Assessing Patient Satisfaction with Live-Interactive Teledermatology Visits During the COVID-19 Pandemic: A Survey Study
Introduction
The coronavirus disease 2019 (COVID-19) pandemic has propelled the use of teledermatology to minimize in-person visits1 while preserving access to care. Previously, teledermatology in both store-and-forward and live-interactive formats has been proposed to address disparities in care by reducing wait times, increasing efficiency, and improving access for traditionally underserved patients.2 Patient satisfaction with remote care is reportedly high, with 38–86% of patients reporting a preference for teledermatology in a systematic review.3
During the COVID-19 pandemic, nearly three-quarters of acne patients in Italy were satisfied with their care through live-interactive video,4 whereas in Egypt 91.5% of patients who had either a live-interactive or store-and-forward teledermatology visit reported satisfaction in a postvisit questionnaire.5 As many dermatologists have pivoted to teledermatology during the pandemic, we aimed to characterize patient experiences, satisfaction, and preferences regarding teledermatology visits at an urban academic center serving a diverse patient population.
Materials and Methods
In this Institutional Review Board-approved retrospective survey study, 2,778 adult patients ≥18 years who met inclusion criteria and attended live-interactive teledermatology visits on the patient portal MyChart between March and June 2020 at a single academic center were recruited. Patients received a recruitment e-mail containing the survey link between June and July 2020, with a 1-week follow-up reminder. All data were collected in an anonymized manner.
The online survey (Supplementary Appendix SA) collected information on patient self-reported demographics, reason for visit, and technical difficulties. Patient satisfaction and preferences of live-interactive teledermatology were assessed across four domains: (1) preparation for visit, (2) communication with provider, (3) physical examination, and (4) treatment plan and follow-up. Satisfaction was rated on a 5-point Likert scale. Preference for teledermatology compared with an in-person visit was rated on a 3-point scale. Patients were also asked if they provided clinical photographs before their video visit.
Data analysis was performed using Stata/IC (StataCorp LLC, College Station, TX). Survey responses were reported as a proportion or percentage. Two sample tests of proportions were used to compare satisfaction and preference between different domains. A Pearson chi-square test was used to assess for associations between patient demographics and survey responses.
This study was approved by New York University School of Medicine IRB. Approval number: i20-00890.
Results
A total of 602 patients (21.7%) completed the survey. Females comprised 70.8% of respondents. The majority (52.0%) were between 18 and 45 years, whereas 23.1% were at least 66 years old; 73.8% of respondents identified as white. New patients comprised 14.6% of respondents, whereas 57.9% had between one and three in-person visits within 12 months before their teledermatology visit. Additional demographic data are reported (Table 1).
| CATEGORY | n (%) | ||
|---|---|---|---|
| TOTAL POPULATION | EARLY RESPONDERSa | LATE RESPONDERSa | |
| Total | 602 | 332 | 270 |
| Gender | |||
| Female | 426 (70.8) | 243 (73.2) | 183 (67.8) |
| Male | 171 (28.4) | 88 (26.5) | 83 (30.7) |
| Gender variant/nonconforming | 1 (0.2) | 0 (0.0) | 1 (0.4) |
| No response | 4 (0.7) | 1 (0.3) | 3 (1.1) |
| Age (years)b | |||
| 18–35 | 210 (34.9) | 121 (36.4) | 89 (33.0) |
| 36–45 | 103 (17.1) | 70 (21.1) | 33 (12.2) |
| 46–55 | 67 (11.1) | 33 (9.9) | 34 (12.6) |
| 56–65 | 83 (13.8) | 41 (12.3) | 42 (15.6) |
| 66–75 | 92 (15.3) | 47 (14.2) | 45 (16.7) |
| >75 | 47 (7.8) | 20 (6.0) | 27 (10.0) |
| Ethnicityc | |||
| White | 444 (73.8) | 246 (74.1) | 198 (73.3) |
| Black | 25 (4.2) | 11 (3.3) | 14 (5.2) |
| Hispanic | 60 (10.0) | 32 (9.6) | 28 (10.4) |
