Direct to Patient Synchronous Teledermatology During COVID-19 Pandemic

Abstract

Background:

During the COVID-19 pandemic, teledermatology became a popular mode of health care delivery. Thus, deciphering which diagnoses are best suited for synchronous video visits is important to guide providers on appropriate patient care.

Methods:

We conducted a retrospective study of 1,647 submitted synchronous video visits from September 1, 2020 to March 31, 2021 at a single, large academic institution.

Results:

Video visits' follow-up rate was significantly associated with diagnosis subtype (p < 0.001). Compared with patients with skin lesions and nonskin dermatologic conditions, patients with a rash had higher odds of being recommended to have their follow-up visit as a video visit (odds ratio [OR] = 0.222, p < 0.001; OR = 0.296, p < 0.001). Patients with a rash had lower odds of being recommended to have their follow-up visit as an in-person office visit when compared with skin lesions (OR = 9.679, p < 0.001), nonskin dermatologic conditions (OR = 4.055, p < 0.001), and other skin dermatologic conditions (OR = 2.23, p < 0.01). Demographically, employed, middle-aged patients with private insurance made up the majority of video visit usage. African American patients were less likely to utilize a video visit compared with Asian patients (OR = 2.06, p < 0.038).

Conclusions:

Certain dermatologic diagnoses, most notably rashes, are more conducive to video visit management. Rashes made up 86% of new patient video visits, were more likely to have video visit follow-up if needed and were more likely to not require further follow-up indicating that the management of rashes from initial diagnosis to completion in care is suitable for video visit management.

Introduction

The COVID-19 pandemic shifted the landscape of health care delivery, obliging an increase in remote medical visits in the form of telehealth to limit viral spread. For the field of dermatology, this resulted in an abrupt change as most in-person dermatology consultations were either deferred or transitioned to teledermatology.^1
–3 Before the pandemic, teledermatology was minimally used due to limited reimbursements and the need for HIPAA-compliant platforms despite its accuracy in diagnosis.^1

–4 Teledermatology was mainly utilized by large hospital systems and federally funded agencies, which made teledermatology largely inaccessible to most patients.^1

–5

During the pandemic, the Centers for Medicare and Medicaid Services (CMS) released a 1,135 waiver allowing virtual care with reimbursement and flexibility to use non-HIPAA-compliant platforms.^6

–9 With this care delivery through telehealth services now accessible to patients came new questions. Although recent studies emphasize that the diagnostic/management accuracy of teledermatology is comparable to standard in-person care,^7
–9 there have not been any studies on the diagnostic situations for which telehealth visits are most appropriate.⁸

Video visits in dermatology have considerably increased since the COVID-19 pandemic, with studies displaying two to three times more teledermatology video visits compared with before 2019.¹⁰ In fact, the most profound barrier to video visits before the COVID-19 pandemic was the lack of offering by the providers.^11,12

In terms of diagnoses that are more suitable for video visits, isotretinoin follow-up visit is the most established with studies showing decreased no-show rate compared with an in-person visit.¹³ Furthermore, patient surveys report increased satisfaction with isotretinoin follow-up video visits.^13,14 Acne vulgaris is a particular diagnosis in which video visits have been compared with in-person visits with patients reporting video visits as less time consuming and more financially favorable.^15,16 Studies have also described the types of diagnoses occurring at teledermatology visits, yet no study to our knowledge offers guidelines for additional diagnoses most appropriate for telehealth.^17,18

Overall, video visits were not widely accessible to most of the patient population. In particular Black/Asian/Hispanic patients, uninsured patients, rural status, and increasing age are negatively associated with utilizing a virtual visit while employment status and education level were positively associated with virtual visit utilization.^19,20 However, of the minority patients who did utilize video visits, there was a noticeable improvement in appointment adherence with decreased no-show rates compared with in-person clinic visits.^19
–21

It is important to leverage the lessons learned due to large increase in the usage, secondary to the COVID-19 pandemic to allow continued effective usage of video visits in dermatology. We conducted a retrospective chart review of patient data from teledermatology video visits at a single large academic institution between September 2020 and March 2021 with the aim of providing insights into diagnoses best suitable for teledermatology. Second, we sought to understand how demographics may contribute to utilization of telehealth visits.

