featured
Effectiveness of Online vs In-Person Care for Adults With Psoriasis
abstract
This abstract is available on the publisher's site.
Access this abstract now
IMPORTANCE Innovative, online models of specialty-care delivery are critical to improving patient
access and outcomes.
OBJECTIVE To determine whether an online, collaborative connected-health model results in
equivalent clinical improvements in psoriasis compared with in-person care.
DESIGN, SETTING, AND PARTICIPANTS The Patient-Centered Outcomes Research Institute
Psoriasis Teledermatology Trial is a 12-month, pragmatic, randomized clinical equivalency trial to
evaluate the effect of an online model for psoriasis compared with in-person care. Participant
recruitment and study visits took place at multicenter ambulatory clinics from February 2, 2015, to
August 18, 2017. Participants were adults with psoriasis in Northern California, Southern California,
and Colorado. The eligibility criteria were an age of 18 years or older, having physician-diagnosed
psoriasis, access to the internet and a digital camera or mobile phone with a camera, and having a
primary care physician. Analyses were on an intention-to-treat basis.
INTERVENTIONS Participants were randomized 1:1 to receive online or in-person care (148
randomized to online care and 148 randomized to in-person care). The online model enabled patients
and primary care physicians to access dermatologists online asynchronously. The dermatologists
provided assessments, recommendations, education, and prescriptions online. The in-person group
sought care in person. The frequency of online or in-person visits was determined by medical
necessity. All participants were exposed to their respective interventions for 12 months.
MAIN OUTCOMES AND MEASURES The prespecified primary outcome was the difference in
improvement in the self-administered Psoriasis Area and Severity Index (PASI) score between the
online and in-person groups. Prespecified secondary outcomes included body surface area (BSA)
affected by psoriasis and the patient global assessment score.
RESULTS Of the 296 randomized participants, 147 were women, 149 were men, 187 were white, and
the mean (SD) age was 49 (14) years. The adjusted difference between the online and in-person
groups in the mean change in the self-administered PASI score during the 12-month study period was
–0.27 (95% CI, –0.85 to 0.31). The difference in the mean change in BSA affected by psoriasis
between the 2 groups was –0.05% (95% CI, –1.58% to 1.48%). Between-group differences in the
PASI score and BSA were within prespecified equivalence margins, which demonstrated equivalence
between the 2 interventions. The difference in the mean change in the patient global assessment
score between the 2 groups was –0.11 (95% CI, –0.32 to 0.10), which exceeded the equivalence
margin, with the online group displaying greater improvement.
CONCLUSIONS AND RELEVANCE The online, collaborative connected-health model was as
effective as in-person management in improving clinical outcomes among patients with psoriasis.
Innovative telehealth delivery models that emphasize collaboration, quality, and efficiency can be
transformative to improving patient-centered outcomes in chronic diseases.
access and outcomes.
OBJECTIVE To determine whether an online, collaborative connected-health model results in
equivalent clinical improvements in psoriasis compared with in-person care.
DESIGN, SETTING, AND PARTICIPANTS The Patient-Centered Outcomes Research Institute
Psoriasis Teledermatology Trial is a 12-month, pragmatic, randomized clinical equivalency trial to
evaluate the effect of an online model for psoriasis compared with in-person care. Participant
recruitment and study visits took place at multicenter ambulatory clinics from February 2, 2015, to
August 18, 2017. Participants were adults with psoriasis in Northern California, Southern California,
and Colorado. The eligibility criteria were an age of 18 years or older, having physician-diagnosed
psoriasis, access to the internet and a digital camera or mobile phone with a camera, and having a
primary care physician. Analyses were on an intention-to-treat basis.
INTERVENTIONS Participants were randomized 1:1 to receive online or in-person care (148
randomized to online care and 148 randomized to in-person care). The online model enabled patients
and primary care physicians to access dermatologists online asynchronously. The dermatologists
provided assessments, recommendations, education, and prescriptions online. The in-person group
sought care in person. The frequency of online or in-person visits was determined by medical
necessity. All participants were exposed to their respective interventions for 12 months.
MAIN OUTCOMES AND MEASURES The prespecified primary outcome was the difference in
improvement in the self-administered Psoriasis Area and Severity Index (PASI) score between the
online and in-person groups. Prespecified secondary outcomes included body surface area (BSA)
affected by psoriasis and the patient global assessment score.
RESULTS Of the 296 randomized participants, 147 were women, 149 were men, 187 were white, and
the mean (SD) age was 49 (14) years. The adjusted difference between the online and in-person
groups in the mean change in the self-administered PASI score during the 12-month study period was
–0.27 (95% CI, –0.85 to 0.31). The difference in the mean change in BSA affected by psoriasis
between the 2 groups was –0.05% (95% CI, –1.58% to 1.48%). Between-group differences in the
PASI score and BSA were within prespecified equivalence margins, which demonstrated equivalence
between the 2 interventions. The difference in the mean change in the patient global assessment
score between the 2 groups was –0.11 (95% CI, –0.32 to 0.10), which exceeded the equivalence
margin, with the online group displaying greater improvement.
CONCLUSIONS AND RELEVANCE The online, collaborative connected-health model was as
effective as in-person management in improving clinical outcomes among patients with psoriasis.
Innovative telehealth delivery models that emphasize collaboration, quality, and efficiency can be
transformative to improving patient-centered outcomes in chronic diseases.
Topic Alerts
Click on any of these tags to subscribe to Topic Alerts. Once subscribed, you can get a single, daily email any time PracticeUpdate publishes content on the topics that interest you.
Visit your Preferences and Settings section to Manage All Topic Alerts
Additional Info
JAMA Network Open
Armstrong et al. demonstrated in this exceptionally well-designed study that equivalent patient outcomes and reduction of psoriasis severity (PASI and BSA) were observed comparing traditional in-person care with a connected health teledermatology model. Of note, the teledermatology group almost had half the number of visits compared with the in-person group. There were no differences or limitations in prescribed therapies, which ranged from topicals to phototherapy to traditional systemics and biologics. However, just because we build it, doesn’t necessarily mean they (patients) will come or providers will use it! This is a valuable real-world learning experience that I can share based on my use of (direct-to-patient) teledermatology over the last 13 years.
The benefits to offering teledermatology are well established. However, there are two critical factors in my opinion and experience, which continue to slow adoption.
First, the entire culture of the dermatology practice model will need to adjust to this care delivery modality. As with any successful service that we offer as an extension of our practices, teledermatology education, communication, and workflow implementation of this service are essential requirements for success. Patients, staff, and providers need to be able to understand the value proposition of this care delivery model (consultative vs direct-to patient): access, equivalent outcomes, convenience, reduced costs, and improved office efficiency. A well-constructed and regularly repeated communication plan of this value proposition is crucial and should involve every touch point of the patient-provider experience (website, appointment scheduling, patient calls, check-in/check-out, and provider support). Last and most importantly, providers need to assign office roles (who is responsible for which task) and create a teledermatology visit experience that is efficient, reduces steps, incorporates into the in-office records collection system, and is readily accessible if an online patient contacts or comes into the office, regardless of the platform used.
Second, payer adoption has been slow, and fair compensation for a teledermatology encounter is lacking. This is particularly true in the consultative model that involves 2 or more healthcare professionals providing both diagnostic expertise and care implementation. If outcomes are the same, then a visit is a visit, whether it is online or in person. Dermatologists should be compensated at a fair and similar rate. If an online visit is de-valued and the reimbursement is much lower than a standard reimbursement for a similar in-office visit, then providers will be much less likely to adopt teledermatology. Additional equivalency and cost-reduction studies will be necessary to prove our point to payers!