Abstract
We investigated community pharmacists' management of skin conditions in order to identify a need for further educational support. Twenty community pharmacists in Queensland completed a questionnaire regarding their management of skin conditions and their opinions regarding the usefulness of a potential teledermatology service. The pharmacists' accuracy in managing skin conditions was tested by a dermatologist who reviewed the pharmacists' advice in 33 cases obtained by 14 pharmacists. Overall agreement between the pharmacists and the dermatologist was moderate, with a kappa statistic of 0.58 (P < 0.05) The uptake of a potential teledermatology service was investigated in one pharmacy over one month. Five patients were offered the teledermatology service. Of these, two patients consented and three refused. All pharmacists (n = 20) indicated a desire for further education and supported the idea of a teledermatology service.
Introduction
Teledermatology has been shown to have great potential as an educational tool for specialists, 1,2 general practitioners, 3,4 junior doctors 5 and dermatology trainees. 6 However, the possibilities for its use in a pharmacy setting have yet to be explored. Teledermatology has the potential to assist pharmacists in their triage role of directing patients to the general practitioner (GP) when appropriate. It can also provide an interactive, practice-based continuing education tool for the pharmacist.
Pharmacists are often sought after by the public for advice on skin conditions 7–10 and in this role they have received high satisfaction ratings in both community pharmacy 7 and institutional settings. 11 They are seen to be a convenient alternative for the treatment of minor illness, for advice on self-medication and often as a filter on the way to the GP. 12 While pharmacists are not considered to be independent prescribers in Australia and the UK, some non-prescription products such as hydrocortisone acetate and some anti-fungals are only available under the supervision of a pharmacist. 13,14 Hence pharmacists are expected to have a working knowledge of minor skin conditions in order to verify the appropriate use of Pharmacy Only (UK) or Pharmacist Only (Australia) medicines. 13,14
In a survey in the rural Australian town of Maryborough, it was found that one in five patients with a skin condition sought pharmacist advice, 15 and less than 20% of the over-the-counter products sold in the town's pharmacies were recommended by a doctor. 9 In 2003, the British Association of Dermatologists stated that pharmacists should be given more authority to prescribe medicines for skin complaints which would help relieve the burden on GPs. 16 However there has been little investigation into the accuracy of pharmacist dermatological management. One previous study investigated pharmacists' knowledge of psoriasis management. 17 This report indicated that pharmacists displayed a lack of knowledge in psoriasis management, but a keen interest in becoming involved in a pharmacist-dermatologist partnership. 17
In a small study (n = 19) pharmacists appeared to exhibit high confidence levels in advising on skin conditions. 18 However, the participants had extensive experience with an average duration of registration of almost 18 years. 18 Education in dermatology within pharmacy degrees appeared to be low 18 with one study indicating that there was a deficiency in education with respect to recognition of different skin diseases. 19 Although studies in Australia and Sweden have applauded the pharmacist's ability to save money and decrease the number of unnecessary GP consultations by the use of over-the-counter treatments for minor skin ailments, 7,20 these reports have failed to ascertain whether pharmacists' recommendations are correct. 7,21
The purpose of the present study was to investigate community pharmacists' management of skin conditions in order to identify a need for further educational support.
Methods
Pharmacists and pharmacy interns from community pharmacies were recruited through professional networks and by snowball sampling. The study was divided into three parts:
Pharmacists' views Participating pharmacists completed a questionnaire about their education, their confidence in managing minor skin dermatoses and their opinions on a potential teledermatology service. Pharmacists' management accuracy In a number of community pharmacies, participating pharmacists provided advice to patients about skin problems. The pharmacists' accuracy in managing skin conditions was tested by a dermatologist who reviewed the pharmacists' advice. Pharmacists enrolled adult patients who sought advice regarding a visible dermatological condition. The pharmacist took a photograph of the lesion and forwarded this with a basic history and an outline of their recommendations to a dermatologist. The cameras were owned by the pharmacists or their employer. The dermatologist viewed the images on a standard computer monitor. Pharmacists were asked to ensure that images and histories did not identify individual patients and the investigator blinded the dermatologist from the pharmacists' names. As the dermatologist's recommendations were not used for direct patient care, the time taken for the specialist feedback was not recorded. This part of the study lasted for five months beginning in September 2009. Patient uptake of a teledermatology service In one community pharmacy, two pharmacists counted their requests for advice regarding skin conditions. Over a period of one month, they also took note of the number of times they offered patients participation in the study (Figure 1). The aim was to see if there were barriers to patients participating in a real teledermatology service (for example, if patients refused to have their photograph taken) or barriers for pharmacists (e.g. if it was too time-consuming). Pharmacists documented reasons why they did not offer potential patients study participation and also why some patients declined.
Assessment of teledermatology uptake in one community pharmacy over one month
The study was approved by the appropriate ethics committee.
