Improving cooperation between general practitioners and dermatologists via telemedicine: study protocol of the cluster-randomized controlled TeleDerm study

TELEDerm: Implementing store-and-forward teledermatology consultations in general practice: Results of a cluster randomized trial

BACKGROUND

Although teledermatology has been proven internationally to be an effective and safe addition to the care of patients in primary care, there are few pilot projects implementing teledermatology in routine outpatient care in Germany. The aim of this cluster randomized controlled trial was to evaluate whether referrals to dermatologists are reduced by implementing a store-and-forward teleconsultation system in general practitioner practices.

METHODS

Eight counties were cluster randomized to the intervention and control conditions. During the 1-year intervention period between July 2018 and June 2019, 46 general practitioner practices in the 4 intervention counties implemented a store-and-forward teledermatology system with Patient Data Management System interoperability. It allowed practice teams to initiate teleconsultations for patients with dermatologic complaints. In the four control counties, treatment as usual was performed. As primary outcome, number of referrals was calculated from routine health care data. Poisson regression was used to compare referral rates between the intervention practices and 342 control practices.

RESULTS

The primary analysis revealed no significant difference in referral rates (relative risk  = 1.02; 95% confidence interval = 0.911-1.141; p = .74). Secondary analyses accounting for sociodemographic and practice characteristics but omitting county pairing resulted in significant differences of referral rates between intervention practices and control practices. Matched county pair, general practitioner age, patient age, and patient sex distribution in the practices were significantly related to referral rates.

CONCLUSIONS

While a store-and-forward teleconsultation system was successfully implemented in the German primary health care setting, the intervention's effect was superimposed by regional factors. Such regional factors should be considered in future teledermatology research.

Comanagement of Rashes by Primary Care Providers and Dermatologists: A Retrospective Study

BACKGROUND

There is a high demand for managing skin disease, and dermatologists are in short supply.

OBJECTIVES

To better understand how rashes and other specific skin conditions are co-managed by primary care providers (PCPs) and dermatologists, we estimated the frequency with which PCPs sought consultation with or referral to dermatology and the proportion of patients who had a follow-up dermatology office visit in the following 90 days.

DESIGN AND SETTING

The retrospective longitudinal study included 106,459 patients with a skin condition diagnosed by 3,830 PCPs, from January 2017 to March 2017.

METHODS

Comprehensive electronic medical record data with generalized linear mixed modeling accounted for patient factors including diagnosis and clustering by medical center and PCP.

RESULTS

PCPs escalated 9% of patients to dermatology through consultation or referral, while 5% required a follow-up dermatology office visit within 90 days. Patients with bullous, hair, or pigment conditions or psoriasis were most likely to be escalated. Clustering of escalation and follow-up visits was minimal in relation to medical center (intraclass correlation, 0.04 for both outcomes) or PCP (escalation, intraclass correlation, 0.16; follow-up visits, 0.09).

DISCUSSION

Improving primary care education in skin disease and, for certain skin conditions, standardizing approaches to workup, treatment, and escalation may further streamline care and reduce pressure on the dermatologist workforce.

CONCLUSION

PCPs managed 91% of rashes without consultation or referral to dermatology, and the frequency of patients scheduled for dermatology office visits after primary care was similar from one PCP to another.

Status quo and perspectives of dermatology hospitals in Germany: spectra of health care and staff situation

BACKGROUND

Inpatient care in Germany has been subject to change since the introduction of the DRG-based payment system. There have been no publications on important differentiating factors such as the spectrum of care and the staffing situation in dermatology.

METHODS

Health care analysis of 115 dermatology hospitals in October 2019 using a structured survey questionnaire.

RESULTS

On average, the spectrum of care included 31.0 % general dermatology, 33.6 % surgical dermatology, 15.6 % oncology, and 10.1 % allergology. The clinics had an average of 14 full-time positions and 3 part-time positions (university clinics: 23/5, non-university clinics: 9/2). The mean nationwide proportion of women in the physician teams showed the following distribution: postgraduate physicians 73.3 %, senior physicians 53.0 %, directors 20.0 %. The applicant situation of senior physicians and specialists was assessed as predominantly poor, that of residents as predominantly good. Worse applicant situations were present in non-university hospitals and in rural areas. The satisfaction of the medical directors with the current conditions of inpatient care showed a variable assessment independent of university hospital and non-university hospital status. However, the threat to inpatient care was predominantly assessed as low (71.6 %).

CONCLUSIONS

The overall situation of inpatient dermatological care can be classified as predominantly good. In addition, the majority of dermatology clinics provide a wide range of care with regard to the variety of indications. The general conditions, which in some cases are rated as inadequate, require further measures.

The German health care Innovation Fund - An incentive for innovations to promote the integration of health care

PURPOSE

Many health systems face challenges such as rising costs and lacking quality, both of which can be addressed by improving the integration of different health care sectors and professions. The purpose of this viewpoint is to present the German health care Innovation Fund (IF) initiated by the Federal Government to support the development and diffusion of integrated health care.

DESIGN/METHODOLOGY/APPROACH

This article describes the design and rationale of the IF in detail and provides first insights into its limitations, acceptance and implementation by relevant stakeholders.

FINDINGS

In its first period, the IF offered € 1.2 billion as start-up funding for model implementation and evaluation over a period of four years (2016-2019). This period was recently extended to a second round until 2024, offering € 200 million a year as from 2020. The IF is triggering the support of relevant insurers for the development of new integrated care models. In addition, strict evaluation requirements have led to a large number of health service research projects which assess structural and process improvements and thus enable evidence-based policy decisions.