Methods

STUDY DESIGN

To assess the usage of video visits in a teledermatology context, we conducted a retrospective review of video visits conducted at the University of Michigan Health, a tertiary academic medical center in Ann Arbor, Michigan between September 1, 2020, to March 31, 2021 (Fig. 1).

Fig. 1.

Categorization of video visit diagnoses.

The diagnosis, outcomes, and follow-up recommendations from each video visit were reviewed. If a patient had any additional e-visit (or asynchronous, store-and-forward), video visit, or in-person follow-up appointments during the study period, these were also noted. Patient's age, gender, current insurance, ethnicity/race, occupation, number of children, and marital status at the time of retrospective chart review were taken from the demographics section of the electronic health record for each patient.

We evaluated the follow-up for each visit to better determine whether the initial video visit had been successful for treatment and management of the visit diagnosis. Follow-up visits were either recommended to be e-visits, video visit, or in-person, whereas some visits recommended no additional follow-up. For each visit, the completion status of the follow-up was documented: if completed, if not needed, if completed but as different visit type than recommended, or if the patient never scheduled their follow-up.

PARTICIPANTS

Participants included patients who completed a video visit between September 1, 2020 and March 31, 2021. Inclusion criteria included all video visits completed by the Michigan Medicine Department of Dermatology during the study time frame, along with all follow-ups to those initial visits that occurred during the study time frame, whether through e-visit, video visit, or in-person. Exclusion criteria include erroneous encounters, canceled visits, or those in which the patient did not join the appointment.

ETHICS

Each subject with a video visit during the study period was given a unique code through a random generator that identified them for this study. The study was approved by the Institutional Review Board HUM00198448 Teledermatology during a Pandemic: Appropriate Workflows for Telehealth Visits.

DATA ANALYSES

Data analyses were performed from February to April 2023 using SPSS (version 28.0) and R (version 4.2). Descriptive statistics (proportions) were used to characterize the demographics of the population. Chi square was used to assess for significant differences in age, gender, current insurance, ethnicity/race, occupation, number of children, marital status, and visit type (return vs. new patient) regarding whether they successfully completed the visit or not. A logistic regression was utilized to model the completion of a patient's video visit. Statistical tests were two-tailed with a level of significance set at α = 0.05.

We performed the logistic regression to test whether the completed video visits were associated with their diagnosis subtypes and demographic features mentioned above. We especially focused on the association between the completion of video visits and diagnosis subtypes, adjusting for all other factors. To further explore the factors associated with the recommended follow-up visit type of patients' primary video visit, we dichotomized our four categories of the follow-up recommendations as one versus the rest to be the outcome, and then set up four logistic regression models, accordingly, including patients' diagnosis subtypes and demographic features as covariants. The goodness of fit for our logistic regression models was evaluated by the Hosmer–Lemeshow test.²²

Results

DEMOGRAPHICS

There were 1,416 unique individuals who underwent a video visit during the study time frame. Some underwent multiple video visits but were counted only once for demographic purposes. The median age was 37.02 and 64.8% (n = 917) were female. A majority of patients were Caucasian (n = 1,030, 73.7%) and Non-Hispanic (n = 1,333, 94.1%). Most employment statuses were unknown, but for those known, the most common was employed (n = 416, 29.3%) or current student (n = 417, 29.4%). Furthermore, most patients were married (n = 480, 33.9%) and had private insurance (n = 1,127, 80.0%) (Table 1).

Table 1.

