplant population, COVID-19 directly impacts an inherently vulnerable population in the setting of immunosuppression and co-morbidities, but also further complicates the clinical evaluation and management of kidney transplant candidates and recipients in a strained healthcare environment being challenged by the pandemic. Many transplant centers around the world saw mortality rate spikes in organ recipients related to COVID-19, and changes in care delivery abound. This review evaluates the care of the kidney transplant patient through all phases of the process including pre-operative evaluations, perioperative care, post-transplantation considerations, and how the global pandemic has changed the way we care for our patients.

Survey of Vitreoretinal Specialists in the United States Regarding Telemedicine During the COVID-19 Pandemic

Objective: To evaluate the attitudes, beliefs, and practice patterns of vitreoretinal specialists regarding the utilization of telemedicine during the COVID-19 pandemic, and to identify features which may predict future telemedicine use. Methods: An 11-question anonymous survey was completed electronically in July 2020 by vitreoretinal specialists practicing in the United States. Results: The survey response rate was 13.0% (361/2,774). Thirty-five respondents (9.7%) had used telemedicine before March 1, 2020; after March 1, 2020, 170 (47.1%) reported using telemedicine (p < 0.001). Of the 170 respondents who reported telemedicine use, a majority (65.3%;111/170) performed 0-5 patient visits per week. Female retina specialists, younger physicians, and those with prior telemedicine usage were more likely to use telemedicine. Barriers to telemedicine use included concern for misdiagnosis (332/361, 92.0%), inability to obtain optical coherence tomography imaging (330/361, 91.4%), inability to obtain fundus imaging (327/361, 90.6%), lack of access to and/or comfort with the technology (261/361, 72.3%), potential legal liability (229/361, 63.4%), and low reimbursement (227/361, 62.9%). The majority of respondents (225/361; 62.3%) reported that telemedicine without ancillary imaging was not an acceptable way to evaluate patients. However, 59.2% (214/361) would find telemedicine acceptable if remote imaging was available. Conclusions: The pandemic led to a rapid adoption of telemedicine by vitreoretinal specialists. The majority of specialists using telemedicine performed five or fewer visits per week. The availability of remote imaging may increase confidence in clinical outcomes with a subsequent increase in utilization of telemedicine by vitreoretinal specialists.

Patient Preferences Regarding Virtual Visits in Cutaneous Surgery in the Era of COVID-19

BACKGROUND

The COVID-19 pandemic has caused an increasing shift toward the utilization of telehealth services. There are limited data on patient preferences for these services in dermatologic surgery.

OBJECTIVE

To evaluate patient preferences regarding telehealth in dermatologic surgery for pre- and postsurgical care.

METHODS

A survey was administered to patients in an academic dermatology practice.

RESULTS

Two hundred twenty-four patients participated. An in-person presurgical consultation was preferred by 62.1%, and a postsurgical in-person visit was preferred by 67.7%. The most commonly cited reason was desire for physical interaction with their surgeon. For each 10-year increase in age, there was a 1.26-fold and 1.12-fold increase in preference for in-person consultation and follow-up, respectively. Eighty-seven percent felt safe during office visit, and 41% reported no anxiety regarding fear of contracting COVID-19. The proportion of patients preferring in-person pre- or postsurgical visits was similar regardless of sex, presence of an immunocompromising condition, prior dermatologic surgery, anxiety level for contracting COVID-19, and perceived level of office safety.

CONCLUSION

A majority of patients prefer in-person visits for pre- and postsurgical care. Older patients have a greater preference for in-person care. Anxiety level regarding COVID-19 and perceived level of office safety were not related to preference for in-person visits.

Effect of the COVID‐19 pandemic on surgical oncology practice—Results of an SSO survey

Background and Objectives

The COVID‐19 pandemic significantly affected healthcare delivery, shifting focus away from nonurgent care. The aim of this study was to examine the impact of the pandemic on the practice of surgical oncology.

