MILAN – and optimized primary care physicians’ care of nonreferred patients, Cory Simpson, MD, PhD, reported at the World Congress of Dermatology.
Kari Oakes/MDedge News
Dr. Cory Simpson
With implementation of teledermatology, patient wait times for specialist input dropped from 13.9 days to 1.6 days (P less than .00001).
By allowing dermatologists to evaluate photographs of lesions and perform their own triage of referrals from primary care physicians (PCPs), the teletriage pilot program reduced the number of patients for whom dermatology consults were deemed necessary and also allowed optimal management for the nonreferred patients, said Dr. Simpson, of the University of Pennsylvania, Philadelphia.
“Teledermatology has the potential to increase access to dermatologist-level care, especially for underserved patients,” he commented. “It allows us to educate primary care physicians in resource-limited settings, and it also allows us to avoid suboptimal care of skin disease by nonspecialists – especially the more judicious use of antimicrobial agents and corticosteroids.”
Dr. Simpson explained to the international audience that, for many in the United States, access to a dermatologist requires a lengthy wait that can extend to months.
In Philadelphia, University of Pennsylvania dermatology residents and attending physicians volunteer in an outreach program that serves an uninsured population of primarily Latino immigrants. Operating 1 or 2 evenings a month, the medical and surgical dermatology clinics can accommodate from 8-12 appointments per clinic.
The clinic had been overwhelmed with referrals from PCPs, but Dr. Simpson and his colleagues realized that many of the conditions they were seeing – verruca vulgaris, hand dermatitis, and psoriasis, for example – did not necessarily need a face-to-face dermatologic evaluation.
The AccessDerm app, available at no cost by the American Academy of Dermatology, allows PCPs and dermatologists to communicate and collaborate. “This is a store-and-forward program, meaning the primary physician takes the photos and sends them to an off-site dermatologist who can then review them at his or her convenience,” Dr. Simpson said. “It’s a smartphone-based app, so actually, while I was at this conference, even though I’m thousands of miles from Philadelphia, I got through three consults this morning on my smartphone. It’s a very convenient way to be a volunteer.”
The consultation is between the PCP and the dermatologist, he added. “It’s the dermatologist talking to the PCP, and the patient receives the care recommendations from their primary doctor – so there’s no direct communication with the patient.”
Using the app, PCPs photographed skin lesions and completed simple history and physical exam modules within the app. Then, Dr. Simpson and his dermatology colleagues reviewed the photos and pertinent information.
If diagnostic uncertainty persisted after the teledermatology review, or if Dr. Simpson and his colleagues judged that a procedure such as a biopsy or lesion destruction was required, then the patient was scheduled for an appointment, with an interim plan put in place. Otherwise, patients were managed by teledermatology alone.
Of the 131 patients involved in the pilot study, 48 (37%) were female; the average patient age was 31.7 years (range, 1-92 years).
About 40% of patients were seen for inflammatory conditions, and another 20% for nonpigmented neoplasms. Almost 18% were seen for infectious reasons, with the remainder divided between pigmented neoplasms, hair disorders, and other conditions.
It turned out, said Dr. Simpson, that about two-thirds (65%) of the teletriage consultations ended in a definitive plan not requiring a face-to-face dermatology appointment. About a quarter (23%) were deferred to an in-person dermatology appointment, and the remaining 12% had an interim plan while more information was gathered.
Of the 32 neoplasms addressed by the teletriage strategy, 21 (66%) were deferred to an in-person visit. By contrast, 24 of the 95 non–neoplastic teletriage encounters were deferred to an in-person visit (P less than .001).
Overall, the strategy opened up 18% more appointment slots for new patients, Dr. Simpson said.
As part of the teletriage process, PCPs provided their proposed plan of care before receiving a dermatologist’s advice. When comparing the PCP’s plan to the dermatologist’s final plan, he and his colleagues found that there was a complete change of plan for three-quarters of visits (76%). A partial change happened 14% of the time, and only one in ten patients had no change in treatment plan as a result of the teledermatology consult. “This indicates again that specialist input matters,” he noted.
“This also gives us an opportunity to educate primary care physicians,” Dr. Simpson said, pointing out that in replies, he and his dermatologist colleagues included information about common diagnoses, including first-line treatments and “worrisome features they should be thinking about.”
He and his collaborators found that proper treatment would have been provided 30% of the time without a teledermatology consult, but that patients would have been undertreated 27% of the time. Overtreatment would have occurred at a rate of 11%, and care would have been unnecessarily delayed for about one in four patients. Unnecessary ED visits were averted for 6% of patients with the teletriage approach.
Examples of undertreatment included use of a weak topical steroid, missing infections or the need for referral, and using a suboptimal acne regimen. On the other hand, Dr. Simpson said, overtreatment with unnecessary antibiotics, antifungals, and antivirals also was averted; on some occasions, the PCP plan for an oral corticosteroid or an overly potent topical steroid was shifted to a more appropriate plan by teledermatology.
In sum, said Dr. Simpson, “teletriage via AccessDerm allowed us to reduce by tenfold the wait time for specialist input in dermatology cases. We were able to remove almost two-thirds of people from the queue ... waiting for dermatology appointments, which was very helpful to our clinic.”
And most importantly, he added, “this allowed us to allocate the limited number of in-person appointments that we had at this volunteer clinic to those that were more complicated cases.”
Dr. Simpson reported that he had no relevant disclosures. The project was funded by Penn Medicine and the American Academy of Dermatology.