Cross-sectional survey shows that price and wait time affect patient preferences for delivery of dermatologic care
Authors: Aditya Nellore, Shane A. Grace, Martin R. Dittmer, Eric S. Armbrecht, Mallory S. Abate
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: The coronavirus disease 2019 pandemic has forced the unprecedented adoption of telemedicine services across medical specialties, making it more important than ever to understand patient preferences and what factors influence them. The purpose of this study was to identify which delivery modality is preferred by patients: face-to-face versus store-and-forward versus live video, and how out-of-pocket cost, lack of access to a face-to-face visit, wait time, and demographic variables influence this preference. We performed a cross-sectional survey study that was approved by Saint Louis University's institutional review board. A 14-question survey was created via Qualtrics and disseminated via Amazon Mechanical Turk, an online marketplace for participants to take surveys (Supplemental Fig 1 available via Mendeley at https://data.mendeley.com/datasets/5f7hbhsrwr/1). Each participant was paid $0.10. Responses were recorded anonymously. Descriptive statistics were calculated for each survey item. The Pearson χ2 test was used for statistical analysis. The sample size for analysis was N = 433, based on the number of responses recorded via Qualtrics. Among the 433 online surveys completed, 108 were eliminated because of missing data. The mean age of our study population was 35 years (Supplemental Fig 2 available via Mendeley at https://data.mendeley.com/datasets/5f7hbhsrwr/1). Most participants owned a smartphone (97%) and would therefore have access to applications necessary for telemedicine. Our analysis revealed several statistically significant findings. For example, our data suggest that when patients are required to pay for an evaluation, store-and-forward may be the preferred option, even when face-to-face is available (Table I). When face-to-face was not an option, participants did not have a strong preference between the two virtual methods when they are free; however, when asked to pay for a virtual visit, 64% choose store-and-forward for $50 over live video for $75. This suggests that the distinction between store-and-forward or live video may not be as important to patients as the overall cost of health care.Table IPrice and wait time influence patient choice of delivery method (N = 325)ChoiceScenariosPriceFree with no waitFTF $100 vs pay for virtualFTF $100 with 1-hour wait vs virtual for freeFTF not an option vs virtual for freeFTF not an option vs pay for virtualFTF$067%————FTF$100—37%———FTF with 1-hour wait$100——31%——LV$012%——54%—LV$75—15%39%—36%SAF$021%——46%—SAF$50—48%30%—64%—100%100%100%100%100%FTF, Face-to-face; LV, live video; SAF, store-and-forward. Open table in a new tab FTF, Face-to-face; LV, live video; SAF, store-and-forward. We also found that income level was statistically significant in influencing participant choice. Our findings suggest that patients with lower household income might value face-to-face interaction more than those with higher incomes, who seem to prefer the store-and-forward method (Table II). Town type, insurance type, education level, age, and gender were not found to be statistically significant influencing factors in choice of delivery in any scenario.Table IIIncome level influences patient preference of delivery of dermatologic care∗Note that rurality does not influence the choice. P values were calculated using the Pearson χ2 test. P < .05 tells us that the percentage distributions that we see across demographic groups is statistically significant.Free with no waitP valueFTF (n = 216)SAF (n = 70)LV (n = 39)Overall (N = 325)67%21%12%—Income group.026 <$20,000 (n = 55)75%16%9%— $20,000-$44,999 (n = 107)67%20%13%— $45,000-$139,999 (n = 127)67%19%14%— ≥$140,000 (n = 36)50%44%6%—Town type.333 Rural (n = 49)63%27%10%— Small town (n = 77)70%23%7%— Medium-sized city (n = 102)61%23%17%— Urban (n = 97)71%16%13%—FTF for $100 vs paying for virtualFTF $100 (n = 120)SAF $50 (n = 155)LV $75 (n = 50)Overall (N = 325)37%48%15%—Income group.030 <$20,000 (n = 55)35%51%15%— $20,000-$44,999 (n = 107)42%44%14%— $45,000-$139,999 (n = 127)43%37%20%— ≥$140,000 (n = 36)25%72%3%—Town type.697 Rural (n = 49)41%47%12%— Small town (n = 77)34%54%12%— Medium-sized city (n = 102)39%42%19%— Urban (n = 97)35%48%17%—Bold indicates statistical significance.FTF, Face-to-face; LV, live video; SAF, store-and-forward.∗ Note that rurality does not influence the choice. P values were calculated using the Pearson χ2 test. P < .05 tells us that the percentage distributions that we see across demographic groups is statistically significant. Open table in a new tab Bold indicates statistical significance. FTF, Face-to-face; LV, live video; SAF, store-and-forward. When participants were asked about perceived diagnostic accuracy between face-to-face versus virtual, 70% of participants thought their dermatologist's diagnostic ability was better with a face-to-face interaction. Only a participant's highest education level was found to be a statistically significant influencing factor in this choice, with 71% of college graduates thinking their dermatologist's diagnostic ability was better face-to-face versus only 49% of high school graduates. The main limitation in our study is that our survey population may not be representative of a dermatology practice population because we surveyed an online marketplace. With telemedicine use on the rise, the landscape of dermatology practice as we know it is changing. To adapt to this dynamic environment, it is imperative that physicians determine which delivery modality is preferred by patients and what factors influence this preference. Our study is just the beginning of this process.