Teledermatology May Benefit Marginalized Populations: National and Institutional Trends during the COVID-19 Pandemic

The COVID-19 pandemic led to a swift expansion of teledermatology (TD) services [1, 2]. Although nationwide adaptation was possible due to changes in licensure, billing, and infrastructure [3], TD is not a new concept. Unfortunately, regulatory barriers had previously prevented the widespread utilization of TD witnessed today. This is unsurprising, as TD may provide better, faster, and cheaper care to its users [4, 5]. Most importantly, TD provides improved access to often inaccessible dermatology services, particularly to underserved populations [6]. Our study aimed to report national and institutional TD service demographic-specific utilization and institutional no-show rates during the COVID-19 pandemic for the purpose of understanding the pandemic-specific trends in TD utilization.

This study characterizes national and a single-institution TD use during the COVID-19 pandemic. With TD, dermatologists may better care for patients who typically encounter challenges with in-person visits, though data for this hypothesis are lacking and there is evidence to suggest the contrary as variability in internet access may create a digital divide and healthcare disparities [6, 7] .

Our results and analysis show that non-white utilization was higher for TD, a trend that nationally increased over the course of the pandemic with our institutional data showing lower no-show rates for this group. Jointly, this suggests that TD may be especially appealing to minority patients and their families. Historically speaking, minority groups have had difficulty accessing dermatologic care, with technological gaps, a shortage of dermatologists, long wait times, and high costs each contributing to healthcare disparities [8, 9]. Demographics such as race/ethnicity, socioeconomic status, and county of residence are associated with decreased access to dermatologists as well as broadband services [7‐9]. While these trends are encouraging for the future of TD, we noted a significant drop in TD utilization including the number of actual telehealth visits, despite initial widespread adoption. We speculate that, besides 2020 Q2 numbers being inflated, challenging technology experiences, limited diagnosis and biopsy abilities, and poor resolution of video/images may be considered as reasons for the initial peak of inflated expectations having led to an “expected” trough of disillusionment [10]. This finding does not preclude the possibility of improved dermatology access for minority populations via telehealth options, including phone visits that require no internet access. Importantly, this study demonstrates trends of TD utilization that may represent demographic-based preference of care modality. While internet deserts and geospatial location may create barriers to entry for video visits, it should be noted that telehealth options including telephone visits have a much lower barrier to entry. These are included in the current study within TD encounters. The future of TD is largely uncertain, but our findings demonstrate the importance of maintaining TD as an accessible avenue for dermatologic care.

Our data found that younger individuals and females were more likely to utilize TD services, which is consistent with previously published Medicaid TD usage demographics (58.7% < 17 years of age; 58.2% females) [11]. While this study did not stratify diagnosis at the time of the encounter, these findings may be explained by patients attempting to establish care or having difficulties in access to care [11] .

Limitations include a single-institution report for no-show data that may not be representative of the overall national and other non-academic centers’ experience. National data are also limited to the groups that participate with AAD’s DataDerm. A decline in TD utilization as the pandemic progressed could have been artificially inflated due to the shutdown of in-person dermatology services during the first few months of the pandemic. Our data sources presented information in the aggregate, preventing more individual-level analyses (particularly temporal). Future national or multicenter studies with individual long-term data and diagnosis stratification are needed to build on these findings. Another caveat that we recognize is that there are likely geographic differences in TD utilization during the pandemic, perhaps related to factors such as access to internet and access to compatible technology. However, the DataDerm registry did not provide the zip codes for the encounter data that would enable this analysis.

Our work provides evidence for TD utilization and perhaps preferences among various demographic groups, demonstrating disproportionate impact on improving access for and engagement of medically marginalized groups such as non-white races, females, and patients living farther away or out-of-state from their dermatologist, provided that access to broadband internet and technology literacy are not significant barriers [2, 6, 7, 12]. TD is preferred by younger patients, who are the next generation of healthcare consumers. Understanding TD trends can assist institutions in optimizing resource utilization and inform current and future healthcare delivery models for universal care access.