Teledermatological Follow-Up Consultations in Individual Prevention of Occupational Dermatoses: A Monocentric Feasibility Study on Quality and Satisfaction by Patients and Physicians

Abstract

Teledermatology has become very popular, and not only due to the SARS-CoV-2 pandemic. Patients with occupational skin diseases (OSDs) could also benefit from teledermatology services as part of their follow-up care, but the opportunities and challenges for patients and dermatologists, especially regarding quality and satisfaction, need exploration. In this single-center feasibility study, 215 patients taking part in a tertiary prevention program for OSD were invited to participate. After obtaining consent, a follow-up video consultation appointment with the center’s dermatologists was made. Quality and satisfaction with the consultations were evaluated by fully standardized online questionnaires filled in by the patients and dermatologists. A total of 68 teledermatological follow-up consultations were conducted by 10 dermatologists on 42 patients. Half of the dermatologists (50.0%) and 87.6% of the patients were satisfied with the video consultations. However, the lack of physical examination seems to be a problem, especially from the physicians’ point of view (75.8%). A total of 66.1% of the dermatologists and 87.5% of the patients saw video consultations as useful supplements to face-to-face consultations. The results of our feasibility study indicate general satisfaction of patients and physicians with teledermatological sessions in occupational dermatology, especially as a useful supplement to face-to-face consultation.

1. Introduction

Digitalization is advancing in all areas of medical applications, and e-health offers are constantly increasing [1,2]. The ban on remote treatment has been lifted, and makes it possible for physicians to provide advice and treatment exclusively via virtual communication media in individual cases, even to patients they do not yet know [3]. Such e-health offers are summarized under the term “telemedicine”, which is a sub-area of eHealth [1,4,5]. The term eHealth also includes the sub-areas of eAdministration, ePrevention, eResearch, and eLearning. It has already been shown that telemedicine services can improve physician–patient communication—especially in rural areas with poor medical infrastructure—and thus improve the physician–patient relationship [5,6,7,8,9,10]. With the outbreak of the SARS-CoV-2 pandemic at the beginning of the year 2020, the situation changed fundamentally and the demand for telemedicine services rose sharply, since thanks to telemedicine patients do not have to expose themselves to any risk of infection either on the way to or in the clinic, and can additionally save time and costs for transport to the clinic [4,10,11,12].

The area of telemedicine that deals with dermatoses is called ‘teledermatology’ [1,2,4]. In teledermatology, three different telemedical procedures are used: the store-and-forward system (SaF), the real-time procedure, and hybrid forms [1,4,8,9,11,13]. Previous studies and reports have shown that the diagnostic agreement rates between face-to-face and tele-consultations were almost the same [5,9,14]. Teledermatological consultations also played a key role in the treatment of several inflammatory skin diseases during the pandemic and can expand safe access to dermatological care in a cost-effective and efficient manner [11,15]. In addition, teledermatology has enabled physicians to treat their patients even if they live far away or are in quarantine [16].

Patients treated for OSDs in Germany primarily suffer from contact dermatitis of the hands, but a high number of patients with occupational skin cancer caused by natural ultraviolet (UV) radiation are also taken care of [9,17]. Occupational contact dermatitis of the hands can be categorized as irritant contact dermatitis (ICD) or allergic contact dermatitis (ACD) [18]. The treatment and overall management of patients with occupational contact dermatitis is provided under the dermatologist’s procedure (so-called Hautarzt-verfahren of the German Social Accident Insurance) in Germany [19]. As a part of this dermatologist’s procedure, the statutory accident insurance finances different prevention programs of a hierarchical multi-step intervention procedure, such as the outpatient secondary individual prevention (SIP) or the inpatient/outpatient tertiary prevention program (TIP) [20,21]. The TIP is offered to patients with severe or refractory skin diseases and consists of a three-week inpatient phase in a specialized center. Apart from intensified diagnostics and treatment, the patients undergo health education and psychological interventions to gain knowledge, increase motivation, and change attitudes and behavior towards the adequate use of skin protection and care in the workplace [20,21]. Moreover, adequate personal protective equipment is selected and afterwards provided to the patients. This is followed by a three-week outpatient phase with absence from work under the supervision of a local dermatologist. Afterwards, the patients ideally return to their workplaces with an improved skin condition and optimized skin protection measures. After the dismissal, patients are monitored through follow-up outpatient visits. Teledermatological consultations in the form of the video consultation have considerable potential for the reduction of face-to-face consultations in the monitoring of patients with OSDs [9]. However, in the field of teledermatology, there is still a need for research with regard to benefits and limitations, since no studies are yet available for a large part of dermatological diseases [2]. A few studies have investigated patient and physician satisfaction with and quality of teledermatological procedures, but very rarely in direct comparisons of the two groups and not specifically for patients with OSDs. Therefore, the aim of this feasibility study was to evaluate the quality and satisfaction of teledermatological consultations from the point of view of patients with OSDs and their dermatologists.

