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Bezalel S, Fabri P, Park HS. Implementation of Store-and-Forward Teledermatology and Its Associated Effect on Patient Access in a Veterans Affairs Dermatology Clinic. JAMA Dermatol. 2015;151(5):556–557. doi:10.1001/jamadermatol.2014.5272
Dermatology is one of the specialties in the US Department of Veterans Affairs (VA) health care system that has the highest demand. To address this issue, many VA facilities have implemented the use of store-and-forward teledermatology (SFT). At the beginning of 2013, the VA Medical Center in Tampa, Florida, implemented the broader use of SFT services to improve veteran access to dermatologic care. In previous studies, SFT has been proven to decrease time to intervention1,2 and decrease clinic-based visits.1,3,4 However, its effect on patient access to the main dermatology clinic (MDC) has been less well studied. To determine if SFT is positively associated with improved patient access to the MDC, we retrospectively compared January 1 through May 31, 2012, during which SFT was not being heavily used, with January 1 through May 31, 2013, when SFT was fully implemented. In 2012, there were 1557 new patient clinic visits and 28 SFT encounters. In 2013, there were 1508 new patient clinic visits and 608 SFT encounters.
The research service at the James A. Haley Veterans’ Hospital (Tampa, Florida) deemed this project to qualify as a quality assurance and quality improvement activity; hence, this study was exempt from institutional review board approval. The clinical database was queried for percentage of no-shows, average new and established patient wait times, capacity, and percentage of new patients being seen within 30 days. Variables were compared for the 2 time intervals using the unpaired t test. The effect of completed consultations on each variable was determined using linear regression and analysis of variance. Significance was set at P < .05. Statistical analysis was performed using Microsoft Excel Data Analysis software (Microsoft Corp).
There was a significant decrease in the percentage of no-shows (7.91% to 6.16%, t = 3.87; P < .002) and new patient wait times (32.9 days to 9.75 days, t = 17.05; P < .001) between the 2 time periods, but not for established patient wait times (4.14 days to 1.49 days, t = 0.95; P = .37) or clinic capacity, defined as the sum of appointment slots allocated to a given clinic or location (1612.6 to 1722.8, t = –1.139; P = .29). There was a significant correlation between the quantity of SFT consultations completed and the percentage of new patients being seen at the MDC within 30 days (R2 = 0.88; P < .05), new patient wait times (R2 = 0.95; P < .001), and percentage of no-shows (R2 = 0.74; P = .001), but not with established patient wait times (R2 = 0.10; P = .36).
In previous studies, SFT decreased the time for dermatologic intervention and unnecessary consultations.1-4 A recent literature review revealed programs that had 2 of 4 critical factors (effective preselection, high-quality photographic images, high-quality dermoscopic images if pigmented lesions are evaluated, and supportive infrastructure and culture) had filtering percentages near 50%.5 Our analysis suggests that SFT may improve patient access to the MDC by decreasing the percentage of no-shows and the average wait time for new patients. Interestingly, the quantity of SFT consultations completed was directly associated with an increase in the percentage of new patients being seen at the MDC within 30 days, a decrease in the rate of no-shows, and a decrease in new patient wait times. To determine if these effects were confounded by a change in capacity, we analyzed capacity for both time intervals and found no statistical difference. Our study is limited by the observational pre-post study design, lack of a control group, relatively small number of patients, short follow-up, and veteran population being studied. The differences in the results of the pre-post study outcomes may not be causally related to the selected SFT intervention and may be related to one or a number of other factors entirely. Additional studies will be needed to establish the clinical significance of our observation.
Accepted for Publication: November 30, 2014.
Corresponding Author: Spencer Bezalel, BS, University of South Florida Morsani College of Medicine, 12901 Bruce B. Downs Blvd, MDC Box 4, Tampa, FL 33612 (SBezalel@health.usf.edu).
Published Online: February 11, 2015. doi:10.1001/jamadermatol.2014.5272.
Author Contributions: Dr Fabri and Mr Bezalel had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: All authors.
Acquisition, analysis, or interpretation of data: Bezalel, Fabri.
Drafting of the manuscript: Bezalel, Park.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Bezalel, Fabri.
Administrative, technical, or material support: Bezalel, Park.
Study supervision: Fabri, Park.
Conflict of Interest Disclosures: Dr Park is an attending physician in the Dermatology Section and Deputy Associate Chief of Staff for Education, James A. Haley Veterans’ Hospital and Clinics, Tampa, Florida. Dr Fabri is an attending physician in the Surgical Service, James A. Haley Veterans’ Hospital and Clinics. No other disclosures were reported.
Funding/Support: This study was supported in part by the resources and the use of facilities at the James A. Haley Veterans’ Hospital, Tampa, Florida.
Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The contents of this article do not represent the views of the US Department of Veterans Affairs or the United States government.
Additional Contributions: We are indebted to Suzette M. Maynard, James A. Haley Veterans’ Hospital, for her time and help with data extraction. She was not compensated for her contribution.
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