Methods

A web‐based survey of questions about changes in practice during the COVID‐19 pandemic was approved by the Society of Surgical Oncology (SSO) Research and Executive Committees and sent by SSO to its members.

Results

A total of 121 SSO members completed the survey, 77.7% (94/121) of whom were based in the United States. Breast surgeons were more likely than their peers to refer patients to neoadjuvant therapy (p = 0.000171). Head and neck surgeons were more likely to refer patients to definitive nonoperative treatment (p = 0.044), while melanoma surgeons were less likely to do so (p = 0.029). In all, 79.2% (95/120) of respondents are currently using telemedicine. US surgeons were more likely to use telemedicine (p = 0.004). Surgeons believed telemedicine is useful for long‐term/surveillance visits (70.2%, 80/114) but inappropriate (50.4%, 57/113) for new patient visits.

Conclusion

COVID‐19 pandemic resulted in increased use of neoadjuvant therapy, delays in operative procedures, and increased use of telemedicine. Telemedicine is perceived to be most efficacious for long‐term/surveillance visits or postoperative visits.

Teledermatology in 2020: past, present and future perspectives

Born in 1995, teledermatology (TD) turns 25 years old today. Since then, TD evolved according to patients and physicians needs. The present review aimed to summarize all the efforts and experiences carried out in the field of TD and its subspecialties, the evolution and the future perspectives. A literature search was conducted in PubMed and Google Scholar. The state of the art of the "tele-dermo research" included TD and clinical trials, TD/TDS web platforms, TDS and artificial intelligence studies. Finally, the future perspective of TD/TDS in the era of social distancing was discussed. Using TD in specific situations adds several benefits including time-effectiveness of intervention and reduction in the waiting time for the first visit, reduced travel-costs, reduced sanitary costs, equalization of access from patient to specialistic consult. The communication technologies devices currently available can adequately support the growing needs of tele-assistance. A main limit is the current lack of a common clear European regulation for practicing TD, encompassing privacy issues and data management. The pandemic lockdown of 2020 has highlighted the importance of performing TD for all those patient, elderly and/or fragile, where the alternative would be no care at all. Many efforts are needed to develop efficient workflows and TD programs to facilitate the interplay among the different TD actors, along with practice guidelines or position statements.

Telemedicine versus on-site treatment at a surgical university clinic: Study of 225 consecutive patients

INTRODUCTION

Recently, telemedical services are increasingly used. It remains unclear, if outpatients in general surgery can be treated via telemedicine (e.g. telework). We aimed to evaluate, if diagnosis and therapies of outpatients in general surgery can be found using a mobile healthcare communication app instead of personal contact.

MATERIAL AND METHODS

In a prospective, double blind, anonymized clinical study we included consecutive outpatients at a general surgery department at a university hospital. For the telemedical "treatment" the on-site doctors uploaded variables (e.g. anamnesis, radiograph, etc.) for each patient. The telemedical doctor received the information only via app and did not see the patient physically. Both, the doctor on-site and the virtual telemedical-doctor then uploaded the diagnosis and their suggested therapy - blinded to each other. The outpatient received the on-site treatment only. The virtual treatment was solely for scientific purposes and had no therapeutic impact.

RESULTS

225 consecutive surgical outpatients (53 % female and 47 % male) were included. Mean age was 61 years. In 84 % of cases the telemedical diagnosis matched the on-site diagnosis. The telemedical treatment was not inferior as compared to the on-site treatment in 94 % of all cases and the same therapy was proposed in 76 %. In 6% of all cases the telemedical therapeutic regimen could possibly harm or lead to an over- or under treatment of the patient.

CONCLUSION

Telemedical consultation seems to work in the field of general surgery. Telemedicine in general surgery potentially could decrease waiting time for an appointment and patient frequency. However, the potential harm of a wrong therapy remains due to the lack of a clinical observation.