2. Materials and Methods

2.1. Study Design

This monocentric, evaluative feasibility study was conducted from June 2021 to June 2022 at the Institute for Interdisciplinary Dermatological Prevention and Rehabilitation (iDerm) at the University of Osnabrück, Osnabrück, Germany. Ethic approval was obtained by the Ethics Commission of the University of Osnabrück (procedure number 35/2021).

2.2. Participants

Adult female and male patients who took part in the TIP at the iDerm within the study period and who did not participate in another study involving face-to-face follow-up visits were invited to participate. Interested patients were provided with oral and written information by their dermatologist. Only patients who gave their written consent to participate in the study were enrolled. Exclusion criteria were age under 18 years, participation in another study, or missing written consent. All patients who denied participation within the framework of this project (teledermatological consultations) were offered standard face-to-face follow-up consultations as usual.

2.3. Teledermatological Consultation

In week three and week seven after the TIP, participants received a teledermatological consultation (i.e., online video consultation) with the dermatologist who took care of the respective patient during the TIP at our institute. This consultation substituted for the usual face-to-face follow-up consultation in our clinic (usually also three and seven weeks after discharge). Two days before the teledermatology appointment, a special link with a password for access to the open-source web conferencing tool BigBlueButton (BBB) (invokable GmbH, Remscheid, Germany) was sent via e-mail, with regulations for the device to be used.

The T3 follow-up examination usually marks the end of the 3-week working leave following the TIP and usually includes the question of whether the gloves recommended for the workplace during the TIP have already been supplied. Furthermore, the patient is asked about his or her skin condition (improved, stayed the same, worsened) and about the therapy during the preceding 3-week work absence. Finally, the patient’s skin condition is assessed by the dermatologist.

At the time of the T4 follow-up examination, the patient has usually already worked for 4 weeks, so one question during the examination relates to the fit/suitability of the recommended gloves for the workplace, whereupon follow-up counseling by a health educator may still be initiated. Furthermore, the patient is asked again about his skin condition under working conditions (improved, stayed the same, worsened) and about the current therapy. Finally, the patient’s skin condition is assessed by the dermatologist as in T3.

2.4. Questionnaire

Immediately after the teledermatological consultation, both patients and dermatologists received another email with a link to the fully standardized online questionnaire on LimeSurvey (LimeSurvey GmbH, Hamburg, Germany). Each patient was given a personal code that made it possible to compare the dermatologist’s and the patient’s evaluation for each session. The dermatologist who performed the video consultation was also informed of the corresponding code. Information on how to fill in the questionnaire was included at the beginning of the questionnaire. If patients had problems with the online questionnaire, they were offered the opportunity to fill out a written postal questionnaire and then received the questionnaire and a pre-paid return envelope by post. The pseudonymized questionnaire had four sections for the dermatologists and five sections for the patients, asking for: (i) sociodemographic characteristics (i.e., personal code, age, gender, education) and the tools used for the teledermatological session (i.e., device, speaker, microphone, help from others), (ii) evaluation of the importance of the teledermatological session (only in the patients’ questionnaire), (iii) rating of different statements about the quality of the consultation, e.g., “The use of video consultation technology is a useful addition to face-to-face counselling” on a 5-point Likert scale for agreement/satisfaction (1 = strongly agree, 2 = rather agree, 3 = neither agree nor disagree, 4 = rather disagree, 5 = strongly disagree), (iv) the technical devices used, and (v) a personal evaluation of the teledermatological session, including open questions, e.g., “What did you particularly like?”. The surveys for both groups are shown in Appendix A. The questions in section (iii) were based on the questions translated into German from the questionnaire on the satisfaction and usefulness of telemedicine, whose construct validity and internal consistency reliability have already been demonstrated for English and Spanish [22], and on questions from a survey on patient satisfaction with telemedicine in a prison [23]. Before the start of the actual feasibility study, a pretest was conducted with five TIP patients to check the comprehensibility of the questionnaire.

