Teledermatology in rural, underserved, and isolated environments: A review

Purpose of review: Summarize the current evidence for teledermatology in rural, underserved, and isolated environments including its use during the current COVID-19 pandemic. Recent findings: Teledermatology is a reliable and cost-effective tool that can reduce face-to-face visits and improve the timeliness of care for medically underserved populations. Recent studies have shown many additional benefits of teledermatology, including improving patients\u27 health outcomes and increasing local providers\u27 knowledge of dermatologic conditions. Despite these benefits, many low-income and rural populations lack access to digital technology and high-speed internet, limiting the reach of telemedical services. Summary: Overall, barriers in access to care are unique across the globe, and thus teledermatology interventions should address and adapt to the needs of the local patient population. Certain strategies, such as implementing simple, SF models, using standardized TD consult templets, and providing real-time information technology support could potentially mitigate disparities and improve the effectiveness of TD programs in underserved areas

Using Implementation Science to Understand Teledermatology Implementation Early in the COVID-19 Pandemic: Cross-sectional Study

BackgroundImplementation science has been recognized for its potential to improve the integration of evidence-based practices into routine dermatologic care. The COVID-19 pandemic has resulted in rapid teledermatology implementation worldwide. Although several studies have highlighted patient and care provider satisfaction with teledermatology during the COVID-19 pandemic, less is known about the implementation process. ObjectiveOur goal was to use validated tools from implementation science to develop a deeper understanding of the implementation of teledermatology during the COVID-19 pandemic. Our primary aims were to describe (1) the acceptability and feasibility of the implementation of teledermatology and (2) organizational readiness for the implementation of teledermatology during the COVID-19 pandemic. We also sought to offer an example of how implementation science can be used in dermatologic research. MethodsAn anonymous, web-based survey was distributed to Association of Professors of Dermatology members. It focused on (1) the acceptability, feasibility, and appropriateness of teledermatology and (2) organizational readiness for implementing teledermatology. It incorporated subscales from the Organizational Readiness to Change Assessment—a validated measure of organizational characteristics that predict implementation success. ResultsOf the 518 dermatologists emailed, 35 (7%) responded, and all implemented or scaled up teledermatology during the pandemic. Of the 11 care providers with the highest level of organizational readiness, 11 (100%) said that they plan to continue using teledermatology after the pandemic. Most respondents agreed or strongly agreed that they had sufficient training (24/35, 69%), financial resources (20/35, 57%), and facilities (20/35, 57%). However, of the 35 respondents, only 15 (43%) agreed or strongly agreed that they had adequate staffing support. Most respondents considered the most acceptable teledermatology modality to be synchronous audio and video visits with supplemental stored digital photos (23/35, 66%) and considered the least acceptable modality to be telephone visits without stored digital photos (6/35, 17%). Overall, most respondents thought that the implementation of synchronous audio and video with stored digital photos (31/35, 89%) and telephone visits with stored digital photos (31/35, 89%) were the most feasible. When asked about types of visits that were acceptable for synchronous video/audio visits (with stored digital photos), 18 of the 31 respondents (58%) said “new patients,” 27 (87%) said “existing patients,” 19 (61%) said “medication monitoring,” 3 (10%) said “total body skin exams,” and 22 (71%) said “lesions of concern.” ConclusionsThis study serves as an introduction to how implementation science research methods can be used to understand the implementation of novel technologies in dermatology. Our work builds upon prior studies by further characterizing the acceptability and feasibility of different teledermatology modalities. Our study may suggest initial insights on how dermatology practices and health care systems can support dermatologists in successfully incorporating teledermatology after the pandemic

Global influenza surveillance systems to detect the spread of influenza-negative influenza-like illness during the COVID-19 pandemic: Time series outlier analyses from 2015–2020

