K Steele

Multicentre randomised control trial comparing real time teledermatology with conventional outpatient dermatological care : societal cost-benefit analysis

Abstract Objectives: Comparison of real time teledermatology with outpatient dermatology in terms of clinical outcomes, cost-benefits, and patient reattendance Design: Randomised controlled trial with a minimum follow up of three months. Setting: Four health centres (two urban, two rural) and two regional hospitals Subjects: 204 general practice patients requiring referral to dermatology services; 102 were randomised to teledermatology consultation and 102 to traditional outpatient consultation. Main outcome measures: Reported clinical outcome of initial consultation, primary care and outpatient reattendance data, and cost-benefit analysis of both methods of delivering care. Results: No major differences were found in the reported clinical outcomes of teledermatology and conventional dermatology. Of patients randomised to teledermatology, 55 (54%) were managed within primary care and 47 (46%) required at least one hospital appointment. Of patients randomised to the conventional hospital outpatient consultation, 46 (45%) required at least one further hospital appointment, 15 (15%) required general practice review, and 40 (39%) no follow up visits. Clinical records showed that 42 (41%) patients seen by teledermatology attended subsequent hospital appointments compared with 41 (40%) patients seen conventionally. The net societal cost of the initial consultation was £132.10 per patient for teledermatology and £48.73 for conventional consultation. Sensitivity analysis revealed that if each health centre had allocated one morning session a week to teledermatology and the average round trip to hospital had been 78 km instead of 26 km, the costs of the two methods of care would have been equal. Conclusions: Real time teledermatology was clinically feasible but not cost effective compared with conventional dermatological outpatient care. However, if the equipment were purchased at current prices and the travelling distances greater, teledermatology would be a cost effective alternative to conventional care

Patient satisfaction with realtime teledermatology in Northern Ireland

Teledermatology consultations were organized between two health centres and two hospitals in Northern Ireland using low-cost videoconferencing equipment. A prospective study of patient satisfaction was carried out. Following each teleconsultation, patients were asked to complete a questionnaire assessing their satisfaction with the service. Over 22 months, 334 patients were seen by a dermatologist over the video-link, and 292 patients 87 completed the 16-item questionnaire. Patients reported universal satisfaction with the technical aspects of teledermatology. The quality of both the audio and the display was highly acceptable to patients. Personal experiences of the teledermatology consultation were also favourable: 85 felt comfortable using the video-link. The benefits of teledermatology were generally recognized: 88 of patients thought that a teleconsultation could save time. Patients found the teledermatology consultation to be as acceptable as the conventional dermatology consultation. These findings suggest overall patient satisfaction with realtime teledermatology.

A comparison of real-time and store-and-forward teledermatology: a cost-benefit study

Background Increasing use of teledermatology should be based on demonstration of favourable accuracy and cost–benefit analysis for the different methods of use of this technique.

Diagnostic accuracy and clinical management by realtime teledermatology. Results from the Northern Ireland arms of the UK Multicentre Teledermatology Trial

Diagnostic accuracy and management recommendations of realtime teledermatology consultations using low-cost telemedicine equipment were evaluated. Patients were seen by a dermatologist over a video-link and a diagnosis and treatment plan were recorded. This was followed by a face-to-face consultation on the same day to confirm the earlier diagnosis and management plan. A total of 351 patients with 427 diagnoses participated. Sixty-seven per cent of the diagnoses made over the video-link agreed with the face-to-face diagnosis. Clinical management plans were recorded for 214 patients with 252 diagnoses. For this cohort, 44 of the patients were seen by the same dermatologist at both consultations, while 56 were seen by a different dermatologist. In 64 of cases the same management plan was recommended at both consultations; a sub-optimum treatment plan was recommended in 8 of cases; and in 9 of cases the video-link management plans were judged to be inappropriate. In 20 of cases the dermatologist was unable to recommend a suitable management plan by video-link. There were significant differences in the ability to recommend an optimum management plan by video-link when a different dermatologist made the reference management plan. The results indicate that a high proportion of dermatological conditions can be successfully managed by realtime teledermatology.

A randomized controlled trial assessing the health economics of realtime teledermatology compared with conventional care: an urban versus rural perspective

A randomized controlled trial was carried out to measure the cost-effectiveness of realtime teledermatology compared with conventional outpatient dermatology care for patients from urban and rural areas. One urban and one rural health centre were linked to a regional hospital in Northern Ireland by ISDN at 128 kbit/s. Over two years, 274 patients required a hospital outpatient dermatology referral - 126 patients (46%) were randomized to a telemedicine consultation and 148 (54%) to a conventional hospital outpatient consultation. Of those seen by telemedicine, 61% were registered with an urban practice, compared with 71% of those seen conventionally. The clinical outcomes of the two types of consultation were similar - almost half the patients were managed after a single consultation with the dermatologist. The observed marginal cost per patient of the initial realtime teledermatology consultation was 52.85 for those in urban areas and 59.93 per patient for those from rural areas. The observed marginal cost of the initial conventional consultation was 47.13 for urban patients and 48.77 for rural patients. The total observed costs of teledermatology were higher than the costs of conventional care in both urban and rural areas, mainly because of the fixed equipment costs. Sensitivity analysis using a real-world scenario showed that in urban areas the average costs of the telemedicine and conventional consultations were about equal, while in rural areas the average cost of the telemedicine consultation was less than that of the conventional consultation.

