To the Editor: Through the COVID-19 pandemic, many dermatology practices across the United States have adapted by providing telemedicine services. However, it remains unclear how teledermatology impacts existing racial and socioeconomic health disparities. Initial studies of teledermatology in the pandemic's early months were relatively small and did not evaluate patterns of patient access.1 , 2 Here, we present demographic and medical profiles of 14,334 patients seen in-person, by telemedicine, or both in the Department of Dermatology at a large academic health system from March 17 to August 31, 2020 compared to 22,055 patients seen during the same period the year prior.
Age, race/ethnicity, sex, insurance type, interpreter use, and diagnoses were extracted from the medical record. Diagnoses were categorized as previously described.3 Additional methodologic details are described in Supplemental Methods available via Mendeley at https://data.mendeley.com/datasets/x8dcwsbjmn/1.
Interestingly, minority patients made up a larger share of patients seen for care during the COVID-era overall than pre-COVID (P < .001) (Supplemental Table I). At the same time, a smaller proportion of COVID-era patients required an interpreter or reported that English was not their primary language (P < .001). Patients with private insurance comprised a greater proportion of patients seen in the COVID-era than pre-COVID (70.8% vs 59.1%, P < .001), with fewer self-paying and Medicare patients seen than pre-COVID (22.0% vs 32.7%, P < .001).
Compared to non-Hispanic White patients, Asian or non-Hispanic Black patients were more likely to be seen by teledermatology only (Asian: adjusted odds ratio, 1.50; 95% CI, 1.28-1.75; non-Hispanic Black: adjusted odds ratio, 1.50; 95% CI, 1.38-1.64) (Fig 1 , Table I ). White patients made up a greater proportion of patients who were seen in-person and were less likely to be seen by teledermatology only (70.1% vs 53.8%, respectively, P < .001). Patients with private insurance also comprised more of the patients seen by teledermatology only (83.2% vs 60.9%, respectively, P < .001), whereas Medicare and self-paying patients made up a smaller fraction of patients seen by teledermatology only (10.4% vs 25.2%, respectively, P < .001; 1.1% vs 8.0%, respectively, P < .001).
Fig 1.
Unadjusted and adjusted odds ratios for teledermatology-only encounter. OR, Odds ratio.
Table I.
Baseline differences between patients seen in-person, by video only, or both in-person and video in period 2 (COVID-era)
| Demographic characteristics | In-person only |
In-person and video |
Video only |
|
|---|---|---|---|---|
| (N = 6019) | (N = 1778) | (N = 6537) | P value | |
| Age, mean (SD), y | 52.8 (20.5) | 50.0 (21.3) | 36.2 (21.2) | <.001 |
| Gender, N (%) | <.001 | |||
| Female | 3536 (58.7) | 1058 (59.5) | 4323 (66.1) | |
| Male | 2483 (41.3) | 720 (40.5) | 2214 (33.9) | |
| Race/Ethnicity, N (%) | <.001 | |||
| Asian | 242 (4.0) | 89 (5.0) | 493 (7.5) | |
| Hispanic or Latino | 243 (4.0) | 76 (4.3) | 381 (5.8) | |
| Native Hawaiian or Other Pacific Islander | 3 (0.0) | 1 (0.1) | 11 (0.2) | |
| Non-Hispanic Black | 1098 (18.2) | 315 (17.7) | 1830 (28.0) | |
| Non-Hispanic White | 4200 (69.8) | 1246 (70.1) | 3517 (53.8) | |
| Other/Refused | 233 (3.9) | 51 (2.9) | 305 (4.7) | |
| English as primary language, N (%) | .12 | |||
| No | 106 (1.8) | 19 (1.1) | 111 (1.7) | |
| Yes | 5913 (98.2) | 1759 (98.9) | 6426 (98.3) | |
| Interpreter used, N (%) | .13 | |||
| No | 5920 (98.4) | 1760 (99.0) | 6429 (98.3) | |
| Yes | 99 (1.6) | 18 (1.0) | 108 (1.7) | |
| Insurance, N (%) | <.001 | |||
| Private | 3597 (59.8) | 1083 (60.9) | 5439 (83.2) | |
| Medicare | 1514 (25.2) | 405 (22.8) | 683 (10.4) | |
| Self-pay | 483 (8.0) | 5 (0.3) | 70 (1.1) | |
| Other/Unknown | 346 (5.7) | 96 (5.4) | 311 (4.8) | |
| Change in insurance | 66 (1.1) | 183 (10.3) | 14 (0.2) |
SD, Standard deviation.
The reasons why non-White patients sought care were more similar between pre-COVID and COVID eras compared to White patients (Supplemental Table II). Black patients were more likely to be seen during the COVID-era for alopecia (14.0% vs 10.9%, P = .002) and scarring (3.2% vs 2.1%, P = .022) conditions compared to pre-COVID, but less likely to seen for acneiform/follicular disorders (20.8% vs 24.2%, P = .009). White patients were proportionally more likely to be seen for neoplastic (42.1% vs 33.0%, P < .001) and scarring (5.0% vs 2.7%, P < .001) conditions in the COVID-era compared to pre-COVID. Differences in diagnoses among patients by age are reported in Supplemental Table III.
Though telemedicine has long heralded greater access to health care for patients,4 , 5 its adoption was relatively slow until the COVID-19 pandemic. By carefully implementing the right technologies, teledermatology has the potential to increase access to care for patients who have otherwise faced barriers to receiving care.
The findings, implications, and limitations of our study are further explored in Supplemental Discussion.
Conflicts of interest
Dr Kwatra is an advisory board member for Pfizer, Regeneron Pharmaceuticals, Galderma, and Menlo Therapeutics. The remaining authors state no conflict of interest.
Footnotes
Funding sources: This work was supported by The Maryland Dermatologic SocietyMDS127961 (to ALG) and NIHT32 GM136577 (to CV) and NIHF30 DK120160 (to OT).
IRB approval status: Reviewed and approved by the Johns Hopkins School of Medicine Institutional Review Board (IRB00257728) with a waiver of informed consent.
Key words: COVID-19; health care access; health care disparities; health policy; remote care; teledermatology; telemedicine.
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