Patient Demographics

N = 1,416	ALL PATIENTS ( n , %)
Insurance
Government	273 (19.3)
Private	1,127 (79.6)
None	16 (1.1)
Race
Asian	137 (9.7)
Black or African American	143 (10.1)
Caucasian	1,030 (72.7)
Other	106 (7.5)
Ethnicity
Non-Hispanic	1,333 (94.1)
Hispanic	61 (4.3)
Unknown	22 (1.6)
Occupation
Employed	416 (29.4)
Retired	85 (6.0)
Student	417 (29.4)
Unknown	498 (35.2)
Gender
Male	499 (35.2)
Female	917(64.8)
Relationship status
Married	480 (33.9)
Other	328 (23.2)
Single	458 (32.3)
Unknown	498 (35.2)
Visit type
New patient	779 (55.0)
Return patient	637 (45.0)
Age
<35	934 (67.5)
>35	713 (32.5)
Patient's number of children
0	362 (25.6)
1–3	321 (22.7)
>3	32 (2.3)
Unknown	701 (48.5)

When compared with African American patients, Asian patients had higher odds of utilizing a video visit, adjusting for all other covariates (odds ratio [OR] = 2.06, p < 0.038). Compared with Caucasian patients, African American patients did not have a significant variation in video visit usage (p < 0.109).

DIAGNOSIS SUBTYPE

There were 1,647 total video visits completed during the study period, of which, visits for rash encompassed the majority of visits (n = 1,297, 78.7%) and the least were for a diagnosis of other skin problems (n = 60, 3.6%) (Table 2). At the completion of the visits, the most common recommendations were for a subsequent video visit (n = 606, 36.8%) or no additional follow-up was needed because the concern was able to be addressed during the visit (n = 611, 37.0%).

Table 2.

Encounter Diagnoses for All Video Visits

DIAGNOSES	ALL VIDEO VISITS COUNT (%)
DIAGNOSES	N = 1,647
Rash	1,297 (78.7)
Nonspecific (includes eczema)	575 (34.9)
Acne	546 (33.2)
Blistering disorder	36 (2.2)
Psoriasis	128 (7.8)
Urticaria	12 (0.7)
Skin lesion/spot	169 (10.3)
Skin lesion	165 (10.0)
Arthropod bite	3 (0.2)
Warts	1 (0.1)
Other, skin condition	60 (3.6)
DRESS/SJS	4 (0.2)
Edema	6 (0.3)
HS/hyperhidrosis	33 (2.0)
Infection	14 (0.8)
Unknown	2 (0.2)
Wound	1 (0.1)
Other, nonskin condition	117 (7.1)
Alopecia	89 (5.4)
Nail changes	9 (0.5)
Ocular or oral lesions	19 (1.2)
Not dermatology	4 (0.2)

DRESS, Drug Rash with Eosinophilia and Systemic Symptoms; HS, Hidradenitis Suppurativa; SJS, Stevens Johnson Syndrome.

With all other demographic covariates adjusted, the diagnosis of rash alone was significantly associated with video visit completion (OR = 1.65, p < 0.040). When compared with patients with skin lesions and nonskin dermatologic conditions, patients with a rash had higher odds of being recommended to have their follow-up visit as a video visit (OR = 0.222, p < 0.001; OR = 0.296, p < 0.001) (Fig. 2). Of all patients recommended to have video visit follow-up, 93% of patients completed the follow-up video visit, 4% of patients never scheduled or missed their follow-up visit, and 3% of patients had an office visit follow-up when they were recommended for video visit follow-up.

Fig. 2.

Recommended follow-up visit type by diagnosis.

Patients with a rash had lower odds of being recommended to have their follow-up visit as an in-person office visit when compared with skin lesions (OR = 9.679, p < 0.001), nonskin dermatologic conditions (OR = 4.055, p < 0.001), and other skin dermatologic conditions (OR = 2.23, p < 0.01).

Patients with a rash had no significant change in likelihood of e-visit follow-up compared with skin lesions, nonskin dermatologic conditions, and other skin dermatologic conditions.

Compared with patients diagnosed with skin lesions, patients with a rash had higher odds of being recommended for no further follow-up (OR = 0.400, p < 0.001).

