Retrospective study of trends in dermatology telemedicine and in-person visits at an academic center during COVID-19
Authors: Rhiannon C. Miller, Claire R. Stewart, Shari R. Lipner
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: Many dermatologists have encountered difficulties providing timely in-person appointments during the COVID-19 pandemic because of social distancing requirements. While telemedicine may be effectively used for dermatologic care, triaging patients for in-person visits (IPVs) versus video visits (VVs) has not been adequately studied.1Vyas K.S. Hambrick H.R. Shakir A. et al.A systematic review of the use of telemedicine in plastic and reconstructive surgery and dermatology.Ann Plast Surg. 2017; 78: 736-768Crossref PubMed Scopus (95) Google Scholar Our objectives were to analyze the characteristics of in-person and telemedicine dermatology visits to determine effective appointment allocation. In accordance with New York State–mandated closures beginning March 22, 2020, Weill Cornell Dermatology limited in-person visits from March 23 through June 1 for patients requiring immediate in-person care. Patient visits March 16 through May 5 were queried from EPIC after institutional review board approval. All IPVs and VVs were sorted and ordered randomly. IPVs after VV triage were excluded. A total of 250 charts (50 IPVs and 200 VVs) were analyzed. Patients presenting for IPVs versus VVs were on average older (54.1 vs 39.6 years of age), Medicare-insured (44% vs 16%), and had melanoma (10% vs 2.5%) and nonmelanoma skin cancer histories (26% vs 12%; all P < .05). There were no significant differences in gender, home-to-clinic distance, and new versus established patients (Table I).Table IDemographics, visit type, and follow-upDemographics and visit informationVideo visits, n = 200In-person visits, n = 50P valueAge, y39.5654.08.00∗Statistically significant (P < .05).Female, %6259.75Single, %5352.89Home-to-clinic distance (miles from 10065)32.3234.16.96Private insurance, %7954.00∗Statistically significant (P < .05).History of nonmelanoma skin cancer, %1226.01∗Statistically significant (P < .05).History of melanoma, %310.02∗Statistically significant (P < .05).Visits that were new patient visits, %2022.69Visits that were established patients with new complaints, %2822.43Time until next follow-up visit for this issue In-person follow-up for this issue, %2536.12Average time until follow-up in-person visit for this issue, days81.182.2.93 Video follow-up for this issue, %2722.47Average time until follow-up video visit for this issue, days42.829.1.20∗ Statistically significant (P < .05). Open table in a new tab There were significantly greater proportions of benign nevi (14% vs 3.5%), actinic keratoses (14% vs 5.5%), seborrheic keratoses (22% vs 3.5%), disorders of skin sensation (8% vs 2%), and nonmelanoma skin cancer (12% vs 1.5%) diagnoses in IPVs compared with VVs (Table II). IPVs were significantly more likely to present with chief complaints related to skin lesions (34% vs 18% in the VVs). Notably, a procedure was performed in 64% of IPVs.Table IIDiagnoses and medicationsPercent or nP valueDiagnoses, % Dermatitis and eczema (L20-L30)2622.61 Acne (L70)2016.52 Other skin disorders (L81 and L83-L99)2028.22 Other long term (current) drug therapy (Z79)1012.68 Cysts and follicular disorders (L72-73)912.52 Nail disorder (L60-62)92.10 Hair disorders (L63-68)78.81 Papulosquamous disorders (L40-45)62.26 Actinic keratosis (L57)614.04∗Two-tailed t test for independent means was used for all continuous variables (ie, age, distance, etc). The χ2 test was used for categorical variables (gender, insurance, diagnoses, etc); when cell frequency was <5, the Fisher exact test was used. All tests were done at a significance level of α = 0.05. Personal history of malignancy (Z85)46.54 Benign nevi/neoplasms (D22-23, I78.1, and Q82.5)414.00∗Two-tailed t test for independent means was used for all continuous variables (ie, age, distance, etc). The χ2 test was used for categorical variables (gender, insurance, diagnoses, etc); when cell frequency was <5, the Fisher exact test was used. All tests were done at a significance level of α = 0.05. Diseases of lips, oral mucosa, tongue (K13-14)42.59 Rash (R21)44.87 Rosacea (L71)44.87 Seborrheic keratosis (L82)422.00∗Two-tailed t