2.5. Data Analysis

Data analysis was performed with SPSS for Windows, version 27.0 (IBM Corp. Released 2020. Armonk, NY, USA: IBM Corp). The results of the descriptive data analysis are given as percentages (%) and mean values (M). Agreement ratings of ‘full agreement’ and ‘agreement’ were considered positive ratings.

3. Results

3.1. Participant Characteristics

Of the 215 patients who participated in the TIP between June 2021 and June 2022, 45 patients participated in another study involving face-to-face follow-up visits and were therefore excluded from our feasibility study. Another 123 patients gave no written consent. The reasons for non-participation are shown in

Table 1. Reasons for non-participation in the study.

Reasons for Non-Participation	n	(%)
Participation in another study involving face-to-face follow-up visits	46	37.4%
Patient would prefer to attend the appointment in person	42	34.2%
Physician would prefer to follow up with patient in person	23	18.7%
Lack of technical equipment on the part of the patient	13	10.6%
Concerns about image quality on the part of the patient	10	8.1%
Patient lives nearby the clinic and wants therefore to come in person	10	8.1%
Poor internet connection on the part of the patient	8	6.5%
Concerns about the quality of the video consultation on the part of the patient	7	5.7%
Skin areas other than hands are affected	3	2.4%
No follow-up	2	1.6%
Language barrier on the part of the patient	2	1.6%
Patient has concerns about his technical competence	1	0.8%
Negative experience with online conferences on the part of the patient	1	0.8%
Not known	1	0.8%

(more than one answer was possible).

A total of 47 patients gave written consent. No appointment could be made with five of these patients and they were thus subsequently excluded, resulting in 68 teledermatological sessions with 42 patients. Of the 42 participant patients, 17 patients (40.5%) took part in one teledermatological session, 24 patients (57.1%) in two teledermatological sessions, and one patient (2.4%) in three teledermatological sessions. Forty-eight questionnaires were completed by 32 patients after the teledermatology sessions (response rate of 70.5%), while 62 questionnaires were completed by the physicians (response rate of 91.2%). Only one patient (2.4%) requested and completed a written postal questionnaire. Of the respondent patients, 57.8% were female and the mean age was 45.0 years (standard deviation (SD) = 12.1). On the dermatologists’ side, 10 dermatologists participated in the feasibility study and performed a various number of teledermatological consultations (M = 6.2; SD = 4.6; range = 1–17). Of the dermatologists, 70.0% were female and the mean age was 40.9 years (SD = 8.5). All of the participating dermatologists were trained in occupational dermatology and familiar with the targeted patient population. The educational and occupational qualifications of the patient cohort as well as the devices used by the patients and physicians are shown in

Table 2. Educational and occupational qualification of the patient’s cohort.

Educational and Occupational Qualification n (%)	Patients n (%); Total of Patients: n = 32
Educational qualification n (%)
No educational qualification	0
Secondary school/elementary school leaving certificate	7 (21.8%)
Intermediate school leaving certificate/secondary school leaving certificate	15 (46.9%)
Advanced technical college certificate	1 (3.1%)
General higher education entrance qualification/A-levels	4 (12.6 %)
Not specified	5 (15.6%)
Occupational qualification n (%)
No occupational qualification	1 (3.1%)
Vocational training	18 (56.2%)
German ‘Master Craftsman’	6 (18.8%)
University degree	1 (3.1%)
Other occupational qualification	2 (6.2%)
Not specified	4 (12.6%)

and

Table 3. Devices of the study population.

