Teledermatology May Benefit Marginalized Populations: National and Institutional Trends during the COVID-19 Pandemic

The COVID-19 pandemic spurred a rapid expansion of teledermatology (TD) services. While regulatory changes facilitated nationwide adoption, TD's potential to improve access, particularly for underserved populations, has long been recognized. Prior to the pandemic, regulatory barriers hindered widespread use. Studies suggest TD can offer better, faster, and cheaper care, improving access to dermatological services, especially for those in underserved areas. This study aimed to analyze national and institutional data to understand demographic-specific TD utilization and no-show rates during the pandemic.

Existing literature highlights the potential of teledermatology to improve access to dermatological care, particularly for underserved populations. However, data on demographic-specific utilization during the COVID-19 pandemic were limited. Previous research has shown TD's effectiveness in reducing face-to-face visits and minimizing costs. Concerns about the digital divide and unequal access to technology, particularly among minority groups, have also been raised. This study builds upon previous work by examining national and institutional data to understand the pandemic's impact on TD utilization across different demographics.

This retrospective cohort study used two datasets: 1) National data from the American Academy of Dermatology's DataDerm registry (April 1, 2020 – June 30, 2021), encompassing 13,964,816 encounters; and 2) Institutional data from Duke University Health Systems (March 1, 2020 – April 30, 2021), including 54,400 encounters. Data collected included visit type (TD vs. in-person), sex, race, age/generation, and location (in- vs. out-of-state for national data). TD utilization was calculated as the percentage of TD users within each demographic group, compared to in-person utilization. Chi-square tests were used to analyze associations between encounter type and demographic variables, with adjusted p-values reported to control for family-wise error rate. For the institutional data, no-show rates were also analyzed.

Both national and institutional data showed significant associations between TD utilization and sex, race, and age (adjusted p<0.001). Nationally, TD utilization was higher among females (66.0% of TD users vs. 58.3% of in-person users), non-white patients (15.0% vs. 11.7%), and younger patients (63.6% vs. 26.3%). Out-of-state patients also showed proportionally higher TD utilization (14.6% vs. 4.2%). At Duke University Health Systems, similar trends were observed: higher TD utilization among females (61.7% vs. 57.0%), non-white patients (37.4% vs. 22.3%), and younger generations (62.6% vs. 43.8%). Nationally, TD utilization decreased over time (2.9% of total visits in 2020 Q2 vs. 0.3% in 2021 Q2). Institutionally, the decrease was from 8.2% in the first half of the pandemic to 2.9% in the second half. No-show rates were lower for telehealth visits among Black patients and younger generations at Duke.

The findings suggest that TD may disproportionately benefit marginalized populations, including non-white patients, females, and younger individuals. This aligns with the known challenges these groups face in accessing in-person dermatological care, such as technological gaps, dermatologist shortages, long wait times, and high costs. The observed decrease in TD utilization over time may be attributed to several factors including initial inflated expectations due to the pandemic's impact on in-person care, technical challenges, limitations in diagnostic capabilities, and image quality issues. Despite the decline, the study's results highlight the potential of TD to improve access to care, especially when considering alternative telehealth modalities such as phone visits, which have a lower barrier to entry. The preference for TD among younger patients is also significant, indicating the potential for future adoption and integration within broader healthcare systems.

This study demonstrates that TD utilization varied significantly across demographic groups during the COVID-19 pandemic, with higher usage among marginalized populations. These findings underscore the importance of considering TD as a key component of future healthcare delivery models to improve access and equity in dermatological care. Further research should focus on addressing the identified limitations, such as exploring the influence of geographic disparities in internet access and conducting longitudinal studies with individual-level data and diagnostic stratification.

The study's limitations include the use of a single institution for no-show data, potentially limiting generalizability. National data are also limited to DataDerm participants. The initial peak in TD utilization may have been artificially inflated due to the pandemic-related shutdown of in-person services. Aggregate data prevented detailed individual-level analysis, particularly temporal trends. Future research should include multicenter studies with individual-level long-term data and diagnosis stratification, considering geographic variations in internet access and technology literacy.