Pediatric Teledermatology in the General Teledermatology Practice: Population Variances in Contrasting Health Care Scenarios

Abstract

Introduction:

Pediatric dermatology access is limited. Pediatric teledermatology (TD) opens the opportunity to explore diverse dermatological pathology promptly. Different TD modalities and providers may influence the consulting population. This study compares a synchronous TD from a private provider with the asynchronous TD of the public sector in Chile’s health care system.

Methods:

A descriptive and inferential analysis of 168 synchronous and 239 asynchronous pediatric teleconsultations, responded from January 2023 to August 2023.

Results:

Pediatric teleconsultations accounted for nearly one-fifth of all consultations in both models. The synchronous group was significantly older (p = 0.0065; 10.18 years ± 5.43 [0–18 years]) than the asynchronous group (8.65 years ± 5.74 [0–18 years]). June marked the highest and lowest teleconsultation volumes in synchronous and asynchronous platforms, respectively. The most frequent diagnostic group in both modalities was the noninfectious inflammatory pathology. Significant differences were noted within this group (p < 0.0001), with acne and dermatitis being predominant in the synchronous model. Significant differences also emerged within the infectious inflammatory group (p = 0.002), with bacterial and fungal infections being more common in the synchronous modality, whereas chronic viral infections predominated in the asynchronous group.

Discussion:

Pediatric TD is an emerging tool that optimizes access, manages the demand, and reduces waiting times. Seasonal variations may influence caregiver preferences for a specific attention model. The consulting population using synchronous and asynchronous modalities differs significantly in age and diagnostic distributions. Understanding these differences is crucial for effectively addressing specific practice gaps in each attention model.

Introduction

The advancement in information and communication technologies has promoted telemedicine as a feasible option for providing health care attention to diverse health care backgrounds.¹ Teledermatology (TD) is a valuable tool for providing dermatologic care to isolated communities and supporting primary care providers.^2,3 It may serve as a tool to optimize patient referrals, manage demand, improve access to timely care, and reduce waiting times.^4,5 In this sense, TD in pediatric patients provides a unique opportunity to promptly explore various pediatric skin pathologies. Previous studies suggest that up to a third of pediatric consultations in primary health care centers are related to a dermatological issue,⁶ but unfortunately, pediatric dermatology services are limited.⁷ In turn, implementing TD in the pediatric population offers reduced waiting times, lower costs, and less exposure of patients to epidemiological risks.⁸ Nevertheless, most studies on pediatric TD systems focus on the synchronous modality, leaving the asynchronous model largely unexplored.

THE CHILEAN SCENARIO

Chile exhibits a unique geographical and demographic distribution, ranking as one of the longest countries in the world.⁹ It faces challenges such as limited connectivity between cities and significant variations in population density across different regions.⁹ Moreover, most specialized resources are concentrated in the central regions, leaving limited access to specialized health care in the distant northern and southern regions.¹⁰ These factors pose significant challenges to access to specialized care, making TD crucial for addressing these unmet needs.^11,12

The health care system in Chile operates on a mixed financing model, comprising a public sector, private sector, and armed forces health care system.¹³ Each sector functions independently,¹⁴ with state funds financing the public sector, covering 76.5% of the population.¹⁵ In contrast, the private sector operates through private health insurance programs, covering 15.4% of the population.¹⁵ Finally, the armed forces health care system covers 1.75% of the population, whereas 4.29% have no affiliation.¹⁵ It is important to note that the public sector covers the lower income portion of the population, financing most health services and providing free access to health care for vulnerable segments. In contrast, the private sector serves the portion of the population with higher incomes. It exhibits shorter waiting times than the public sector but at a higher out-of-pocket expenditure.¹⁵

The public sector establishes a health care network based on case complexity and resources, offering primary, secondary, and tertiary levels of care. Conversely, the private sector primarily focuses on secondary and tertiary care, providing direct access to specialized services upon demand. However, it lacks primary care’s preventive policies and resolvability.¹⁴ In Chile, the public health care sector comprises 29 health care services covering all country regions. The patient’s initial contact with the network is through primary health care centers. If the patient requires an evaluation by a specialist, a referral to secondary care at a reference health care center is necessary.¹⁶ In this context, public service’s asynchronous TD platform acts as a supportive tool for diagnosis and prompt access to dermatological care, linking primary health care and referral centers. It is implemented in the early stages of the referral chain, providing timely access and rapid diagnostic suggestions on a case. It began in 2009, adopting an asynchronous model of attention,¹⁶ and since December 2018, it has been managed through the Hospital Digital Project of the Chilean Ministry of Health.¹⁷

In contrast, the synchronous TD model is only available in the private sector, with a wide range of providers, each with a local flow of attention under the regulatory framework of the Ministry of Health.