	Video Consultations; Ratings by Patients (n = 48)	Video Consultations; Ratings by Dermatologists (n = 62)
Devices, n (%)
Smartphone	12 (25.0%)	0
Laptop	23 (47.9%)	0
Tablet	6 (12.5%)	0
PC	4 (8.3%)	60 (96.8%)
Speaker, n (%)
Headset	6 (12.5%)	47 (75.8%)
External Microphone	1 (2.1%)	12 (19.4%)
Integrated Microphone	34 (70.8%)	0
Webcam, n (%)
External Webcam/Camera	3 (6.3%)	60 (96.8%)
Integrated Laptop Camera	22 (45.8%)	0
Integrated Smartphone Camera	12 (25.0%)	0
Integrated Tablet Camera	6 (12.5%)	0

.

Among patients, the most commonly used device was a laptop (47.9%), while physicians mainly used a computer (96.8%). As a speaker, most patients (70.8%) used their integrated microphone of the used device. On the part of the dermatologists, 75.8% used a headset to communicate during the video consultation. For image transmission, most of the patients (83.3%) used the integrated device camera (45.8% integrated laptop camera; 25.0% integrated smartphone camera; 12.5% integrated tablet camera), whereas 96.8% of the dermatologists used an external webcam.

3.2. Quality and Satisfaction with Teledermatological Consultations from Patients and Dermatologists

During the teledermatological consultation, nearly half of the patients (44.2%) had help with the technical implementation and in 42.1% of the cases they were supported by a family member. Of the patients who had no support, 83.3% would not have wanted any help either.

Most (83.3%) patients felt good during their teledermatological session and the majority (81.2%) of the patients coped well with the online consultation platform BBB. Almost all (91.7%) of the patients rated the dialogue atmosphere in their teledermatological examination as good.

Almost half (46.6%) of the patients agreed that the consultation helped them to ease their problem, and of the physicians 72.6% agreed that the video consultation had helped their patients with their problem. The majority (87.5%) of the patients saw the teledermatological consultation as a useful supplement to the personal consultations, and in addition most (75.0%) of the patients found the video consultation just as satisfying as a face-to-face conversation; nevertheless, only 41.7% of the patients agreed with the statement that the teledermatological consultation could replace the personal consultation. Similar to this, only 37.1% of dermatologists agreed with the statement that teledermatological consultations can replace face-to-face consultations, and almost half (46.7%) of dermatologists consider talking to the patient during the video consultation to be as effective as a face-to-face consultation; more than half (66.1%) of the physicians see the video consultation as a useful addition to face-to-face counselling.

Most (70.8%) patients would use teledermatological consultations again, but only nearly half (48.4) of the dermatologists would like to continue offering digital services. Only 16.7% of the patients stated the lack of physical examination to be a problem and 10.4% of the patients were bothered that the dermatologist could not palpate their skin lesions, but most (77.4%) of the dermatologists agreed that the lack of physical examination was a problem and 75.8% were also bothered by the fact that they were not able to touch the skin lesions of their patients. Half (52.1%) of the patients stated that they believed their dermatologist was able to get a good picture of their skin condition, but only 12.9% of the physicians agreed to this statement. Asked about the time-saving factor of video consultations, almost all (95.9%) patients agreed that the teledermatological consultations were time-saving for them, while only 42.0% of the dermatologists agreed with this statement for themselves. The majority (87.6%) of the patients were satisfied with their teledermatological consultation; only 16.7% of the patients stated that they would feel more comfortable with a face-to-face conversation. Of the dermatologists, half (50.0%) of them were satisfied with the video consultation carried out, but 58.1% would feel more comfortable with a face-to-face consultation. These selected results are shown in Figure 1 and

Table 4. Selected results of the survey; comparison of physicians’ and patients’ questionnaires.