Discussion

The COVID-19 pandemic decreased in-person dermatology consultations to reduce the spread of the disease, with a subsequent major transition of care to teledermatology.^1
–3 With this shift toward virtual care, an 1,135 waiver was released by the CMS and some major private insurance providers, expanding compensation and eligibility for telehealth services. The CMS expansion, coupled with evidence of patient satisfaction due to convenience, decreased cost, and less time consumption than the traditional office visit, has led to teledermatology becoming an increasingly integral component of the field.^6

–9

This retrospective study aimed to describe the types of diagnoses that were suitable for management over a video visit platform compared with diagnoses that eventually required in-person management. Additionally, this study illustrated discrepancies in synchronous visit usage from a demographic standpoint. To our knowledge, this is the first study analyzing the demographics of patients who were able to complete dermatology video visits, as well as the first to consider the outcomes of teledermatology visits during the pandemic to characterize dermatologic conditions suitable for virtual care.

Overall, this study illustrated that patients who were employed or students, married, had private insurance, and middle aged (around 37 years) were more likely to complete a video visit. These findings align with current trends in overall utilization of teledermatology: those with insurance compared with those without insurance and younger patients were more likely to engage with telehealth.^23

–26 The higher video visit usage of patients with private insurance is likely due to more financial means to readily access and utilize technology. This corresponds with employed patients and students more likely to complete a video visit; however, in contrast to this, another study found that those who completed telehealth visits were not more likely to be employed.²⁷

Although higher rates of telehealth were seen in patients with government insurance, the lower completion rate for those with government insurance compared with private insurance in this study could be due to the governmental insurance encompassing an older subset of patients who may primarily have Medicare.²⁸ Other studies have confirmed technology as a potential barrier to telehealth displaying lower socioeconomic, elderly, and technology illiteracy as barriers to video visits.^28,29

New patients (55%) and returning patients (45%) were roughly equal in completing video visits. This indicates that video visits are amenable to providing initial care of a dermatologic condition and can provide strong continuity of care through video visit follow-up. Furthermore, we show that 93% of patients recommended for video visit did complete their video visit follow-up. Only 3% of patients who were recommended for video visit follow-up converted to an in-person follow-up. This suggests that video visits were likely efficacious in managing patient concerns; however, further follow-up is needed to investigate whether these statistics hold true in a nonpandemic time frame.

Studies have shown disparities in telehealth utilization by race and ethnicity.^26,30 Previous literature has shown that African American, Asian, and Latinx patient populations are negatively associated with utilizing a video visit.^18,19 However, in our results, while no significant conclusions were expressed on African American and Latinx patients, Asian patients were significantly more likely to complete a video visit. Asian Americans are more likely to have access to technology and on average have higher income than other minority groups, which could correlate to higher video visit completion rates.³¹ While studies specific to teledermatology are limited, a comprehensive study of over 10,000 telehealth visits displayed that Asian, younger, and privately insured patients were more likely to utilize video visits.^32
–34 The lower rates of Hispanic and Black or African American patients who completed a video visit compared with the overall population suggest that there may be underlying disparities in access to telehealth based on socioeconomic status and social determinants of health, but this was not statistically significant and requires further analysis.

Additionally, the academic center in this study has fewer minority patients because of its location and outreach, which may further limit the numbers recruited in our study and limits the generalizability of our results to centers with a different demographic profile.

Our results indicate that certain dermatologic diagnoses, most notably rashes, are more likely to be managed through continued video visit follow-up while other diagnoses have a greater need for in-person management. Rash, which includes acne, blistering disorders, psoriasis, urticaria, and nonspecific rash, represents 77% of the video visits conducted. This is consistent with a longitudinal study of over 20,000 patients displaying that only 23% of new rash diagnoses were managed with initial office visit follow-up.³⁵ Furthermore, our results indicate that rashes were not only more likely to have an initial video visit, but also more likely to be recommended for video visit follow-up compared with skin lesions, other skin, and nonskin dermatologic conditions. This is likely because rashes can often be visualized through the virtual physical examination, and in many cases, do not require further examination by touch, dermoscopy, or biopsy. Notably, rashes made up 86% of new patient video visits suggesting that clinicians believed rashes were well equipped for initial video evaluation. This is likely because the most common rashes, such as acne (33% of all video visits), can be diagnosed from history and visual physical exams.

