What was the research about?
Psoriasis is a long-term skin disease that causes red, scaly patches. These patches may itch, hurt, or bleed. A dermatologist is a doctor trained to treat the skin. People with psoriasis can wait a long time or have to travel a long way to see a dermatologist. Online visits might help solve this problem.
In this study, the research team compared two ways of providing care to patients with psoriasis:
- Online visits with dermatologists
- In-person, face-to-face visits with dermatologists or primary care doctors
What were the results?
Online and in-person visits resulted in similar improvements in patients’
- Quality of life
- Symptoms of depression
Compared with patients who had in-person visits, patients who had online visits spent less time traveling to doctors’ appointments. They also spent less time in doctors’ offices.
Who was in the study?
The study included 296 adults from California and Colorado with psoriasis. Of these, 63 percent were white, 6 percent were Asian, 3 percent were black, 2 percent were Pacific Islander, 2 percent were American Indian/Alaska Native, and 24 percent were another race. Also, 34 percent were Latino. The average age was 49, and 50 percent were women. To be in the study, patients needed internet access and a digital camera or a cell phone with a camera. Patients also needed a primary care doctor.
What did the research team do?
The research team assigned patients by chance to either online visits or in-person visits. To start an online visit with a dermatologist, the patient or the patient’s primary care doctor
- Took photos of the patient’s skin
- Put the photos and other information on a secure website
Within 48 hours, the dermatologist
- Recommended treatments to the patient and the primary care doctor through the website
- Wrote online prescriptions
- Provided patient education
If the patient or primary care doctor had questions, the dermatologist answered them online or by phone. Patients assigned to in-person visits saw a doctor of their choice as usual.
Patients filled out surveys before the study started and then every three months for one year. The surveys asked about skin health, quality of life, and depression.
The research team worked with people with psoriasis to plan the study and the website.
What were the limits of the study?
Patients’ views about online or in-person visits might have affected how they thought about their treatment and changes in their health.
Future research could test online visits for more people and people from different parts of the country. Researchers could also look at online visits for people with other long-term health problems.
How can people use the results?
Dermatologists, primary care doctors, and health clinics could use the results when planning ways for patients with psoriasis to get care.
To compare the effects of an online collaborative connected health (CCH) approach to psoriasis care with usual in-person care on disease severity, quality of life, symptoms of depression, and access to specialty care
|Design||Randomized controlled trial|
|Population||296 patients with plaque psoriasis|
Primary: improvement in psoriasis disease severity
Secondary: improvements in quality of life, symptoms of depression, access to specialty care
|Timeframe||1-year follow-up for primary outcome|
This randomized controlled equivalency trial compared an online CCH approach with usual in-person, face-to-face care for patients with psoriasis.
Researchers randomized patients to receive either CCH or usual care. Patients and providers in both groups determined the frequency of visits. In the CCH group, both patients and their primary care providers could communicate with dermatologists online. To initiate a dermatologist visit, the primary care provider or patient took photographs of the patient’s skin and then uploaded the images, patient medical history, and other information onto a secure internet-based platform. The dermatologist evaluated the data and provided treatment recommendations, patient education, and online prescriptions to the patient and primary care provider within 48 hours. If the primary care provider or patient had questions, the dermatologist answered them online or by phone. In the usual care group, patients could seek office-based care from any provider they chose, including dermatologists or primary care providers.
The study included 296 adults with a range of psoriasis disease severity from California and Colorado. Of these patients, 63% were white, 6% were Asian, 3% were black, 2% were American Indian/Alaska Native, 2% were Pacific Islander, and 24% reported race as other; 34% were Latino. The mean age was 49, and 50% were female. To be in the study, patients needed internet access, a digital camera or cell phone with a camera, and access to a primary care provider.
Patients completed online surveys at baseline and every three months for one year.
Patients with psoriasis, community health organizations, professional societies, and health policy organizations worked with researchers to plan and conduct the study.