Ratings by Dermatologists (n = 62)					Ratings by Patients (n = 48)
	Fully Agree		Rather Agree			Fully Agree		Rather Agree
	n	%	n	%		n	%	n	%
The video consultation helped the patient to ease his/her problem.	21	33.9	24	38.7	The video consultation helped me to ease my problem.	8	16.7	14	29.2
The use of video consultation technology is a useful addition to face-to-face counselling.	23	37.1	18	29.0	The use of video consultation technology is a useful addition to face-to-face counselling.	28	58.3	14	29.2
The video consultation can replace the personal consultation with the patient.	14	22.6	9	14.5	The video consultation can replace the personal consultation with the dermatologist.	9	18.8	11	22.9
I would like to continue offering digital services, e.g., video consultations/online seminars.	15	24.2	15	24.2	I would like to continue using digital services, e.g., video consultations/online seminars.	22	45.8	12	25.0
The lack of physical examination during video consultation is a problem.	30	48.4	18	29.0	The lack of physical examination during video consultation is a problem.	3	6.3	5	10.4
It bothered me that I could not touch/feel the skin/skin lesions of the patient during the video consultation.	29	46.8	18	29.0	It bothered me that the dermatologist could not touch/feel my skin/skin lesions during the video consultation.	1	2.1	4	8.3
The conversation with the patient during the video consultation is just as effective as a personal conversation.	19	30.6	10	16.1	The conversation with the dermatologist during the video consultation is just as satisfying as talking to him/her in person.	18	37.5	18	37.5
Video consultations save me time.	22	35.5	4	6.5	Video consultations save me time.	32	66.7	14	29.2
I was satisfied with the video consultation I had with the patient.	7	11.3	24	38.7	I was satisfied with the video consultation I had with the dermatologist.	33	68.8	9	18.8
I would feel more comfortable with a face-to-face conversation.	15	24.2	21	33.9	I would feel much more comfortable with a face-to-face conversation.	3	6.3	5	10.4
I could clearly see the skin condition of the patient.	2	3.2	6	9.7	During the video consultation, the dermatologist was able to get a good picture of my skin condition.	15	31.3	10	20.8

. The results of the questionnaires for all patients and dermatologists are shown in the Appendix B and Appendix C.

A striking result of the open questions was the insufficient image quality, which was complained about by the dermatologists in 27 questionnaires (43.5%). The answers to the open questions further show that 28.0% of the dermatologists had photos of the patient’s skin condition sent to them in advance or after the teledermatological video consultation in order to be able to more accurately assess it. The translated responses for the open-ended questions can be found in Appendix D.

4. Discussion

The aim of this feasibility study was to evaluate the quality and satisfaction of teledermatological consultations from the point of view of patients with OSDs and their dermatologists. The present study is, to the best of our knowledge, the first to focus on teledermatological consultations in this specific patient group. Our feasibility study has shown that most of the patients rated the quality of and satisfaction with video consultations positively, while dermatologists also rated it positively, but overall a bit lower.

The high satisfaction level of the patients was in line with other studies in the field of teledermatology [13,24,25,26,27,28], even though there are yet no comparable studies available in dermatological patients with occupational dermatoses. For example, Mostafa and Hegazy reported that 91.5% of patients considered their initial consultation via teledermatology to be equivalent to face-to-face consultations [12], while 75.0% of our patients considered their video consultations to be as satisfying as face-to-face consultations. These results are in contrast to the results of the study by Nicholson et al. in which 42.0% of patients with two-week-wait skin cancer referrals would have preferred face-to-face counselling [29]. However, our patients also saw barriers to teledermatology; only about half of the patients felt that their dermatologist was able to examine their skin disease well. This was also the finding of Pearlman et al., in whose study about half of the patients stated that their physician was only able to recognize their skin to an “excellent” or “good” degree, and several comments in the open-ended questions indicated that video consultation was better for follow-up consultations [13].