| Asian | 48 (8.0) | 28 (8.4) | 20 (7.4) |
| Middle Eastern or North African | 7 (1.2) | 3 (0.9) | 4 (1.5) |
| Native Hawaiian or other Pacific Islander | 3 (0.5) | 2 (0.6) | 1 (0.4) |
| Other | 14 (2.3) | 10 (3.0) | 4 (1.5) |
| No response | 17 (2.8) | 9 (2.7) | 8 (3.0) |
| Number of prior in-person visits | |||
| New patient | 88 (14.6) | 51 (15.4) | 37 (13.7) |
| 1–3 | 348 (57.8) | 193 (58.1) | 155 (57.4) |
| 4–9 | 125 (20.8) | 68 (20.5) | 57 (21.1) |
| 10–25 | 34 (5.6) | 16 (4.8) | 18 (6.7) |
| >25 | 6 (1.0) | 3 (0.9) | 3 (1.1) |
| No response | 1 (0.2) | 1 (0.3) | 0 (0.0) |
| Reason for teledermatology visitc | |||
| Acne | 109 (18.1) | 67 (20.2) | 42 (15.6) |
| Rosacea | 30 (5.0) | 16 (4.8) | 14 (5.2) |
| Eczema | 81 (13.5) | 48 (14.5) | 33 (12.2) |
| Psoriasis | 38 (6.3) | 18 (5.4) | 20 (7.4) |
| Skin cancer or lesion of concernb | 96 (15.9) | 43 (13.0) | 53 (19.6) |
| Ulcer | 7 (1.2) | 3 (0.9) | 4 (1.5) |
| New rash | 108 (17.9) | 59 (17.8) | 49 (18.1) |
| Hives | 17 (2.8) | 11 (3.3) | 6 (2.2) |
| Hair or nails | 53 (8.8) | 32 (9.6) | 21 (7.8) |
| Other | 175 (29.1) | 102 (30.7) | 73 (27.0) |
| No response | 3 (0.5) | 1 (0.3) | 2 (0.7) |
| Technology | |||
| Difficulty connecting with physician | 61 (10.1) | 41 (12.3) | 20 (7.4) |
| Photographs uploaded in advance | 353 (58.6) | 191 (57.5) | 162 (60.0) |
| Reasons for not uploading photographs | |||
| No cutaneous finding | 11 (4.4) | 8 (5.7) | 3 (2.8) |
| Photographs were unnecessary | 46 (18.5) | 25 (17.7) | 21 (19.4) |
| Difficulty taking/uploading photo | 20 (8.0) | 12 (8.5) | 8 (7.4) |
| Unaware of the option | 148 (59.4) | 88 (62.4) | 60 (55.6) |
| Patient preference | 11 (4.4) | 4 (2.8) | 7 (6.5) |
Technical difficulties with the visit were reported by 10.2% of respondents. 15.1% of respondents aged ≥66 years reported technical issues during their visit. Photographs were uploaded in advance by 58.8% of respondents. Of those who did not upload photographs, commonly cited reasons included being unaware of the option, having no cutaneous findings, or deeming photographs unnecessary. Only 2.3% indicated not knowing how to upload photographs.
Overall, at least 70% of respondents were equally or more satisfied with teledermatology compared with in-person visits across all four domains (Fig. 1). However, significantly more patients were “dissatisfied” or “very dissatisfied” with the virtual physical examination (26.7%, all p < 0.01) compared with the proportions of patients who were dissatisfied with the other three domains. Similarly, significantly more patients (57.9%, all p < 0.01) preferred in-person visits over teledermatology for a physical examination (Fig. 2).
Fig. 1. More than 90% of patients surveyed were at least equally satisfied with teledermatology visits as compared with in-person visits with regard to visit preparation, patient–provider communication, and treatment plan and follow-up. Notably, 26.7% of patients reported that they were either “dissatisfied” or “very dissatisfied” with the physical examination component.
Fig. 2. More than 80% of patients expressed either equal or greater preference for teledermatology visits as compared with in-person visits with respect to preparation for the visit, communication with the provider, and treatment plan and follow-up. However, 57.9% of patients preferred an in-person over a virtual physical examination.
In subgroup analysis, male gender was significantly associated with satisfaction with treatment plan and follow-up (p = 0.03). Compared with younger patients, more patients ≥66 years preferred in-person visits with regard to visit preparation, provider communication, and treatment plan and follow-up (all p < 0.01). Compared with returning patients, new patients were significantly less satisfied with communication (p = 0.02) and with treatment plan and follow-up (p < 0.01), but preferred teledermatology with regard to visit preparation (p = 0.01). Providing clinical photographs before the live-interactive visit had no impact on patient satisfaction or preference across all domains.