Data analysis
A standard package was used for analysis (SPSS 17.0). Descriptive data from questionnaire results, and teledermatology uptake, were expressed as simple proportions. Pharmacists' accuracy was presented as simple proportions as well as a kappa statistic. Categorical data groups were compared by a Fisher's exact test.
Results
A total of 17 pharmacists and three pharmacy interns were recruited. All participants worked in Queensland, with 12 from Brisbane and eight from the regional centres of Toowoomba and Warwick. Twelve pharmacists had 1–10 years post-university experience and five had over ten years experience. Eleven participants had completed their training at the University of Queensland, seven at other Australian universities and one each at universities in New Zealand and the UK.
Pharmacists' views
All pharmacists and interns completed the questionnaire. 75% (15/20) had no more than ten years experience with the same percentage undertaking some form of continuous education in dermatology. Responses to the pharmacist questionnaire regarding confidence in management of skin conditions and perceived adequacy of undergraduate education are summarised in Table 1. Pharmacist experience, confidence and perceived training were divided into categories according to the pharmacist questionnaire – for example, the level of experience (1–4 years, 5–10 years, 11–20 years, >20 years), pharmacist confidence in managing skin conditions (not very confident, sometimes confident, mostly confident). These were tabulated to see if a pharmacist with more experience exhibited a higher level of confidence in giving general skin care advice. There was no significant relation between pharmacist experience and confidence, or gender and confidence.
Pharmacist questionnaire responses (n = 20)
All pharmacists agreed with the statement ‘A teledermatology service would be useful in helping me give advice about lesions I am not confident with.’ There was also 100% agreement that further dermatological education was desirable. The education was mainly requested from a dermatologist, followed by a GP or another pharmacist.
The most commonly cited barriers to a teledermatology service included the time to process the paperwork in the pharmacy, as well as the possible delay in receiving the teledermatologist's advice, the availability and reliability of an Internet connection in pharmacy and the question of remuneration to the teledermatologist and to the pharmacy.
Pharmacists' management accuracy
Only 14 pharmacists (including the 3 interns) managed one or more cases during the five-month study period. In total, they managed 33 patient queries (including 5 from the interns). The dermatologist was unable to assess one of these cases due to poor image quality, and one due to the complexity of the problem. Of the pharmacists whose advice was assessed by the dermatologist, 86% (12/14) had no more than ten years experience and half described their undergraduate training in dermatology as poor or very poor (the characteristics were similar in the whole group) Most pharmacists (79%) had undertaken some type of continuous professional education in dermatology (usually materials from the Pharmaceutical Society of Australia or drug companies).
In the 31 cases which were assessed by the dermatologist, there was complete agreement about management in 58% of cases, partial agreement in 26% and disagreement in 10%. In 6% of cases the dermatologist felt that the pharmacist's referral to a GP was unnecessary (in the Australian health-care system, if a pharmacist is unsure, or thinks that a patient requires a prescription medication, they will refer the patient to a GP). In these two unnecessary referrals, the dermatologist felt that the pharmacist should have been able to manage the cases by providing appropriate education and using medications that were available over-the-counter (without a prescription), i.e. without requiring a GP referral. The interns were included in the overall assessment as their case numbers were small, and they performed similarly to the rest of the pharmacists (including 3 cases of total agreement, 1 case of partial agreement and 1 case which was not usable due to image quality).
Overall agreement between the pharmacist and the dermatologist was moderate, with a kappa statistic of 0.58 (P < 0.05). The most common dermatological conditions (as considered the primary differential diagnosis by the dermatologist) that were managed by the pharmacist were eczema/dermatitis, followed by mycoses (Table 2).
Level of pharmacist-dermatologist agreement
aincludes contact, atopic, seborrhoeic
bincludes pityriasis versicolor, pityrosporum folliculitis, candida, tinea
cincludes nail disease, warts, impetigo, pressure ulcer, possible skin cancer
Factors influencing the accuracy of pharmacist management
In order to compare pharmacists' ability with other categorical data, pharmacists were given a score for each case (where total agreement = 10 points, partial agreement = 5 points, disagreement = 0 points) which was then divided by the number of cases they submitted to obtain an average score. Pharmacists who had undertaken further education in dermatology were more likely to be in agreement with the dermatologist's recommendations (P = 0.044 using Fisher's exact test).
Pharmacist experience, confidence and perceived training were divided into categories according to the pharmacist questionnaire – for example, the level of experience (1–4 years, 5–10 years, 11–20 years, >20 years), pharmacist confidence in managing skin conditions (not very confident, sometimes confident, mostly confident), perceived undergraduate training (very poor, poor, adequate, good, very good). Area of practice was categorised as rural vs. metropolitan. The categorical data were tabulated and Fisher's exact test used for comparisons. None of these comparisons showed significant differences. This included comparing pharmacist experience, area of practice, confidence and perceived undergraduate training with their level of agreement with the dermatologist.