In our study, we were able to show that the dermatologists were satisfied with the video consultations, although only just less than half of them (48.4%) would want to continue offering video consultations. This result was in slight contrast to the results of Alakeel, who was able to show in his study that 67.8% of the dermatologists surveyed would continue to offer video consultations [30]. Kennedy et al. showed similar results in their study [31]. One reason for the discrepancy could be that 77.4% of the dermatologists in our study saw the lack of physical palpation as a problem and 75.8% were bothered by it. Other studies also regard the assessment of skin lesions solely on the basis of image documentation as critical [14,32,33]. Most of the patients in our study did not see a problem with this, which could be due to the fact that they probably did not know about the importance of the palpatory examination and felt very comfortable overall. Another reason could be that the patients in our study were already able to establish a relationship of trust with their physician during their three-week stay. Many of the dermatologists also complained about the poor image quality of the video consultations, which could be a second reason for the low interest in further video consultations. It was frequently stated in the open questions that the patient had been asked to send photographs of their skin condition in order to improve their assessment of the skin condition. A quick and easily feasible solution for the poor image transmission during the real-time video consultation could therefore be the combination of SaF and real-time video consultation. This would enable both the maintaining of personal contact and exchange with the patient and a better chance to assess the skin condition, which may improve the satisfaction of the dermatologist.

A large difference between patients’ and physicians’ answers could also be seen with regard to the time-saving factor of video consultations. While almost all patients agreed that video consultations saved them time, only 42.0% of dermatologists agreed with this statement for themselves. This could be due to the fact that the physicians were at their usual workplace during the video consultations, while the patients could save themselves the long journey. In addition, patients do not have to spend time in the waiting area, because they can do other things at home during the online waiting time. In future studies, it would be of interest to compare in more depth the time-saving factor between face-to-face and teledermatological follow-up consultations. Due to increased hygiene procedures (i.e., longer duration and frequency of hand washing), an increase in hand eczema has been reported in the general population and in high-risk occupations during the COVID-19 pandemic [34]. Such effects might have an additional impact on waiting times for patients, in which case teledermatology could be beneficial.

In addition, for our feasibility study it must be taken into account that this was a study with patients who were insured by the statutory accident insurance and who may have a different level of suffering or motivational background that prompts them to return to their former activity than patients with statutory health insurance. A comparison with patients with normal insurance, which could be conducted in future studies, would certainly be interesting.

There are some publications that address the opportunities and limitations of teledermatology in the field of OSDs from a theoretical perspective [9]. To our best knowledge, this is the first practical research in the field of OCD, especially ICD or ACD, that also compares patients’ and dermatologists’ perspectives on quality and satisfaction with teledermatological consultations. Another strength of our study is that the patients’ and dermatologists’ opinions could be directly compared for most items, whereas most studies only focus on the patients’ side.

Regarding limitations, a certain degree of selection bias is likely, as presumably it was mostly patients with sufficient technical possibilities or competences, or family support, and with enough motivation to try this technology, who participated in the teledermatological consultations and subsequently responded to the (online) study form. For older patients, a solely postal survey might have positively affected the response rate; however, it should be mentioned that this offer was made to all participants. Another limitation is the small sample size of our feasibility study and the described patient–physician bond, due to three week in-patient close monitoring prior to video consultation, which could bias the results. Furthermore, due to the relatively small sample size of our feasibility study, no statistical significance in the results was calculated, nor were any further statistical interferences found. It would be possible to investigate in larger studies whether and what influence the experience, age and gender of the dermatologists had on the respective assessment of the teledermatological examination of patients, which was not possible in our study due to the limited number of participating dermatologists. In general, further surveys are needed to establish the external validity of the presented results. As the quality of teledermatology is likely to be very dependent on many factors, namely the quality of the camera, microphone, and networks, it might be not sufficient to only classify the device by its kind (laptop, tablet, and smartphone). In future studies, further information on the cameras, microphones, and networks used could be assessed additionally to provide a more detailed overview.

5. Conclusions

To our knowledge, this is the first study to comprehensively evaluate patients’ and dermatologists’ satisfaction with and assessment of the quality of teledermatological consultations in the field of OSDs. In conclusion, the collected data indicated the general satisfaction of both patients and their physicians, especially in regard to interaction-related parameters, although the lack of physical examination seems to be a problem. Even though the overall quality of the video consultation technique was good, it could still be improved with better internet connectivity to enable concrete and satisfactory assessments of the skin conditions. Furthermore, in future teledermatological procedures, attention should be paid to minimum requirements regarding the quality of the technical equipment. Overall, video consultations seem to pose an appropriate consultation method in occupational dermatology, especially as a supplement to face-to-face consultations.