Discussion
We present a survey study capturing patients’ experiences, satisfaction, and preferences for live-interactive teledermatology visits occurring at a single academic center in a COVID-19 hotspot. Patients were overall satisfied with their televisits, with >90% of patients reporting satisfaction with patient–physician communication and treatment plan, which is unsurprising given the alternatives: potential infectious exposure in transit to or during an in-person visit or forgoing medical care. To account for the impact of pandemic conditions on satisfaction ratings, we also included questions assessing patients’ preferences between teledermatology and in-person visits and show that >80% of patients indicated at least an equal preference for teledermatology in all domains except for the physical examination where 57.9% of patients preferred in-person over teledermatology examination.
In a recent review of 23 teledermatology survey studies from a 10-year period (2010–2020) before the COVID-19 pandemic, patients with a wide variety of dermatologic conditions were overall satisfied.6 However, only one study assessed live-interactive visits, whereas the remainder addressed store-and-forward teledermatology. Furthermore, although additional studies evaluating satisfaction with live-interactive teledermatology were published before 2010,7 changes and improvements to technology over time as well as the more widely accepted use of videoconferencing technology underscore the need for newer updated studies evaluating live-interactive teledermatologic care.
Interestingly, telemedicine patients before the pandemic who were less likely to have in-person access to a provider reported higher satisfaction levels than patients new to telemedicine during the pandemic.8 Similarly, we report new patients were less likely to be satisfied with the communication and treatment plans/follow-up aspects compared with returning patients, which could be due to overall unfamiliarity. However, new patients preferred teledermatology visit preparation over the in-person equivalent.
Visit preparation was not formally defined in our survey, although aspects of visit preparation include travel for in-person visits and uploading photographs and downloading software for a live-interactive teledermatology visit. Preference for teledermatology visit preparation could be attributed to factors such as reduced wait times and convenience of use.2,7 Although our survey did not directly assess these elements, 95.0% of respondents were at least “equally satisfied” with their visit preparation.
We also found that male patients were significantly more satisfied with their treatment plan and follow-up compared with female patients. As prior studies have reported the opposite trend,9 better characterization of gender differences in telehealth satisfaction is warranted.
Older respondents ≥66 years (23.1% of our cohort) significantly preferred in-person visits with regard to all domains aside from physical examination. In a cross-sectional study assessing telemedicine readiness in the United States, an estimated 38% of adults aged ≥65 years were not ready for video visits, mainly due to technology inexperience.10 Although only 15.1% of respondents aged ≥66 years reported technical issues during their visit, our survey may not have fully assessed technical aptitude and prior experience with teledermatology. Nevertheless, telemedicine has been reported to adequately address two-thirds of dermatoses in patients >60 years,11 indicating a need to improve the teledermatology experience for older patients.
Notably, 57.9% of our surveyed patients preferred an in-person physical examination, a finding previously reported by both patients and providers.12 From the providers’ perspective, patient-provided photographs may enhance the clarity and ease of the virtual examination. However, we did not find any differences in satisfaction or preference between patients who uploaded photographs before their visit and those who did not.
Limitations of our study include the use of a nonvalidated survey, low response rate, and reliance on self-reported data. However, with >600 respondents, this represents the largest survey cohort assessing patient satisfaction with teledermatology and uniquely evaluates the live-interactive format. We also performed a wave analysis to address potential nonresponse bias13 by comparing patients who responded to the initial versus follow-up e-mail and found no significant differences (Supplementary Appendix SA).
Conclusions
Our study demonstrates high levels of patient satisfaction with live-interactive teledermatology during the COVID-19 pandemic across four surveyed domains. However, patients demonstrated a preference for in-person physical examinations, suggesting a need and opportunity to improve virtual examinations. In addition, aspects of the visit and visit format are differentially preferred by certain populations.
Videoconferencing technology has become more widespread and accepted during pandemic conditions, and its use is likely to continue in the future. As most prior studies evaluating teledermatology have focused on store-and-forward technology or assessed live-interactive formats from >10 years prior,6 our assessment of patient satisfaction and preferences with regard to teledermatology utilizing videoconferencing is useful in assessing the current benefits and shortcomings of this visit format. These findings and future studies into patients’ experiences with live-interactive teledermatology visits will be invaluable in improving the patient–provider experience and ultimately patient care.
Authors’ Contributions
G.K. and R.H.K. conceived of the presented idea. All authors participated in the study design, data collection, and data analysis/interpretation. All authors also participated in the writing and editing of the article.
Disclosure Statement
K.L.S. is a consultant and investigator for Pfizer and an investigator for Regen Labs. The other authors have no interests to disclose relevant to this study.
Funding Information
No funding was received for this article.
Supplementary Material
References
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