Diagnostic Concordance of Telemedicine as Compared With Face-to-Face Care in Primary Health Care Clinics in Rural India: Randomized Crossover Trial.

BACKGROUND: With the COVID-19 pandemic, there was an increase and scaling up of provider-to-provider telemedicine programs that connect frontline health providers such as nurses and community health workers at primary care clinics with remote doctors at tertiary facilities to facilitate consultations for rural patients. Considering this new trend of increasing use of telemedicine, this study was conducted to generate evidence for patients, health providers, and policymakers to compare if provider-to-provider telemedicine-based care is equivalent to in-person care and is safe and acceptable in terms of diagnostic and treatment standards. OBJECTIVE: This study aims to compare the diagnosis and treatment decisions from teleconsultations to those of in-person care in teleclinics in rural Gujarat. METHODS: We conducted a diagnostic concordance study using a randomized crossover study design with 104 patients at 10 telemedicine primary care clinics. Patients reporting to 10 telemedicine primary care clinics were randomly assigned to first receive an in-person doctor consultation (59/104, 56.7%) or to first receive a health worker-assisted telemedicine consultation (45/104, 43.3%). The 2 groups were then switched, with the first group undergoing a telemedicine consultation following the in-person consultation and the second group receiving an in-person consultation after the teleconsultation. The in-person doctor and remote doctor were blinded to the diagnosis and management plan of the other. The diagnosis and treatment plan of in-person doctors was considered the gold standard. RESULTS: We enrolled 104 patients reporting a range of primary health care issues into the study. We observed 74% (77/104) diagnostic concordance and 79.8% (83/104) concordance in the treatment plan between the in-person and remote doctors. No significant association was found between the diagnostic and treatment concordance and the order of the consultation (P=.65 and P=.81, respectively), the frontline health worker-doctor pair (both P=.93), the gender of the patient (both P>.99), or the mode of teleconsultation (synchronous vs asynchronous; P=.32 and P=.29, respectively), as evaluated using Fisher exact tests. A significant association was seen between the diagnostic and treatment concordance and the type of case (P=.004 and P=.03, respectively). The highest diagnostic concordance was seen in the management of hypertension (20/21, 95% concordance; Cohen kappa=0.93) and diabetes (14/15, 93% concordance; Cohen kappa=0.89). The lowest values were seen in cardiology (1/3, 33%) and patients presenting with nonspecific symptoms (3/10, 30%). The use of a digital assistant to facilitate the consultation resulted in increased adherence to evidence-based care protocols. CONCLUSIONS: The findings reflect that telemedicine can be a safe and acceptable alternative mode of care especially in remote rural settings when in-person care is not accessible. Telemedicine has advantages. for the potential gains for improved health care-seeking behavior for patients, reduced costs for the patient, and improved health system efficiency by reducing overcrowding at tertiary health facilities.

Diagnostic accuracy and management concordance of otorhinolaryngological diseases through telehealth or remote visits: A systematic review & meta-analysis.

INTRODUCTION: COVID-19 has led to delays in providing healthcare in both emergency and non-emergency settings, especially in surgical subspecialties which rely heavily on referrals and in-person visits. Without an established telehealth infrastructure, many otorhinolaryngological departments experienced decreases in consultations. Telemedicine has attempted to bridge the gap between pre- and post-pandemic periods by creating a safe avenue of communication between otorhinolaryngologists and patients. This review hopes to address the accuracy of telemedicine in patient diagnosis and management. METHODS: Searches were conducted since study conception until June 30, 2022, on multiple databases including PubMed, SCOPUS, and CINAHL for this systematic review and meta-analysis. Diagnostic accuracy, management accuracy, kappa, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were meta-analyzed by comparing virtual visits to in-person visits (gold standard). RESULTS: Nineteen studies were included in this review. A total of 1518 patients were included across all studies. When comparing virtual visits against in-person visits, accurate diagnosis was made in 86.2% [82.1,89.9, I2 = 73.5%, P < 0.0001] of patients and management accuracy was 91.5% [86.1,95.7, I2 = 81.8%, P < 0.0001] when treating patients. Kappa value determining interrater reliability was 0.8 [0.7,0.9, I2 = 81.8%, P < 0.0001]. CONCLUSION: Our data suggest that diagnostic and management concordance is above 80% when comparing diagnosis and management strategies in patients who underwent both telehealth and in-person visits with an otorhinolaryngologist. In uncomplicated patients, telehealth might be a reliable source for diagnosis and management however, in-person consultation is likely still required for pathologies in which physical exam, imaging or procedural elements represent a vital component of the work-up.

Effectiveness and use of reverse transcriptase polymerase chain reaction point of care testing in a large-scale COVID-19 surveillance system.