A randomized controlled trial to assess the clinical effectiveness of both realtime and store-and-forward teledermatology compared with conventional care

The clinical effectiveness of realtime teledermatology, store-and-forward teledermatology and conventional outpatient dermatological care were evaluated in a randomized control trial. A total of 204 patients took part – 102 patients were randomized to the realtime teledermatology consultation, 96 of whose cases were also referred using a store-and-forward technique, and 102 to the conventional outpatient consultation. There were no differences in the reported clinical outcomes of realtime teledermatology and conventional dermatology. Of those randomized to the realtime teledermatology consultation, 46% required at least one subsequent hospital appointment compared with 45% of those randomized to the conventional outpatient consultation. In contrast, the dermatologist requested a subsequent hospital appointment for 69% of those seen by store-and-forward teledermatology. An analysis of costs showed that realtime teledermatology was clinically feasible but more expensive than conventional care, while the store-and-forward teledermatology consultation was less expensive but its clinical usefulness was limited. Sensitivity analysis indicated that realtime teledermatology was as economical as conventional care when less artificial assumptions were made about equipment utilization, costs and travel distances to hospital.

Patient cost-benefit analysis of teledermatology measured in a randomized control trial.

A randomized controlled trial of the costs and benefits of teledermatology consultations compared with traditional hospital consultations was carried out. Over a nine-month period, 197 patients were referred from general practice for a dermatological opinion, 98 for a teledermatology consultation and 99 for a hospital consultation. Eighty patients required an additional subsequent hospital appointment. Patients were asked to complete an economic questionnaire after each consultation, and 164 questionnaires were returned: 62% of those randomized to the teledermatology consultation responded compared with 58% of those randomized to the hospital consultation. Patients seen by teledermatology at their own health centre had shorter distances to travel and spent less time overall attending the appointment compared with those seen at the hospital. However, the teledermatology consultations were more time-consuming for the general practitioner and dermatologist. These findings indicate that teledermatology has more benefits for the patient than for the health-care delivery team.

Consultation charges in Ireland deter a large proportion of patients from seeing the GP: results of a cross-sectional survey

Objective: To estimate the effect of a consultation charge on the health-seeking behaviour of patients. Methods: Cross-sectional survey of patients carried out in Northern Ireland, where services are free at the point of delivery, and the Republic of Ireland, where 70% of the population are charged a consultation fee to see the general practitioner (GP). Results: There were 11 870 respondents to the survey (response rate 52%). In the Republic of Ireland, 18.9% of patients (4.4% of non-paying patients and 26.3% of paying patients) had a medical problem in the previous year but had not consulted the doctor because of cost; this compares with only 1.8% of patients in Northern Ireland. Because those in the Republic of Ireland on low income are entitled to free care, the effects of the consultation charge were most marked in the middle of the income distribution, with such patients being over four times as likely to have been deterred as those in the most affluent group. However, amongst paying patients, it was the poorest and those with the worst health who were most affected. Compared to the most affluent patients and those without depression, the likelihood of not having seen the GP due to cost was 6.75 (95% confidence interval [CI] 3.79, 11.09) for the poorest patients and 2.01 (95% CI 1.53, 2.52) for those with depression. Conclusion: Even in countries with exemptions for the poor and more vulnerable, a consultation charge can deter a large proportion of poorer and less healthy patients from seeing their GP.

Impact of Osteoarthritis and Analgesic Treatment on Quality of Life of an Elderly Population

OBJECTIVE: To determine the quality of life of elderly patients with osteoarthritis (OA) compared with that of their peers with no chronic illnesses and to investigate the associations between analgesic use and quality of life. SUBJECTS: Patients >65 years of age with OA taking analgesics with (n = 33) and without (n = 26) comorbidities, and control patients with no chronic illness and not taking analgesics (n = 37). METHODS: Quality of life was assessed by the SF-36 and level of pain was measured by a visual analog scale. Multiple regression analysis was used to determine the medication characteristics and additional patient factors significantly associated with SF-36 scores. RESULTS: OA patients had significantly (p < 0.05) lower scores than control patients in all quality-of-life domains. OA patient scores were lowest for the domains of role-physical, bodily pain, and physical functioning. OA patients with comorbidities also had poorer general and mental health. Pain- and analgesic-related factors were significantly (p < 0.05) associated with physical health status, reduced vitality, general health, and social functioning. A better quality of life was associated with noncompliance, fewer visits to the physician, and taking oral nonsteroidal antiinflammatory agents. Presence of adverse drug reactions and sleep disturbance did not influence SF-36 scores significantly. CONCLUSIONS: Quality of life of elderly OA patients with and without additional comorbidities was significantly poorer than that of their healthy peers, particularly in the domains associated with physical status, but also affecting vitality, social functioning, and general health. Level of pain suffered and perceived effectiveness of analgesic medication in pain control were important factors associated with quality of life.

Effect of camera performance on diagnostic accuracy: preliminary results from the Northern Ireland arms of the UK Multicentre Teledermatology Trial

The diagnostic accuracy of realtime teledermatology was measured using two different video cameras. One camera was a relatively low-cost, single-chip device camera 1 , while the other was a more expensive, three-chip camera camera 2 . The diagnosis obtained via the videolink was compared with the diagnosis made in person. Sixty-five new patients referred to a dermatology clinic were examined using camera 1 followed by a standard face-to-face consultation on the same day. A further 65 patients were examined using camera 2 and the same procedure implemented. Seventy-six per cent of conditions were correctly diagnosed by telemedicine using camera 2 compared with 62 using camera 1. A working differential diagnosis was obtained in 12 of cases using camera 2 compared with 14 using camera 1. The percentage of `no diagnosis`, wrong and missed diagnoses was halved using camera 2 compared with camera 1. These results suggest that the performance of the more expensive camera was superior for realtime teledermatology.