Asynchronous telemedicine for isotretinoin management: A direct care pilot

To the Editor: During the COVID-19 pandemic, telemedicine has sustained health care^{1 , 2} and will remain an integral aspect of care delivery. However, synchronous telemedicine (ST) requires provider-patient co-availability and fails to address the capacity constraints of our specialty. Asynchronous telemedicine (AT), on the other hand, may enhance access^{3 , 4} by allowing more routine care to be delivered in a scalable fashion. This method would free in-person and synchronous telemedicine appointments for urgent, higher-value dermatologic care.

We piloted a direct-care AT program for isotretinoin management in established acne patients at our urban, academic dermatology clinic. Patients upload photographs and complete an online structured questionnaire through a non–electronic medical record (EMR)-based web portal accessible on any internet-enabled device. The physician uses the same portal to respond asynchronously, and the final AT note is ported into the EMR. Although physicians may theoretically hesitate to remotely adjust isotretinoin dosing without a synchronous visit, we hypothesized that in practice, there would be no difference in dosing outcomes between AT and ST groups. Between March 1 and May 7, 2020, 126 patients completed 182 isotretinoin AT visits, which we retrospectively compared with ST visits from the same period (Tables I and II ). Analysis was conducted in Stata 15.1 (StataCorp, LLC–College Station, TX).

Table I.

Demographics for patients starting in isotretinoin asynchronous versus synchronous telemedicine visit

	AT∗	ST†
	N = 126	N = 17
Age (y)‡
Mean (SD)	21.7 (5.8)	28.1 (16.2)
Median	21	21
Gender
Female	79 (62.7%)	10 (58.8%)
Male	47 (37.3%)	7 (41.2%)
Race
Asian	8 (6.3%)	1 (5.9%)
Black	3 (2.4%)	0
Mixed race	2 (1.6%)	0
Other/unavailable§	14 (11.1%)	3 (17.6%)
White	99 (78.6%)	13 (76.5%)
Ethnicity
Non-Hispanic‖	101 (80.2%)	10 (58.9%)
Hispanic or Latino	12 (9.5%)	1 (5.9%)
Unavailable	13 (10.3%)	6 (35.3%)
Insurance
Commercial/private	107 (84.9%)	12 (70.6%)
Government	19 (15.1%)	5 (29.4%)
Month completed at enrollment
Range	0-10 mo	0-17 mo
Median	3 mo	3 mo
Months in program
1	68 (54.0%)	12 (70.6%)
2	57 (45.2%)	5 (29.4%)
3	1 (0.8%)	0 (0%)
Days to AT visit completion
By patient	0.9 ± 1.7 (median 0)	N/A
By MD	1.2 ± 1.5 (median 1.0)	N/A

^∗Most AT visits (n = 179; 87.7%) were completed by 5 providers.

^†ST group were those patients scheduled directly for phone visit without enrollment in AT visit during the same period March 1 to May 7, 2020. (At our institution, most ST visits were conducted as phone visit accompanied by patient-submitted photographs).

^‡Age difference between patients in AT and ST visits (P = .123; t test, unequal variance, 2-tailed).

^§Race listed in medical record as Other, Unavailable, and Declined.

^‖Includes Declined and Other.

Table II.

Dose outcomes for isotretinoin AT versus ST^∗ visits

	Overall	AT only	ST only	P value
	N = 204	N = 141	N = 63
1st or 2nd HCG, Start	18	13	5	.611‡
Same	129	88	41
Increase	33	23	10
Decrease, stop†	11	6	5
Finish	13	11	2
	AT overall	AT only	AT with Phone	P value
	N = 182	N = 141	N = 41
1st or 2nd HCG, Start	15	13	2	.239‡
Same	116	88	28
Increase	27	23	4
Decrease, stop†	11	6	5
Finish	13	11	2

^∗ST = phone visit (n = 22) plus asynchronous visit converted to phone visit (n = 41).

^†Stop means isotretinoin stopped before course complete (n = 1).

^‡χ² test for homogeneity (2-tailed).

We developed the AT program prepandemic to offset access constraints to our clinic and targeted isotretinoin patients because they require frequent office visits. The pandemic prompted us to rapidly enroll many isotretinoin patients into AT during clinic closures. Most isotretinoin AT visits (77.5%) were completed successfully without conversion to ST visits. We investigated clinician behavior by using dose adjustments as a proxy for clinician comfort with asynchronous care delivery. Isotretinoin AT visits encompassed the full spectrum of therapy from start to finish, and dosing outcomes were not different between AT and ST groups. Importantly, dosing outcomes were also not different between AT-only and AT-converted-to-ST groups, meaning these conversions were not prompted by dosing adjustments. Taken together, these results suggest that dermatologists were comfortable remotely adjusting isotretinoin dosing (both escalating for therapeutic effect and decreasing to manage side effects) without a synchronous encounter. Another benefit of the isotretinoin AT program was alignment of screening pregnancy test with the clinical encounter. During the pandemic, iPledge (https://www.ipledgeprogram.com/iPledgeUI/home.u) allowed home pregnancy tests, which facilitated program compliance. This highlights the usual administrative burden iPledge imposes on patients and clinical practices, and a broader isotretinoin telemedicine system may overcome iPledge hurdles.

Our AT program was funded internally without insurance billing, and we recognize that lack of reimbursement for AT remains the greatest barrier to broader utilization.⁵ However, the trend in telemedicine reimbursement may eventually allow coverage for AT encounters that replace office visits. Further studies of the asynchronous care model will inform utility of AT for routine follow-up and even triage across a spectrum of conditions. We urge our colleagues to continue practicing teledermatology and consider incorporating AT to improve patient access and clinical productivity. These efforts will keep our specialty poised at the leading edge of health care delivery.

Conflicts of interest

None disclosed.