The Impact of COVID-19 on Otolaryngology Community Practice in Massachusetts

OBJECTIVES

Coronavirus disease 2019 (COVID-19) significantly affected many health care specialties, including otolaryngology. In response to governmental policy changes, many hospitals and private practices in Massachusetts canceled or postponed nonurgent office visits and elective surgeries. The objective of this study was to quantify the impact of COVID-19 on the provision and practice trends of otolaryngology services for 10 private practices in Massachusetts.

STUDY DESIGN

Retrospective review.

SETTING

Multipractice study for community practices in Massachusetts.

METHODS

Electronic billing records from 10 private otolaryngology practices in Massachusetts were obtained for the first 4 months of 2019 and 2020. Questionnaires from these otolaryngology practices were collected to assess financial and staffing impact of COVID-19.

RESULTS

The local onset of the COVID-19 pandemic had a significant decrease of 63% of visits in comparison to equivalent weeks in 2019. Virtual visits overtook in-person visits over time. A greater decline in operating room (OR) procedures than for office procedures was recorded. Ninety percent of practices reduced working hours, and 80% furloughed personnel. Seventy percent of practices applied for the Paycheck Protection Program (PPP).

CONCLUSION

COVID-19 has had a multifaceted impact on private otolaryngology practices in Massachusetts. A significant decline in provision of otolaryngology services aligned with the Massachusetts government's public health policy changes. The combination of limited personnel and personal protective equipment, as well as suspension of nonessential office visits and surgeries, led to decrease in total office visits and even higher decrease in OR procedures.

Telemedicine Services Provided to Medicare Beneficiaries by Otolaryngologists Between 2010 and 2018

Importance

Clinicians are increasingly adopting telemedicine in an effort to expand patient access and efficiently deliver care. However, the extent to which otolaryngologists provide telemedicine services is unclear.

Objective

To characterize recent trends in the use of telemedicine by otolaryngologists to deliver care to Medicare beneficiaries.

Design, Setting, and Participants

A retrospective cross-sectional analysis was conducted between January 1, 2010, and December 31, 2018, using publicly available Medicare Physician/Supplier Procedure Summary data on physicians practicing in the field of otolaryngology and benchmark specialties (dermatology and psychiatry) that provided telemedicine services to Medicare beneficiaries.

Main Outcomes and Measures

Primary outcomes were the mean annual number of telemedicine services delivered per active physician and mean annual payment per active physician for these services. Secondary outcomes included the number, setting, and complexity of telemedicine services.

Results

Between 2010 and 2018, otolaryngologists provided 2127 total telemedicine services (7 unique service types) to Medicare beneficiaries and received $88 574 in total payment for these services. During this period, the mean number of telemedicine services increased at a compound annual growth rate (CAGR) of 11.0%, and the mean Medicare payment per otolaryngologist increased at a CAGR of 21.8%. In comparison, telemedicine use during this period generally increased at a higher rate in the fields of dermatology (mean number of services per active physician at CAGR of 13.0%; mean Medicare payment per active physician at CAGR of 12.5%) and psychiatry (mean number of services per active physician at CAGR of 25.8%; mean Medicare payment per active physician at CAGR of 26.6%). In 2018, outpatient evaluation and management visits accounted for most telemedicine services provided (337 of 353 [95.5%]) and the payments received ($17 542.13 of $18 470.47 [95.0%]) by otolaryngologists. In contrast, physicians in other specialties also provided substantial portions of telemedicine services in the inpatient (psychiatry, 18 403 of 198 478 [9.3%]; dermatology, 231 of 1034 [22.3%]) and skilled nursing facility settings (psychiatry, 14 690 of 198 478 [7.4%]; dermatology, 46 of 1034 [4.4%]).

Conclusions and Relevance

This study suggests that the extent to which otolaryngologists used telemedicine to deliver care to Medicare beneficiaries between 2010 and 2018 was rare. Although there was relative growth in the use of telemedicine by otolaryngologists during this period, absolute growth remained low. Policy makers and provider organizations should support otolaryngologists in the adoption of telemedicine technologies, especially while coronavirus disease 2019 (COVID-19) viral suppression efforts necessitate prolonged restriction of physical clinic throughput.