Background Surveillance systems are important in detecting changes in disease patterns and can act as early warning systems for emerging disease outbreaks. We hypothesized that analysis of data from existing global influenza surveillance networks early in the COVID-19 pandemic could identify outliers in influenza-negative influenza-like illness (ILI). We used data-driven methods to detect outliers in ILI that preceded the first reported peaks of COVID-19. Methods and findings We used data from the World Health Organization’s Global Influenza Surveillance and Response System to evaluate time series outliers in influenza-negative ILI. Using automated autoregressive integrated moving average (ARIMA) time series outlier detection models and baseline influenza-negative ILI training data from 2015–2019, we analyzed 8,792 country-weeks across 28 countries to identify the first week in 2020 with a positive outlier in influenza-negative ILI. We present the difference in weeks between identified outliers and the first reported COVID-19 peaks in these 28 countries with high levels of data completeness for influenza surveillance data and the highest number of reported COVID-19 cases globally in 2020. To account for missing data, we also performed a sensitivity analysis using linear interpolation for missing observations of influenza-negative ILI. In 16 of the 28 countries (57%) included in this study, we identified positive outliers in cases of influenza-negative ILI that predated the first reported COVID-19 peak in each country; the average lag between the first positive ILI outlier and the reported COVID-19 peak was 13.3 weeks (standard deviation 6.8). In our primary analysis, the earliest outliers occurred during the week of January 13, 2020, in Peru, the Philippines, Poland, and Spain. Using linear interpolation for missing data, the earliest outliers were detected during the weeks beginning December 30, 2019, and January 20, 2020, in Poland and Peru, respectively. This contrasts with the reported COVID-19 peaks, which occurred on April 6 in Poland and June 1 in Peru. In many low- and middle-income countries in particular, the lag between detected outliers and COVID-19 peaks exceeded 12 weeks. These outliers may represent undetected spread of SARS-CoV-2, although a limitation of this study is that we could not evaluate SARS-CoV-2 positivity. Conclusions Using an automated system of influenza-negative ILI outlier monitoring may have informed countries of the spread of COVID-19 more than 13 weeks before the first reported COVID-19 peaks. This proof-of-concept paper suggests that a system of influenza-negative ILI outlier monitoring could have informed national and global responses to SARS-CoV-2 during the rapid spread of this novel pathogen in early 2020. Natalie L Cobb and colleagues use routine influenza surveillance data to detect outliers in influenza-like-illness during the COVID-19 pandemic. Author summary Why was this study done? Early detection of respiratory viral outbreaks, such as SARS-CoV-2, is key for public health response and mitigation measures. In this study, we used routine influenza surveillance data to detect outliers in influenza-like illness (ILI) during the COVID-19 pandemic that could suggest spread of SARS-CoV-2. We hypothesized that using data-driven methods would identify increased case counts of influenza-negative ILI prior to reported peaks of COVID-19. What did the researchers do and find? We used routine influenza surveillance data from the World Health Organization’s FluNet and applied automated outlier detection methods to identify outliers in influenza-negative ILI in 2020 across 28 countries. In 16 countries, we detected outliers that preceded the first reported COVID-19 peaks, with an average lag time of 13.3 weeks. In 7 countries, the week of the first outlier changed when accounting for missing data in the models. What do these findings mean? This study serves as a proof of concept and suggests a potential role for the use of automated data monitoring and outlier detection systems to identify outbreaks in respiratory viral illness. These findings also highlight the importance of strengthening routine disease surveillance networks to enhance our ability to identify novel diseases and inform public health responses on a global scale

A type III effectiveness-implementation hybrid evaluation of a multicomponent patient navigation strategy for advanced-stage Kaposi's sarcoma: protocol.

BackgroundFor people with advanced-stage Kaposi's sarcoma (KS), a common HIV-associated malignancy in sub-Saharan Africa, mortality is estimated to be 45% within 2 years after KS diagnosis, despite increasingly wide-spread availability of antiretroviral therapy and chemotherapy. For advanced-stage KS, chemotherapy in addition to antiretroviral therapy improves outcomes and saves lives, but currently, only ~50% of people with KS in western Kenya who have an indication for chemotherapy actually receive it. This protocol describes the evaluation of a multicomponent patient navigation strategy that addresses common barriers to service penetration of and fidelity to evidence-based chemotherapy among people with advanced-stage KS in Kenya.MethodsThis is a hybrid type III effectiveness-implementation study using a non-randomized, pre- post-design nested within a longitudinal cohort. We will compare the delivery of evidence-based chemotherapy for advanced-stage KS during the period before (2016-2020) to the period after (2021-2024), the rollout of a multicomponent patient navigation strategy. The multicomponent patient navigation strategy was developed in a systematic process to address key determinants of service penetration of and fidelity to chemotherapy in western Kenya and includes (1) physical navigation and care coordination, (2) video-based education, (3) travel stipend, (4) health insurance enrollment assistance, (5) health insurance stipend, and (6) peer mentorship. We will compare the pre-navigation period to the post-navigation period to assess the impact of this multicomponent patient navigation strategy on (1) implementation outcomes: service penetration (chemotherapy initiation) and fidelity (chemotherapy completion) and (2) service and client outcomes: timeliness of cancer care, mortality, quality of life, stigma, and social support. We will also describe the implementation process and the determinants of implementation success for the multicomponent patient navigation strategy.DiscussionThis study addresses an urgent need for effective implementation strategies to improve the initiation and completion of evidence-based chemotherapy in advanced-stage KS. By using a clearly specified, theory-based implementation strategy and validated frameworks, this study will contribute to a more comprehensive understanding of how to improve cancer treatment in advanced-stage KS

Barriers and facilitators to chemotherapy initiation and adherence for patients with HIV-associated Kaposi's sarcoma in Kenya: a qualitative study.