Pre-existing literature strongly displays acne's ability to be managed through a video visit platform; however, most studies focus on isotretinoin follow-up visits as opposed to new acne diagnoses through video visit.³⁶ The initial treatment for acne is stepwise, and often times does not require further intervention such as cryotherapy or biopsy, which makes acne a strong candidate for video visit management, as confirmed by other studies.¹⁶ For returning rash video visits, the diagnosis is usually established, and appointments require monitoring of disease and management of side effects. These visits are likely well-suited for video visits as the physician can adequately address patient concerns through the virtual platform.

Additionally, rashes were more likely than skin lesions to be recommended for no further follow-up. These findings demonstrate that video visits can be used for the entire management of certain rashes from initial diagnosis to follow-up and completion of care, which is similar to success seen in other studies.³⁷ Furthermore, compared with skin lesions, which consist of basal cell carcinoma, squamous cell carcinoma, melanoma, actinic keratoses, and atypical nevi, rashes do not as regularly require further dermoscopy or biopsy.³⁸ Additionally, skin lesions, such as warts, often utilize cryotherapy or laser therapy for removal, which require in-office evaluation and other studies have also suggested this.^38,39 In contrast to our results, a Norwegian study displayed both rashes and skin lesions were suitable for teledermatology; however, the majority of these visits were e-visits as opposed to synchronous video visits.^40,41 This could suggest the possible role of video visit management for skin lesions although more investigation is needed based on our results.

Although rash was more likely than other diagnoses to have video visit follow-up, patients with a rash had no significant difference in likelihood of e-visit follow-up compared with skin lesions, nonskin dermatologic conditions, and other skin dermatologic conditions. An e-visit allows patients to asynchronously submit photos to the provider. This interface likely requires a more thorough assessment of the patient's diagnosis as there is no real-time video discussion or examination of the patient.

Limitations of this study include analysis of patients from only one academic health center that may cater to a specific patient population with access to telehealth platforms. Furthermore, the results obtained in this study lack clear generalizability as patient demographics and diagnoses may differ between academic institutions and community practices in different locations. Furthermore, this study was conducted during the COVID-19 pandemic; future studies are needed to compare this data set with one taken in nonpandemic times as there may be changes in patient preferences for in-person care. This retrospective descriptive data describe which diagnoses and patient demographics were more likely to be managed with continued video visit follow-up; however, we did not assess the quality of care or patient satisfaction with the video visit platform. Additional studies are needed to investigate if the effectiveness of video visits in treating rashes is noninferior to in-person management.

Furthermore, due to the limited and unbalanced number of samples of medical conditions within each subtype, we did not run regression analyses on the subtypes of rashes that would have further defined which specific rash is more suitable for video visits than others. However, the two most prevalent types of rashes, nonspecific rash (34.9% of all video visits) and acne (33.8% of all video visits), had a considerably higher rate of video visit follow-up or no further follow-up compared with other types of rashes.

Conclusion

In summary, this study is unique from pre-existing literature in its retrospective exploration of synchronous video visit management based on dermatology diagnosis subtype and demographics. We illustrate that the diagnosis of rash is more likely to be recommended for video visit follow-up with significantly less need for in-person follow-up compared with other diagnoses. Overall, this study emphasizes that patient demographics and the specific diagnosis contribute to video visit usage. In our study, we saw that 41% of video visits had accompanying patient submitted clinical photos that were available for clinical review before the video visit. Hybrid technology, in which patients send clinically helpful images before the video visits, may improve the quality of video visits and can limit difficulties in visualizing rashes over the video visit platform. Future studies in nonpandemic times and evaluations of the quality of care and patient satisfaction provided over the video visit format are needed to create appropriate use criteria for video visit management of dermatologic conditions.

Footnotes

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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