Patient uptake of a teledermatology service
During the one month study of patient uptake in a community pharmacy in Toowoomba, there were 40 symptom based requests. Five patients were offered the teledermatology service. Of these, two patients consented and three refused (Figure 1). Ethical limitations which excluded children, were the most common reason for not pharmacists not offering study participation.
Discussion
We are not aware of other studies investigating the feasibility of teledermatology in a pharmacy setting and assessing the overall accuracy of pharmacists' dermatological advice. While other studies have looked at pharmacists' confidence, customer satisfaction and other health professionals' views of pharmacist dermatological management, the present study integrated a form of clinical assessment using real-life patients with their actual dermatological conditions.
Teledermatology as a method of educating pharmacists in dermatological conditions was supported by all the participating pharmacists. It was evident in the study that further professional education in dermatology appeared to improve concordance with the teledermatologist, and all pharmacists were keen to learn more. Thus, as the current literature indicates that newer, interactive methods of continuous education for pharmacists are becoming appealing, 22 a teledermatology service for consultation on individual skin conditions may be beneficial. Such a service would encourage active participation by the pharmacist and would have an inherent ability to provide feedback, which are key principles of successful adult learning. 23–25
Online continuous medical education has been suggested as a form of disruptive innovation. 26 This is a concept used to describe innovations which initially target the low end of the market, are generally less expensive and more convenient than those provided by market leaders. 27 Currently it is estimated that around 8% of continuing medical education is derived from online sources. 26 It has been predicted that this will increase to 50% within seven years, affecting the current business model which is dominated by traditional educational suppliers. 26 The notion of disruptive innovation could also be extended to a teledermatology programme in pharmacy based on a ‘consultation on the job’ model as outlined in the present study. Such a model could serve first as a method of pharmacist education but also potentially as a pharmacy service.
It has been argued that money in health care should be diverted away from ‘high-end, complex technologies’ and invested in ‘simplifying complex problems,’ whereby technology is used to improve convenience for the lower end of the market where there is a greater return on investment. 27 This could be a concept describing teledermatology in pharmacy. It has been shown that overall pharmacists are able to appropriately manage minor dermatological conditions that present in the community. This level of treatment is suitable for the majority of patients who present with common conditions, but the quality could be further improved with teledermatologist back-up. Another potential use for teledermatology is to provide rapid medical specialist advice. For example in the case of suspected shingles, early diagnosis and treatment is essential and GP or dermatologist waiting times could hinder timely access to anti-viral medication. In a simple, straightforward case of herpes zoster, a pharmacist-teledermatologist interaction could theoretically allow early institution of management via a specialist prescription.
Due to the small numbers in the present study, definitive conclusions cannot be drawn regarding pharmacists' ability to manage specific types of conditions. However, there were several cases of differences between the pharmacist and the medical specialist. For example in Figure 2, while the pharmacist correctly referred a patient for further management by a GP, they did so with the incorrect diagnosis of shingles in mind. Furthermore, in a case where psoriatic nail or onychomycosis were in the differential diagnosis, the pharmacist only took a photograph of the affected nail, without comparing sides and enquiring about a history of psoriatic plaques (Figure 3). Basic diagnostic skills in the pharmacy are useful but may be improved by a teledermatology service.
Image of a patient's left thigh taken by the pharmacist. The pharmacist referred to a GP due to the possibility of shingles. The dermatologist felt that it was probably contact dermatitis due to its widespread, non-dermatomal distribution and the patient's recent exposure to plants. However, referral to the GP was still appropriate for prescription only topical steroids
Image from the second, distal finger of the left hand, taken by a pharmacist. The pharmacist treated this with a topical anti-fungal preparation, assuming a diagnosis of onychomycosis. The teledermatologist raised the differential diagnosis of a psoriatic nail
Before a teledermatology-pharmacy programme is implemented on a large scale, several obstacles need to be considered. Remuneration for pharmacy and dermatologist time is an important issue for sustainability and would require an economic analysis to be performed.
Study limitations
Our study investigated the opinions of a small sample of pharmacists from a particular area and may not reflect the general views or the abilities of the profession. One pharmacist who obtained high levels of agreement was responsible for nearly a quarter of the cases assessed, which may have skewed the results positively. Furthermore, selection bias may have occurred where pharmacists may have chosen cases where they were more confident. This differs from the practical application of a teledermatology service, where the cases are likely to be the difficult diagnostic and management problems.
Conclusions
The present study suggests that while pharmacists appeared to manage minor dermatoses reasonably well when comparing their level of agreement with a dermatologist, they were still keen to receive more education and agreed that a teledermatology service would be useful to improve education. Teledermatology appears to be a promising resource for pharmacists to improve their knowledge in dermatology in order to provide high quality dermatological advice.