BackgroundKaposi sarcoma is one of the most prevalent HIV-associated malignancies in sub-Saharan Africa and is often diagnosed at advanced stage of disease. Only 50% of KS patients who qualify for chemotherapy receive it and adherence is sub-optimal.Methods57 patients > 18 years with newly diagnosed KS within the AMPATH clinic network in Western Kenya were purposively selected to participate in semi-structured interviews stratified by whether they had completed, partially completed, or not completed chemotherapy for advanced stage KS. We based the interview guide and coding framework on the situated Information, Motivation, Behavioral Skills (sIMB) framework, in which the core patient centered IMB constructs are situated into the socioecological context of receiving care.ResultsOf the 57 participants, the median age was 37 (IQR 32-41) and the majority were male (68%). Notable barriers to chemotherapy initiation and adherence included lack of financial means, difficulty with convenience of appointments such as distance to facility, appointment times, long lines, limited appointments, intrapersonal barriers such as fear or hopelessness, and lack of proper or sufficient information about chemotherapy. Factors that facilitated chemotherapy initiation and adherence included health literacy, motivation to treat symptoms, improvement on chemotherapy, prioritization of self-care, resilience while experiencing side effects, ability to carry out behavioral skills, obtaining national health insurance, and free chemotherapy.ConclusionOur findings about the barriers and facilitators to chemotherapy initiation and adherence for KS in Western Kenya support further work that promotes public health campaigns with reliable cancer and chemotherapy information, improves education about the chemotherapy process and side effects, increases oncology service ability, supports enrollment in national health insurance, and increases incorporation of chronic disease care into existing HIV treatment networks

Telling the story of intersectional stigma in HIV-associated Kaposi's sarcoma in western Kenya: a convergent mixed-methods approach.

IntroductionThe experience of stigma can be multifaceted for people with HIV and cancer. Kaposi's sarcoma (KS), one of the most common HIV-associated cancers in sub-Saharan Africa, often presents with visible skin lesions that may put people at risk for stigmatization. In this way, HIV-associated KS is unique, as people with KS can experience stigma associated with HIV, cancer, and skin disease simultaneously. The aim of this study is to characterize the intersectionality of HIV-related, cancer-related and skin disease-related stigma in people living with HIV and KS.MethodsWe used a convergent mixed-methods approach nested within a longitudinal study of people with HIV-associated KS in western Kenya. Between February 2019 and December 2020, we collected quantitative surveys among all participants and conducted semi-structured interviews among a purposive sample of participants. Quantitative surveys were adapted from the abridged Berger HIV Stigma Scale to assess overall stigma, HIV-related stigma, cancer-related stigma, and skin disease-related stigma. Qualitative data were coded using stigma constructs from the Health Stigma and Discrimination Framework.ResultsIn 88 semi-structured interviews, stigma was a major barrier to KS diagnosis and treatment among people with HIV-associated KS. Participant's stories of stigma were dominated by HIV-related stigma, more than cancer-related or skin disease-related stigma. However, quantitative stigma scores among the 117 participants were similar for HIV-related (Median: 28.00; IQR: 28.0, 34.0), cancer-related (Median: 28.0; IQR: 28.0, 34.8), and skin disease-related stigma (Median: 28.0; IQR: 27.0, 34.0). In semi-structured interviews, cancer-related and skin disease-related stigma were more subtle contributors; cancer-related stigma was linked to fatalism and skin-related stigma was linked to visible disease. Participants reported resolution of skin lesions contributed to lessening stigma over time; there was a significant decline in quantitative scores of overall stigma in time since KS diagnosis (adjusted β = -0.15, p <0.001).ConclusionsThis study highlights the role mixed-method approaches can play in better understanding stigma in people living with both HIV and cancer. While HIV-related stigma may dominate perceptions of stigma among people with KS in Kenya, intersectional experiences of stigma may be subtle, and quantitative evaluation alone may be insufficient to understand intersectional stigma in certain contexts