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Teledermatology potentially feasible for patients with HIV in remote areas
Researchers from the University of Pennsylvania suggest that mobile technology to practice teledermatology is feasible for patients with HIV in Botswana.
“In many parts of the world, particularly in sub-Saharan Africa, there is a severe shortage of dermatologic specialists,” the researchers wrote in JAMA Dermatology. “In these regions, this shortage is felt more acutely in communities with high rates of HIV, since there is an increased burden of both prevalence and severity of skin and mucosal disease in this group. Although the introduction of mobile teledermatology … has significant theoretical potential for improving access to care, much work is needed to optimize and validate the use of this technology on a larger scale in this population.”
The researchers conducted a cross-sectional study that included 76 HIV-positive patients with a skin or mucosal condition. All of the patients received a face-to-face clinical evaluation with a US-based dermatologist. Afterward, the patients participated in a cellular phone encounter with a nurse who collected their information, including photographs, and uploaded the information to a teledermatology evaluation website. Then, three US-based dermatologists and one oral medicine specialist made evaluations from that information.
The face-to-face evaluator made 159 diagnoses among the patients, whereas the remote evaluators made varying numbers of diagnoses ranging from 154 to 313. Several months after the initial evaluations, the researchers had the mobile evaluators review the cases again. The kappa coefficients for the evaluators for test-retest reliability were 0.47 (95% CI, 0.35-0.59), 0.73 (95% CI, 0.63-0.83) and 0.78 (95% CI, 0.67-0.88) for primary diagnosis and 0.17 (95% CI, –0.01 to 0.36), 0.48 (95% CI, 0.32-0.64) and 0.54 (95% CI, 0.38-0.7) for management choices.
The kappa coefficients for reliability between face-to-face dermatology and the remote reviewers were 0.41 (95% CI, 0.31-0.52) and 0.51 (95% CI, 0.41-0.61) for agreement in diagnosis and 0.08 (95% CI, 0.02-0.15) and 0.12 (95% CI, 0.01-0.23) for agreement in management.
Disclosure: One researcher reports relationships with Abbott, Amgen, Celgene, Centocor, Novartis and Pfizer.
Perspective
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This paper outlines an interesting pilot study, providing some useful preliminary data. Certainly, we need to increase access to high-quality medical care for those in underserved areas, including the developing world and large portions of the United States. Telemedicine is an excellent way to increase access to providers; however, it presents some particular difficulties with conditions for which high-quality imaging is essential, such as dermatology. The technology does exist to provide asynchronous, store-and-forward high-definition images to physicians but, as emphasized by the authors, the software and data networks may not be available to very resource-poor regions. The use of smartphone technology over existing cellular networks may be an excellent alternative, but the question remains whether the images are of reasonable quality to provide accurate, valid and reliable representations of the physical exam.
This is a small pilot study that did not quite achieve its enrollment goal for adequate power. In addition, there was some significant intra- and inter-rater variability, and some concerns about test-retest reliability. Having said that, the specialists with the most experience in this population did seem to have reasonable reliability in their diagnostic assessments, which would likely be reproducible over time. We do not yet know if mobile teledermatology using smartphone technology and cellular networks will be an accurate, valid and reliable way to conduct patient assessments and increase access to care in a cost-effective way. However, this study gives us good preliminary data and will hopefully spark larger studies in the future. Indeed, as technology improves and cellular networks expand, mobile telemedicine may prove to be revolutionary in providing access to care where it previously did not exist. This is particularly important when some of these conditions, such as Kaposi sarcoma, can be both life-threatening and treatable.