This study aims to compare and contrast the databases of pediatric TD consultations in the Chilean health care setting, using the synchronous model of a private center and the asynchronous model of the public system.

Methods

STUDY DESIGN AND SETTING

This is a retrospective observational study of pediatric teleconsultations from January 2023 to August 2023. It compares a synchronous TD platform of a private practice center to the asynchronous TD platform of the public sector.

Patients evaluated on the synchronous platform were predominantly self-referrals or referrals from local pediatric clinics. Patients consulted from their homes through a live platform provided by the private center. In contrast, teleconsultations assessed on the asynchronous platform were exclusively referrals from public primary health care centers. In this modality, the patient was required to visit a primary health care center, where a general physician would conduct a routine examination and gather the medical history. Subsequently, the physician would take clinical photographs of the patient's condition and upload them to the ministerial platform, where a specialist at a secondary center would evaluate the case and provide diagnostic and therapeutic suggestions.

PATIENT SELECTION

For the synchronous platform, all patients aged between 0 and 18 were included in the sample. For the asynchronous TD platform, a representative sample size was determined based on the Ministry of Health’s recommendations for sample size calculation in health indicators assessments.¹⁸ Then, a random subset of teleconsultations was selected to ensure it accurately reflected the sample proportion.

DIAGNOSTIC GROUPS

Diagnoses were categorized into five main diagnostic groups as follows: noninfectious inflammatory, infectious inflammatory, benign tumoral, malignant tumoral, and others. Moreover, the most common diagnoses for each platform, defined as those accounting for at least 1% of the total diagnostic sample, were explored.

STATISTICAL ANALYSIS

A descriptive analysis was conducted regarding the age distribution, diagnostic groups, and specific primary diagnoses for synchronous and asynchronous platforms. The descriptive analysis was further detailed for each month included in the study, examining the months with the highest and lowest volume of consultations.

For the inferential analysis, a two-tailed Student’s t-test was conducted to examine differences in age distribution between synchronous and asynchronous TD platform users. Regarding the distribution of diagnoses, a Chi-square test was performed to examine differences between the diagnostic groups and specific diagnoses made on the synchronous and asynchronous platforms.

The data examined were sourced from a routinely accessed, anonymized database from the TD Cell within the Digital Hospital Project of the Chilean Ministry of Health and a private provider referral center. Each health care provider (public or private) ensures the anonymity of the databases. The databases utilized are under the regulatory framework of the Chilean Ministry of Health, available upon request, and are routinely used by the Digital Hospital Project to monitor telemedicine systems in place.⁵ The analysis followed the ethical principles outlined in the Declaration of Helsinki for medical research.

All analyses were conducted using Stata software (Stata/SE 16.0 for macOS, Copyright 1985–2019 StataCorp LLC, College Station, TX, USA). All figures were developed using Microsoft Excel (Office 365, Microsoft Excel v16.66.1 for macOS, Copyright 1985–2022 Microsoft Corp, Redmond, WA, USA).

Results

For the synchronous platform, 962 teleconsultations were recorded during the study period. The sample included 168 pediatric teleconsultations, accounting for 17.5% of all consultations. The average age was 10.18 years ± 5.43 (0–18 years). The month with the highest and lowest number of consultations was June, with 22% (n = 37), and March, with 11.3% (n = 19), respectively.

Of the 47,760 responded teleconsultations for the asynchronous platform, 8,726 (18.3%) pediatric teleconsultations were recorded. From these, a representative sample of 239 teleconsultations was randomly extracted. The average age in this sample was 8.65 years ± 5.74 (0–18 years). The months with the highest teleconsultation volumes were January and March, each with 18.8% (n = 45) of the sample, whereas June recorded the lowest number of consultations with 13.4% (n = 32). The average response time from the dermatologist using asynchronous TD was 2.87 days ± 1.99 days (0–12 days).

Age distributions showed statistically significant differences (p = 0.0065), where patients consulting in synchronous TD tended to be older than those consulting through asynchronous TD. The diagnostic group’s distribution for the synchronous and asynchronous platforms is presented in Fig. 1. The specific diagnostic distribution for the synchronous and asynchronous platforms is presented in Fig. 2 and Fig. 3, respectively. Moreover, the analysis of diagnostic groups showed that noninfectious inflammatory pathology predominated in both modalities of attention. When evaluating for significant differences in specific diagnoses within the diagnostic group, noninfectious inflammatory and infectious inflammatory pathology demonstrated significant differences (p < 0.0001 and p = 0.002, respectively). For the noninfectious inflammatory group, there was a higher frequency of diagnoses for dermatitis, acne, and urticaria in the synchronous platform (Fig. 2), whereas dermatitis, acne, and vitiligo predominated in the asynchronous model (Fig. 3). In the asynchronous platform, while dermatitis and acne constitute a significant percentage of consultations, there is greater diagnostic heterogeneity. A predominance of viral etiology in the asynchronous platform was noted for the infectious inflammatory group, whereas mycotic and bacterial infections were more commonly observed in the synchronous platform. Evaluating significant differences for the diagnostic groups of benign tumoral pathology, malignant tumoral pathology, and others was not possible due to diagnostic heterogeneity.