In both the in-person and online groups, patients achieved equivalent improvements in psoriasis severity. Patients in both interventions also achieved equivalent improvements in quality of life and reduced symptoms of depression.
Patients in the online care group traveled fewer miles on average to get to and from appointments over one year (1.4 versus 109 miles, p=0.0003). Patients in the online care group also spent less time seeking in-person visits over the one-year period (0.1 versus 4.0 hours, p=0.001).
Researchers could not blind participants to study arm assignment, introducing the possibility that results were affected by patients’ or researchers’ expectations.
Conclusions and Relevance
The online CCH approach was as effective as in-person care in improving disease severity, quality of life, and symptoms of depression. Patients receiving online care spent less time on travel and in appointments.
Future Research Needs
Future research could evaluate whether a CCH approach is effective for other chronic dermatologic diseases such as atopic dermatitis or for specialties other than dermatology.
Final Research Report
View this project's final research report.
Article Highlight: This project, highlighted in JAMA Network Open, evaluated whether connecting patients and primary care physicians with dermatologists online was as effective as sending patients to an in-person appointment with a dermatologist. Researchers found that patients in the two groups experienced an equivalent improvement in disease severity, demonstrating that innovative telehealth delivery models can transform care access and delivery among patients with chronic illnesses.
Results of This Project
Related Journal Citations
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Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented, and the researchers made changes or provided responses. The comments and responses included the following:
- Reviewers asked why the study tested equivalence, that the two intervention models were the same, rather than noninferiority, that the online intervention was at least as good as in-person care. The researchers explained that their aim was to determine whether the two models of care were similar in impact on patient outcomes, in both positive and negative directions. They noted that this type of trial required more participants and more resources to conduct.
- Reviewers asked how researchers determined what would be a clinically significant result. The researchers said initial definition of margins for equivalence stemmed from previous clinical trials on psoriasis medications and then from evaluations by clinicians and patients of whether the margins would be considered clinically meaningful.
- Reviewers asked for a per-protocol sensitivity analysis to compare with the primary intention-to-treat analysis the researchers used. Reviewers asked that any differences between the results of these analyses be highlighted and the effects on interpretation be explained. The researchers said they discussed this issue extensively with a senior statistician. They explained that they did not specify a per-protocol analysis in their statistical plan because it was unlikely to change the study conclusions given the low rate of missing data and the low number of online patients who ended up needing to see a provider in person. The researchers offered to perform the additional analysis, which extended beyond the study’s original protocol, perhaps with additional time and funding.
- Reviewers asked for an expanded explanation for how patients and providers engaged, and researchers interviewed them. They also asked for additional information on how patient interviews contributed to data collection and analysis. The reviewers wondered about the process of extracting themes from patient interviews and asked how researchers integrated qualitative and quantitative results. The researchers expanded on the methods for patient engagement and contribution in the report. The researchers said themes emerged from reviewing patient interviews and were not pre-specified. The researchers added a table showing patient quotations and how they interpreted those quotations. The researchers also explained that quantitative and qualitative results were not integrated but that they reported them separately.
- For both study groups, within-group improvement from baseline was small. Reviewers suggested that it was possible that the study compared two relatively ineffective strategies to find them to be similar in their effect. The researchers agreed that the improvement from baseline was small, but said the results reflect the reality for psoriasis patients in the United States since most patients were already on systemic therapies that kept their disease burden low. At present, seeing a dermatologist in person in a clinic is considered the most effective method for managing psoriasis.
- Reviewers asked whether the development of collaborative connected health (CCH), an online approach to psoriasis care, occurred following a complex intervention framework that could be adopted in other parts of the country. The researchers stated they did use such a framework and a phased approach in developing the CCH, which has already been used in other disease areas following a process of patient and other stakeholder feedback.
Conflict of Interest Disclosures
Study Registration Information
^April W. Armstrong was affiliated with the University of Colorado Denver when this project was funded.
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