Pediatric teledermatology: A retrospective review of 1199 encounters during the COVID-19 pandemic.

To the Editor: The incorporation of telemedicine into routine dermatologic care during COVID-19 has created new opportunities to evaluate and optimize our existing teledermatology platforms. Previous pediatric studies have shown that teledermatology improves access to care1, 2 while offering opportunities to improve show rates and reduce wait times. We performed a retrospective review of 1110 video visits (live, interactive, patient-to-provider) and 89 e-consults (store-and-forward, provider-to-provider) during the early COVID-19 pandemic (March 18 to May 1, 2020) to acquire key information on continued applications of teledermatology.

In addition to collecting patient demographics (Table I ) and encounter-specific data (eg, diagnoses and referring provider), we reviewed dermatology provider surveys embedded within each virtual encounter. Video visit surveys asked providers about connectivity issues, video quality, and the use of supplementary photographs. Logistic regression was performed to identify associated factors (Table II ). For e-consults, providers indicated whether the encounter was sufficient to assist in diagnosis or provide advice on treatment. Providers also noted when additional workup and/or triage to an in-person visit were recommended.

Table I

Patient characteristics for all visit types

Characteristic	Pre-COVID in-person visits (N = 18,188), n (%)	COVID in-person visits (N = 347), n (%)	COVID e-consults (N = 89), n (%)	COVID video visits (N = 1110), n (%)
Age group, y (%)
0-1	4053 (22.3)	128 (36.9)	28 (31.5)	303 (27.3)
2-7	4000 (22.0)	74 (21.3)	17 (19.1)	197 (17.7)
8-13	4628 (25.4)	67 (19.3)	21 (23.5)	219 (19.7)
14-18	4911 (27.0)	72 (20.7)	22 (24.7)	354 (31.9)
Over 18	596 (3.3)	6 (1.7)	1 (1.1)	37 (3.3)
Sex
Female	10,149 (55.8)	191 (55.0)	36 (40.4)	604 (54.4)
Male	8039 (44.2)	156 (45.0)	53 (59.5)	506 (45.6)
Race
Black	4289 (23.6)	46 (13.3)	22 (24.7)	212 (19.1)
Other	5510 (30.2)	68 (19.6)	24 (30.3)	270 (24.5)
White	9970 (54.8)	233 (67.1)	40 (44.9)	683 (61.5)
Ethnicity
Hispanic or Latino	1850 (10.2)	31 (8.9)	6 (6.7)	108 (9.7)
Not Hispanic or Latino	16,338 (89.8)	316 (91.1)	83 (92.3)	990 (89.2)
Insurance
Private	9037 (49.7)	242 (69.7)	61 (68.5)	771 (69.6)
Public	8822 (48.5)	83 (23.9)	27 (30.3)	337 (30.4)
Self-pay	329 (1.8)	22 (6.3)	1 (0.08)	0

Table II

Factors associated with provider-reported connectivity issues, video quality, and submission of photographs∗

