Teledermatology effective in diagnosis, management of inpatient disease

Teleconsultation appears to perform well for dermatologic disease management in the inpatient setting and results in highly concordant diagnostic, evaluation, and management decisions when carried out by experienced dermatologists, a study has found.

“This may represent a novel and effective option for community hospitals and may be particularly applicable during times of concern for spread of infectious disease, such as during the 2019-2020 outbreak of the severe acute respiratory syndrome coronavirus 2,” the researchers said.

In this prospective study, the researchers used internal medicine referral documentation and photographs to assess the ability of teledermatology to diagnose disease and manage 41 dermatology consultations from a large urban tertiary care centre. They surveyed 27 dermatology hospitalists. Inter-rater agreement was evaluated by the κ statistic.

A substantial agreement was noted between in-person and teledermatology assessment of the diagnosis with differential diagnosis (median κ, 0.83) and in laboratory evaluation decisions (median κ, 0.67). An almost perfect and a moderate agreement were seen in imaging (median κ, 1.0) and biopsy decisions (median κ, 0.43), respectively. In addition, there was almost perfect agreement in treatment (median κ, 1.0) but no agreement in follow-up planning (median κ, 0.0). [J Am Acad Dermatol 2021;84:1547-1553]

Of note, no association was found between raw photography quality and the primary plus differential diagnosis or primary diagnosis alone.

The high concordance of primary plus differential diagnosis is consistent with previous outpatient literature, with studies showing diagnostic concordance ranging from 41 percent to 100 percent for store-and-forward cases. [Med Clin North Am 2015;99:1365-1379; Arch Dermatol 1997;133:161-167; J Am Acad Dermatol 1999;41:693-702]

Such finding stemmed from limited studies evaluating the use of teledermatology in the inpatient setting. Similar with an earlier investigation, diagnostic concordance improved when the differential diagnosis was considered. [Med Clin North Am 2015;99:1365-1379; J Am Acad Dermatol 2020;82:1262-1267; Emerg Med Australas 2011;23:562-568; JAMA Dermatol 2014;150:419-424]

“The decision by teledermatologists to pursue evaluation in this study was highly concordant, with substantial agreement in the laboratory evaluation desired,” the researchers said. “However, there was only moderate agreement in the decision to biopsy, which is in contrast with a previous inpatient teledermatology study finding a greater than 95-percent concordance in assessing need for biopsy.” [JAMA Dermatol 2014;150:419-424]

Another thing worth considering was the baseline interdermatologist variability that occurred even with face-to-face consultations, because a previous study of face-to-face, clinic-based dermatologists found diagnostic testing to be 85-percent concordant, medical-based therapy 85-percent concordant, and clinic-based therapy 77-percent concordant. Therefore, some degree of concordance might be expected. [J Am Acad Dermatol 1999;41:693-702]

Of note, no association was observed between experience of the teledermatologist and diagnostic concordance, indicating the generalizability of teledermatology across all ages of practicing dermatologists, according to the researchers.

The present study was limited by its single-centre design, selection bias, and the fact that dermatology residents captured the clinical photographs.

“Further study is needed to determine best practices for implementing an inpatient teledermatology programme,” the researchers said.