Fig. 1.

Diagnostic groups for pediatric teledermatology consultations. (A) The main diagnostic groups for the synchronous platform in the private sector. (B) The main diagnostic groups for the asynchronous platform in the public sector.

Fig. 2.

Most common specific dermatological diagnosis for pediatric patients in the synchronous teledermatology platform of the private health care provider.

Fig. 3.

Most common specific dermatological diagnosis for pediatric patients in the asynchronous teledermatology platform of the public health care sector.

Discussion

Access to pediatric dermatology is limited, even though it is a relatively common reason for consultation.¹⁹ Despite attempts to improve accessibility, this specialty still faces substantial unmet needs. Challenges include a shortage of workforce, sociocultural factors, and economic barriers.²⁰ In turn, long waiting times for specialist evaluation can hinder the diagnosis since some pediatric dermatological conditions present a dynamic pattern.²¹ In addition, longer waiting times are associated with less attendance at the appointment when available.²¹

Pediatric TD is an emerging tool that allows for the timely exploration of a wide variety of dermatological conditions and represents an opportunity for increasing diagnostic accuracy in said clinical scenarios.²² Moreover, it offers convenience and accessibility to parents and caregivers, adapting to parent’s working hours, eliminating geographical barriers, and improving the quality of care.^23,24 In this context, implementing pediatric TD systems is vital to improve access to care for pediatric dermatology. Prior studies suggest that TD exhibits favorable rates of diagnostic agreement compared with in-person examinations, and both users and providers report high levels of satisfaction.⁶ In addition, it presents with high levels of resolvability, as most pediatric skin conditions do not require skin biopsy for diagnostic confirmation, and malignant pathology is extremely rare. Thus, in-person examination referrals are lower than TD in adults.²⁵

Although there is no evidence on waiting times for a pediatric dermatological consult in the Chilean context, previous studies have shown that in the public system, wait times for a general dermatology consult average 341 days.⁴ These waiting times, contrasted to the average 2.87 days response time observed in the asynchronous platform, suggest that TD also improves timely access to an initial evaluation in the pediatric population of the public system. In contrast, wait times for a pediatric dermatology consult in the private sector cannot be estimated, as it is highly dependent on the availability of the specific private provider. In contrast, available literature reports that wait times for a pediatric dermatology consult can exceed 100 days.¹⁹

As for consultation volumes, this series evidenced that pediatric TD accounted for almost a fifth of all TD consultations in the general TD practice. This is consistent regardless of the synchronous or asynchronous nature of the consultation. The latter is comparable to the standard pediatric practice, where 10% to 30% of consultations are related to skin diseases.⁷ However, upon comparing both consulting populations, notable distinctions emerge. These differences might be primarily explained by the distinction between private and public settings and the different purposes each sector assigns to the TD platforms. In this sense, the public asynchronous TD platform works as the common referral channel for dermatological care. It serves as a support tool for the general practitioner in primary health care centers. Consequently, it includes all pediatric dermatological consultations requiring specialized care, encompassing various presenting complaints. In contrast, the private synchronous platform mainly addresses acute dermatological pathology or chronic patients that require follow-up for treatment guidance directly from the specialist. In this sense, it tends to present a narrower range of diagnostic distribution and lower case complexity, as it lacks the filter from primary health physicians.

Regarding age distributions, the average age of teleconsultations in the synchronous model was significantly higher than in the asynchronous model. This could be attributed to the larger portion of acne consultations, which in the public sector are mainly managed through primary health care and only moderate-to-severe cases are referred to secondary care. As for diagnostic distribution, the noninfectious inflammatory group constituted the majority of teleconsultations in both TD modalities, including dermatitis and acne. This is consistent with other experiences where inflammatory dermatosis drives the TD consultation in the pediatric setting.²⁶ Moreover, there were significant differences in the specific etiology for the infectious inflammatory group, where bacterial and fungal dermatosis led the infectious consultation in the synchronous modality.

In contrast, viral infections, such as viral warts and molluscum contagiosum, were more common in the asynchronous group. The latter suggests that acute skin infections are more likely to be consulted in the synchronous modality while chronic skin infections are more likely be observed in the asynchronous group. This also aligns with the role of primary health care in the public sector, as they manage most acute infectious diseases and exclusively refer cases with inadequate therapeutic response, diagnostic uncertainty, or cases that require more complex interventions such as curettage or cryotherapy.