test for independent means was used for all continuous variables (ie, age, distance, etc). The χ2 test was used for categorical variables (gender, insurance, diagnoses, etc); when cell frequency was <5, the Fisher exact test was used. All tests were done at a significance level of α = 0.05. Viral skin infections (warts, zoster) (B0-B09)42.59 Neoplasm of uncertain behavior (D48)36.31 Mycoses (B35-36)32.84 Skin infections (L00-L08)32.84 Disorder of skin sensation (R20)28.03∗Two-tailed t test for independent means was used for all continuous variables (ie, age, distance, etc). The χ2 test was used for categorical variables (gender, insurance, diagnoses, etc); when cell frequency was <5, the Fisher exact test was used. All tests were done at a significance level of α = 0.05. BCC/SCC (C44 and D04)212.00∗Two-tailed t test for independent means was used for all continuous variables (ie, age, distance, etc). The χ2 test was used for categorical variables (gender, insurance, diagnoses, etc); when cell frequency was <5, the Fisher exact test was used. All tests were done at a significance level of α = 0.05. Chilblains (T69)201.00 Urticaria (L50)201.00 Bullous disorder (L10-L14)12.56Medications, n Average new medications started0.580.44.25 Average medications continued/reordered0.650.72.65 Average medications changed0.070.02.18 Average medications stopped0.10.08.76∗ Two-tailed t test for independent means was used for all continuous variables (ie, age, distance, etc). The χ2 test was used for categorical variables (gender, insurance, diagnoses, etc); when cell frequency was <5, the Fisher exact test was used. All tests were done at a significance level of α = 0.05. Open table in a new tab There was no significant difference in average medication number or type initiated or discontinued between the 2 visit types (Table II). There were no differences in proportion of patients with follow-up visits or time to follow-up (Table I). Only 8% of VV patients had in-person consultation within 60 days of their VV. For the majority of VVs (71%), an IPV was not recommended. Older adults may be overrepresented in IPVs versus VVs because skin cancers are more prevalent in older individuals and they may have more difficulties using telemedicine. Simplified connections, increased education, and house calls may be considered to improve their usage.2Lipner S.R. Ouchida K. Novel solutions for dermatologic care of geriatric patients and the role of the dermatology house call.J Am Acad Dermatol. 2020; 83: e419Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Median distance to clinic was lower for IPVs versus VVs in previous studies3Cheung L. Leung T.I. Ding V.Y. et al.Healthcare service utilization under a new virtual primary care delivery model.Telemed J E Health. 2019; 25: 551-559Crossref PubMed Scopus (12) Google Scholar; therefore, our discrepant findings may be because of COVID-related safety concerns. Approximately twice as many chief complaints in IPVs versus VVs were for skin lesions. Telemedicine has lower diagnostic accuracy in identifying pigmented lesions and is inadequate in diagnosing precancerous versus cancerous lesions.4Bastola M. Locatis C. Fontelo P. Diagnostic reliability of in-person versus remote dermatology: a meta-analysis.Telemed J E Health. 2020; https://doi.org/10.1089/tmj.2020.0043Crossref Scopus (9) Google Scholar,5de Giorgi V. Gori A. Savarese I. et al.Teledermoscopy in doubtful melanocytic lesions: is it really useful?.Int J Dermatol. 2016; 55: 1119-1123Crossref PubMed Scopus (7) Google Scholar Therefore, patients with concerning lesions should be scheduled for IPVs for clinical examination, dermoscopy, and possibly obtaining a biopsy specimen. Limitations of this study include its single-center, retrospective design and the limited number of patients. We could not account for patients who temporarily relocated from their billing addresses. Outcomes were not analyzed, and this is an important topic for future study. Our findings indicate that diagnosis, treatment, and follow-up for most dermatologic conditions does not vary between IPVs and VVs. In-person dermatology appointments should be preferentially scheduled for examination of concerning skin lesions, full-body skin examination in patients with skin cancer history, and necessary procedures. None disclosed.