BACKGROUND: Rapid COVID-19 testing platforms can identify infected individuals at the point of care (POC), allowing immediate isolation of infected individuals and reducing the risk of transmission. While lab-based nucleic acid amplification testing (NAAT) is often considered the gold standard to detect SARS-CoV-2 in the community, results typically take 2-7 days to return, rendering POC testing a critical diagnostic tool for infection control. The National Football League (NFL) and NFL Players Association deployed a new POC testing strategy using a newly available reverse transcriptase polymerase chain reaction (RT-PCR) rapid test during the 2020 season, and evaluated diagnostic effectiveness compared to other available devices using real-world population surveillance data. METHODS: RT-PCR POC test results were compared to NAAT results from same-day samples by calculation of positive and negative concordance. Sensitivity analyses were performed for three subgroups: (1) individuals symptomatic at time of positive test; (2) individuals tested during the pilot phase of rollout; and (3) individuals tested daily. RESULTS: Among 4989 same-day POC/NAAT pairs, 4957 (99.4%) were concordant, with 93.1% positive concordance and 99.6% negative concordance. Based on adjudicated case status, the false negative rate was 0.2% and false positive rate was 2.9%. In 43 instances, the immediate turnaround of results by POC allowed isolation of infected individuals 1 day sooner than lab-based testing. Positive/negative concordance in sensitivity analyses were relatively stable. CONCLUSION: RT-PCR POC testing provided timely results that were highly concordant with lab-based NAAT in population surveillance. Expanded use of effective RT-PCR POC can enable rapid isolation of infected individuals and reduce COVID-19 infection in the community.

Emergency Use and Efficacy of an Asynchronous Teledermatology System as a Novel Tool for Early Diagnosis of Skin Cancer during the First Wave of COVID-19 Pandemic.

BACKGROUND: After the outbreak of the corona virus disease-19 (COVID-19) pandemic, teledermatology was implemented in the Hungarian public healthcare system for the first time. Our objective was to assess aggregated diagnostic agreements and to determine the effectiveness of an asynchronous teledermatology system for skin cancer screening. METHODS: This retrospective single-center study included cases submitted for teledermatology consultation during the first wave of the COVID-19 pandemic. Follow-up of the patients was performed to collect the results of any subsequent personal examination. RESULTS: 749 patients with 779 lesions were involved. 15 malignant melanomas (9.9%), 78 basal cell carcinomas (51.3%), 21 squamous cell carcinomas (13.8%), 7 other malignancies (4.6%) and 31 actinic keratoses (20.4%) were confirmed. 87 malignancies were diagnosed in the high-urgency group (42.2%), 49 malignancies in the moderate-urgency group (21.6%) and 16 malignancies in the low-urgency group (4.6%) (p < 0.0001). Agreement of malignancies was substantial for primary (86.3%; κ = 0.647) and aggregated diagnoses (85.3%; κ = 0.644). Agreement of total lesions was also substantial for primary (81.2%; κ = 0.769) and aggregated diagnoses (87.9%; κ = 0.754). CONCLUSIONS: Our findings showed that asynchronous teledermatology using a mobile phone application served as an accurate skin cancer screening system during the first wave of the COVID-19 pandemic.

Assessing the Diagnostic Accuracy of Teledermatology Consultations at a Local Veterans Affairs Dermatology Clinic.

With the advances in health information technology and the need for increased access to specialized health care, the advent of telemedicine was designed to bring care to individuals at a distance. Telemedicine decreases barriers to health care and brings medical specialists to underserved areas and populations. We have seen a tremendous increase in the need and utilization of telemedicine during the COVID-19 pandemic due to the lockdowns and social distancing efforts. Virtual care continues to be extended to patients to maintain their health care needs when in-person clinic appointments are not feasible or ideal such as seen during a pandemic. Telemedicine is an additional tool that has proven vital to our healthcare system. To provide optimal care, a strong technological infrastructure must be in place. Once in practice, positive outcomes have been noted for patients and healthcare providers as diagnosis, treatment, and appropriate triage can be made virtually and at the patients' convenience. To ensure high-quality care is provided through the Veterans Affairs teledermatology consultation service, we investigated the concordance of teledermatology diagnoses with clinical examination findings through a retrospective chart review covering a one-year time period. Our study found a concordance of 75.3% between the teledermatology diagnoses and the in-person clinical diagnoses. The main limitation we found to virtual examination is the inability to perform total body skin examinations. We found that 60.2% of patients had additional diagnoses when examined in person, with 8.4% of patients having an additional malignant diagnosis. These findings highlight the need for in-person examinations when feasible to ensure that no other diagnoses go undiscovered if not captured on the submitted images for teledermatology consultation. Despite the limitations posed by photographic examination, teledermatology can be used as a reliable method for diagnosis when a conventional in-person examination is not readily available or ideal, such as during a pandemic, and can serve as a powerful triaging tool.