A Review of Telemedicine Applications in Otorhinolaryngology: Considerations During the Coronavirus Disease of 2019 Pandemic

OBJECTIVE/HYPOTHESIS

Review the published literature of telemedicine's use within otorhinolaryngology (ORL), highlight its successful implementation, and document areas with need of future research.

STUDY DESIGN

State of the Art Review.

METHODS

Three independent, comprehensive searches for articles published on the subject of telemedicine in ORL were conducted of literature available from January 2000 to April 2020. Search terms were designed to identify studies which examined telemedicine use within ORL. Consensus among authors was used to include all relevant articles.

RESULTS

While several, small reports document clinical outcomes, patient satisfaction, and the cost of telemedicine, much of the literature on telemedicine in ORL is comprised of preliminary, proof-of-concept reports. Further research will be necessary to establish its strengths and limitations.

CONCLUSIONS

Particularly during the coronavirus disease of 2019 pandemic, telemedicine can, and should, be used within ORL practice. This review can assist in guiding providers in implementing telemedicine that has been demonstrated to be successful, and direct future research. Laryngoscope, 131:744-759, 2021.

Implementation Guide for Rapid Integration of an Outpatient Telemedicine Program During the COVID-19 Pandemic

BACKGROUND

In the novel coronavirus disease 2019 (COVID-19) pandemic, social distancing has been necessary to help prevent disease transmission. As a result, medical practices have limited access to in-person visits. This poses a challenge to maintain appropriate patient care while preventing a substantial backlog of patients once stay-at-home restrictions are lifted. In practices that are naïve to telehealth as an alternative option, providers and staff are experiencing challenges with telemedicine implementation. We aim to provide a comprehensive guide on how to rapidly integrate telemedicine into practice during a pandemic.

METHODS

We built a toolkit that details the following 8 essential components to successful implementation of a telemedicine platform: provider and staff training, patient education, an existing electronic medical record system, patient and provider investment in hardware, billing and coding integration, information technology support, audiovisual platforms, and patient and caregiver participation.

RESULTS

Rapid integration of telemedicine in our practice was required to be compliant with our institution's COVID-19 task force. Within 3 days of this declaration, our large specialty-care clinic converted to a telemedicine platform and we completed 638 visits within the first month of implementation.

CONCLUSIONS

Effective and efficient integration of a telemedicine program requires extensive staff and patient education, accessory platforms to facilitate video and audio communication, and adoption of new billing codes that are outlined in this toolkit.

Definitions, survey methods, and findings of patient satisfaction studies in teledermatology: a systematic review

Remote consultations likely will grow in importance if the COVID-19 pandemic continues. This review analyzes which methods of teledermatology patients prefer by categorizing how recent studies have defined satisfaction, conducted surveys and concluded patients respond to the different modalities of teledermatology. Using PubMed and Cochrane databases, we reviewed studies from April 5th, 2010 to April 5th, 2020 that included the search terms patient satisfaction and teledermatology. All studies that included patient satisfaction as an outcome were included, but studies not published in English were excluded. We examined domains of satisfaction, survey method, study characteristics (including patient population, country, age, study design and evidence score), findings and statistical comparisons. We thoroughly reviewed 23 studies. Definitions of satisfaction varied, but all concluded patients were satisfied with the live-interactive and store-and-forward modalities. The studies reveal that store-and-forward is appropriate for clinicians with established patients who require regular follow-up. Verified areas of care include treatment of chronic conditions, topical skin cancer therapy, wound monitoring, and post-procedural follow-up. Only four studies conducted statistical analyses. One of those studies compared patient preference for each modality of teledermatology with face-to-face dermatology. While this study reported high satisfaction with each mode of teledermatology, patients still preferred face-to-face. Favorable responses to remote diagnostic capabilities suggest that these offerings improve preference for teledermatology. With only one study evaluating preference between each modality and face-to-face dermatology, more studies should address the discrepancy. Surveys that cover all domains of satisfaction may improve assessments and identify where gaps in preference exist.