	Connectivity issues (Y/N) (N = 1042)			Video quality adequate (Y/N) (N = 1035)			Photographs submitted (Y/N) (N = 1054)
	n	OR (95% CI)	P	n	OR (95% CI)	P	n	OR (95% CI)	P
Age group, y
0-1	198	Reference	-	197	Reference	-	200	Reference	-
1-7	278	1.66 (1-2.75)	.051	276	0.6 (0.36-0.99)	.045	279	1.70 (0.91-3.15)	.095
7-13	332	1.43 (0.8-2.58)	.229	197	0.64 (0.32-1.29)	.151	201	0.74 (0.38-1.40)	.352
13-18	36	1.58 (0.87-2.87)	.134	329	0.66 (0.37-1.17)	.223	337	0.30 (0.12-0.74)	.009
Over 18	198	2.52 (1.01-6.29)	.047	36	1.14 (0.39-3.28)	.812	37	0.89 (0.46-1.69)	.729
Insurance
Commercial	722	Reference	-	717	Reference	-	732	Reference	-
Public	320	0.95 (0.69-1.3)	.728	318	0.7 (0.51-0.95)	.022	322	0.74 (0.53-1.05)	.087
Diagnosis
Acne	225	Reference	-	223	Reference	-	228	Reference	-
Adnexal skin disorder	24	3.16 (1.23-8.09)	.017	24	1.43 (0.49-4.15)	.51	25	0.49 (0.17-1.4)	.181
Alopecia	63	1.01 (0.49-2.08)	.984	63	4.7 (1.71-12.94)	.003	63	0.35 (0.17-0.71)	.003
Dermatitis	295	1.37 (0.81-2.3)	.237	295	1.1 (0.65-1.84)	.728	297	0.52 (0.3-0.89)	.018
Hemangioma	131	1.18 (0.57-2.45)	.647	130	1.11 (0.54-2.3)	.774	132	1.4 (0.58-3.34)	.454
Infection or infestation	63	2.07 (1.02-4.22)	.044	63	0.59 (0.29-1.18)	.137	64	0.93 (0.37-2.33)	.881
Melanocytic nevus	62	1.71 (0.83-3.54)	.148	62	0.59 (0.29-1.18)	.133	63	1.51 (0.57-4.02)	.408
Other	78	0.99 (0.51-1.93)	.971	77	1.11 (0.58-2.12)	.759	78	0.6 (0.31-1.15)	.126
Pigmentary disorder	24	0.96 (0.32-2.87)	.945	23	1.38 (0.46-4.11)	.563	26	2.61 (0.56-12.14)	.221
Psoriasis	31	1.02 (0.42-2.51)	.963	31	1.09 (0.45-2.67)	.845	31	0.66 (0.27-1.64)	.373
Rash	46	0.42 (0.15-1.17)	.097	44	0.87 (0.39-1.93)	.734	47	0.73 (0.3-1.77)	.486
Study week
Week 1	32	Reference	-	31	Reference	-	38	Reference	-
Week 2	132	0.79 (0.35-1.79)	.575	130	1.09 (0.46-2.6)	.841	137	0.65 (0.29-1.43)	.282
Week 3	142	0.7 (0.31-1.57)	.382	140	1.26 (0.53-3)	.599	143	1.86 (0.81-4.25)	.144
Week 4	168	0.87 (0.39-1.93)	.735	167	1.45 (0.62-3.4)	.396	168	2.44 (1.07-5.57)	.033
Week 5	223	0.34 (0.15-0.75)	.007	222	1.54 (0.67-3.57)	.312	223	2.12 (0.97-4.62)	.059
Week 6	260	0.26 (0.12-0.57)	.001	260	3.06 (1.31-7.17)	.01	260	2.14 (0.99-4.64)	.053
Week 7	85	0.18 (0.07-0.48)	.001	85	2.63 (1.01-6.88)	.049	85	2.17 (0.87-5.41)	.095
Visit type
Follow-up	695	Reference	-	691	Reference	-	703	Reference	-
New patient	347	0.89 (0.64-1.24)	.489	344	0.64 (0.47-0.88)	.006	351	2.31 (1.54-3.45)	<.001

OR, Odds ratio.

Bold indicates statistical significance.

Primary care providers placed the most e-consults (36.0%), followed by inpatient providers (30.3%), emergency department providers (22.5%), and other subspecialty services (11.2%). The overall mean turnaround time was 5.84 hours (range, 0.07-188.13 hours), though the emergency department typically received responses within 90 minutes. Providers reported assisting in diagnosis and advising on treatment in more than 90% of the e-consults. Further workup and/or triage to an in-person visit were recommended about half the time (48.8%).

Providers reported issues with connectivity (26.5%) and inadequate video quality (25.5%) in about one-fourth of video visits. Most video visit providers (76%) reported using parent-submitted photographs. When photographs were not submitted, providers said they would have helped with the diagnosis most of the time (73.4%).

The prevalence of public insurance across teledermatology encounters was significantly lower than our practice baseline, and during video visits with patients on Medicaid, providers were more likely to report inadequate video quality. We also observed a significant reduction in Black patients receiving care. These findings are important because disparities in access to dermatologic care disproportionally affect minority children and those enrolled in Medicaid. A platform like e-consults, which relies on providers and does not require families to have internet access, could address these inequities, although widespread implementation would require reimbursement policies that cover several forms of teledermatology.

We learned that e-consult providers primarily assisted in diagnosis or treatment recommendations. Because the turnaround time was relatively quick (6 hours) and the median wait time to see a pediatric dermatologist in our region is approximately 4 months, we see e-consults as an opportunity to expedite care, enhance knowledge among requesting providers, and limit redundant consults.

Providers reported connectivity issues about one-fourth of the time, although we saw a significant reduction in connectivity issues and improvement in the perceived video quality over time (likely reflecting provider and patient acclimation). Given that previous studies have shown both store-and-forward and live interactive teledermatology to be comparable diagnostically,2, 5 a hybrid model may be ideal as store-and-forward modalities eliminate connectivity issues altogether by not requiring a live interactive experience.

Conflicts of interest

None disclosed.