Regarding benign tumoral pathology, the asynchronous platform exhibited more teleconsultations than the synchronous platform. Nevi and vascular tumors were more common in the public sector, which suggests that caregivers may be more inclined to schedule in-person examinations for tumoral pathology in the private sector. Nevertheless, several studies suggest that the use of TD as a triage tool for vascular tumors is associated with earlier in-person evaluation and faster therapeutic interventions compared with regular in-person waiting times.^27,28 Finally, no malignant tumoral diagnosis was observed for both platforms.

Concerning the temporality of consultations, although this study did not include a full-year follow-up, it did include seasonal changes, transitioning from warmer to colder months and evidencing that seasons may influence TD consultation patterns. June had the lowest volume of consultations for the asynchronous platform. Conversely, it recorded the highest volume of consultations for the synchronous modality. Coincidentally, in Chile, June is one of the coldest months of the year and typically corresponds with the highest rate of pediatric respiratory viral circulation and hospitalizations due to a respiratory cause.²⁹ This would be consistent with the decrease in asynchronous teleconsultations observed during June, as parents may be more hesitant to bring their children to primary health care centers, potentially exposing them to ongoing epidemiological risks. This may lead them to delay asynchronous teleconsultations until warmer months. However, more extended follow-up studies on seasonal variations of teleconsultations are needed to draw more definitive conclusions. During the months when consultations were highest and lowest on both platforms, the ages of patients did not significantly differ from the average age distribution observed throughout the study period. In addition, noninfectious inflammatory conditions consistently accounted for most consultations across all months studied, making it difficult to determine if certain diagnoses were more likely to be observed at specific times of the year. However, we anticipate that in larger comparative studies significant differences may emerge, as weather and seasonal patterns are known to influence the onset or worsening of various skin conditions in children.

Limitations

Although teleconsultations from all primary health care centers of the public network were analyzed in the asynchronous platform, only a single private practice center was included for the analisis of the synchronous platform. These unmatched samples may hinder the generalizability of findings to broader health care contexts worldwide, and findings should be critically examined. In addition, it did not further explore the subset of patients requiring in-person examination following teleconsultation nor the diagnostic agreement between in-person and telematic evaluation, thereby limiting the discussion regarding effectiveness and accuracy of the teleconsultations. Moreover, it did not assess the caregiver’s and patient’s satisfaction dimension, which could have been another interesting variable to evaluate. Despite this, the findings presented offer valuable perspectives on the consulting TD pediatric population in contrasting health care backgrounds.

Conclusions

Pediatric teleconsultations in synchronous private and asynchronous public sectors appear comparable. The noninfectious inflammatory pathology was the most frequently consulted diagnostic group on both platforms, with most cases attributed to dermatitis and acne. Overall age in the private synchronous TD platform was higher as compared to the asynchronous TD platform, with a greater portion of consultations attributed to acne. In turn, the asynchronous TD platform included a wider variety of diagnoses, likely because it serves as the main gateway for accessing dermatological care in the public sector, and it might better represent the portion of the pediatric population that requires specialist evaluation after initial assesment by a primary care physician. Understanding these differences is crucial to effectively address specific access gaps that may manifest within each sector, private or public. Moreover, it guides decision-making and resource allocation, as the most common age and diagnostic distribution provide valuable insight on how to effectively meet the sanitary needs of patients and caregivers.

Seasonal variations might influence TD consulting patterns in the pediatric population. It was observed that colder months favored the use of the synchronous platform, while coincidentally, it marked the month with the lowest asynchronous platform usage. Epidemiological factors such as upper respiratory tract infections, usually observed during winter, might affect caregivers’ preferences on specific modalities of attention or may lead them to postpone dermatological consultations until warmer months. Understanding these seasonal trends facilitates the allocation and optimization of resources based on the months expected to experience higher or lower demand for teleconsultations. However, more extended follow-up studies are needed to better estimate these seasonal trends.

Finally, it is essential to underscore that pediatric TD is an emerging tool for clinical practice. It will undoubtedly play a pivotal role in diagnosing and managing pediatric skin diseases in the coming years. Pediatric TD provides unique opportunities to connect patients and caregivers to specialists, optimize access, manage demand, and reduce waiting times for a pediatric dermatological evaluation.

Footnotes

Author Disclosure Statement

The authors have no conflicts of interest to declare.

Authors’ Contributions

H.F., H.H., D.A., and J.L.G.: Conceptualization; H.F., H.H., D.A., and J.L.G.: Data curation; D.A. and J.L.G.: Formal analysis; H.F., H.H., D.A., and J.L.G.: Investigation; H.H., and D.A.: Methodology; H.F. and H.H.: Project administration; H.F. and J.L.G.: Resources; D.A. and J.L.G.: Supervision; H.F., H.H., and D.A.: Visualization; H.H. and D.A.: Writing—original draft; H.F. and J.L.G.: Writing—review & editing.

Funding Information

No funding was received for this article.

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