ORIGINALITY/VALUE

This article is the first of its kind to present the German IF to the international readership. The IF is a political initiative through which to foster innovations and promote integrated health care.

Acceptance of Teledermatological Practices: A Cross-Sectional Study of Practicing Saudi Dermatologists

Background: The increase in demand for Telemedicine globally has continued to rise in recent months, showing remarkable success in a variety of medical fields. As dermatology shows one of the most prolific rates of success, having a clear national picture of practitioner opinion on the subject is important. In this study we aimed to quantify the overall level of acceptance and satisfaction of Saudi dermatologists towards the practice of teledermatology.

Design and setting: Data was collected by means of a survey which included demographic data and level of exposure and overall satisfaction towards Telemedicine in their field. 

Results: A total of 102 questionnaires were returned of which 57.8% had engaged in at least one teleconsultation. Of these, 71.2% showed support for the technology, with negative responses being associated with poor infrastructure or implementation in the workplace.

Conclusion: The acceptance of dermatologists to teledermatology consultations in Saudi Arabia shows a positive tendency, with the majority of those who engaged in the practice saying they would do so again and find it satisfactory. Creating more reliable and robust tools and greater training in their use would be beneficial for its further incorporation.

Lung cancer patients' comorbidities and attendance of German ambulatory physicians in a 5-year cross-sectional study

The majority of lung cancer patients are diagnosed with an advanced stage IV, which has short survival time. Many lung cancer patients have comorbidities, which influence treatment and patients’ quality of life. The aim of the study is to describe comorbidities in incident lung cancer patients and explore their attendance of ambulatory care physicians in Germany. In the observed period, 13,111 persons were first diagnosed with lung cancer (1-year incidence of 36.4 per 100,000). The mean number of comorbidities over 4 quarters was 30.77 ± 13.18; mean Charlson Comorbidity Index was 6.66 ± 2.24. In Germany, ambulatory care physicians most attended were general practitioners (2.6 quarters with contact within 4 quarters). Lung cancer was diagnosed by a general practitioner in 38% of the 13,111 incident patients. The average number of ambulatory care physician contacts over 4 quarters was 35.82 ± 27.31. High numbers of comorbidities and contacts in ambulatory care are common in patients with lung cancer. Therefore, a cross-sectoral and interdisciplinary approach is required for effective, patient-centred care. This was a 5-year cross-sectoral study, based on the InGef research database, which covers anonymized health insurance data of 7.2 million individuals in Germany. Incident lung cancer patients in a 5-year period (2013–2017) were identified. Descriptive statistics were calculated for sociodemographic characteristics, comorbidities, and attendance of ambulatory care physicians.

Mobile technologies to support healthcare provider to healthcare provider communication and management of care

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.

What patients with lung cancer with comorbidity tell us about interprofessional collaborative care across healthcare sectors: qualitative interview study

BACKGROUND

Patients with lung cancer with comorbidity often require treatment and care by different health professionals, in different settings and at different points in time during the course of the disease. In order to organise and coordinate healthcare efficiently, effective information exchange and collaboration between all involved care providers are required. The aim of this study was to assess the views of patients with advanced lung cancer with comorbidity regarding coordination of treatment and care across healthcare sectors.

METHODS

This qualitative study, as part of the main study, The Heidelberg Milestones Communication Approach, used face-to-face guide-based semistructured interviews with patients with advanced lung cancer and their informal caregivers to explore cross-sectoral information exchange and collaboration in Germany. All generated data were audio-recorded, pseudonymised and transcribed verbatim. Data analysis was performed using qualitative content analysis to structure data into themes and subthemes. All data were managed and organised in MAXQDA.

RESULTS

In 15 interviews, participants reported that cross-sectoral collaboration functioned well, if treatments occurred as planned. However, treatment gaps were experienced, especially regarding medication and regimen. As a result, participants felt insecure and obliged to take responsibility for the coordination of healthcare. Patients reported to be in favour of an active patient role but felt that healthcare coordination should still be a responsibility of a care provider. A more intensive information exchange, potentially by using an electronic platform, was expected to strengthen cross-sectoral collaboration.

CONCLUSION

Patients with lung cancer are uncertain about their role in the coordination of treatment and care across healthcare sectors. Healthcare providers should be more aware of care recipients' willingness of taking on a more active role in healthcare coordination.

TRIAL REGISTRATION NUMBER

DRKS00013469.

Digitalisierung in der Medizin während der COVID-19-Pandemie – Möglichkeiten und Grenzen der Teledermatologie

Bei Hautkrankheiten handelt es sich initial oft um Blickdiagnosen. Daher bieten sich dermatologische Fragestellungen für telemedizinische Konsultationen an. Die Ergebnisse zahlreicher internationaler Studien weisen darauf hin, dass die Teledermatologie sowohl von den Patienten als auch den Ärzten in zunehmendem Maße angenommen wird. Nach der Lockerung des Verbots der ausschließlichen Fernbehandlung durch den Ärztetag im Jahr 2018 können Ärzte ihre Patienten auch ohne vorherigen persönlichen Erstkontakt ausschließlich telefonisch oder per Internet behandeln. Durch die Zulassung und den Ausbau der telemedizinischen Tätigkeit in verschiedenen deutschen Bundesländern wurde und wird die Teledermatologie insbesondere während der COVID-19-Pandemie erfolgreich eingesetzt.