Adequacy and Acceptability of the Self-Collected Anal Pap Smear in People Living With Human Immunodeficiency Virus in the Infectious Diseases Clinic.

Background Anal Pap smears are imperative to screening for human papillomavirus (HPV)-associated anal squamous cell cancers, particularly in patients living with human immunodeficiency virus (HIV) given a higher incidence of disease. Self-collection of specimens may be favored by patients and more feasible to collect, increasing screening. Methods This was a single-center observational cohort study at a single academic medical center Infectious Diseases clinic from October to December 2021. We aimed to improve compliance of anal Pap collection documentation of "self-collected" versus "physician-collected" as well as verify if self-collected specimens (SCS) were adequate for interpretation equivalent to physician-collected specimens (PCS). Additionally, we aimed to evaluate patient and provider satisfaction with self-collected anal Paps. Results Sixty anal Pap smears were available for evaluation. The rate of documentation of the collection method (self-collected vs. physician-collected) was 88% during the intervention. A total of 75% of patients opted for self-collection, and 35/45 (78%) of these samples were adequate for interpretation. There was no difference in the adequacy of specimen (the ability of a cytopathologist to interpret the specimen) between the SCS and PCS. Conclusion Limited prior data suggest self-collected anal Pap specimens are adequate for interpretation only slightly less often than PCS. In our small cohort, there was no statistically significant difference between collection methods. Satisfaction with self-collection of specimens was high for both patients and providers. Additional validation in more diverse/larger clinical settings may be helpful to support this practice.

R.I.M.E. and reason: multi-station OSCE enhancement to neutralize grade inflation.

To offset grade inflation, many clerkships combine faculty evaluations with objective assessments including the Medical Examiners Subject Examination (NBME-SE) or Objective Structured Clinical Examination (OSCE), however, standardized methods are not established. Following a curriculum transition removing faculty clinical evaluations from summative grading, final clerkship designations of fail (F), pass (P), and pass-with-distinction (PD) were determined by combined NBME-SE and OSCE performance, with overall PD for the clerkship requiring meeting this threshold in both. At the time, 90% of students achieved PD on the Internal Medicine (IM) OSCE resulting in overall clerkship grades primarily determined by the NBME-SE. The clerkship sought to enhance the OSCE to provide a more thorough objective clinical skills assessment, offset grade inflation, and reduce the NBME-SE primary determination of the final clerkship grade. The single-station 43-point OSCE was enhanced to a three-station 75-point OSCE using the Reporter-Interpreter-Manager-Educator (RIME) framework to align patient encounters with targeted assessments of progressive skills and competencies related to the clerkship rotation. Student performances were evaluated pre- and post-OSCE enhancement. Student surveys provided feedback about the clinical realism of the OSCE and the difficulty. Pre-intervention OSCE scores were more tightly clustered (SD = 5.65%) around a high average performance with scores being highly negatively skewed. Post-intervention OSCE scores were more dispersed (SD = 6.88%) around a lower average with scores being far less skewed resulting in an approximately normal distribution. This lowered the total number of students achieving PD on the OSCE and PD in the clerkship, thus reducing the relative weight of the NMBE-SE in the overall clerkship grade. Student response was positive, indicating the examination was fair and reflective of their clinical experiences. Through structured development, OSCE assessment can provide a realistic and objective measurement of clinical performance as part of the summative evaluation of students.

Impact of obesity on the conversion of immediate-release tacrolimus to extended-release tacrolimus in kidney transplant recipients.

Outcomes analyzing conversion from IR-tacrolimus (IR) to LCP-tacrolimus (LCP) in obesity are limited. This was a retrospective longitudinal cohort study of patients converted from IR to LCP from June 2019 to October 2020. Primary outcomes were conversion ratios for weight-based dose at a steady-state therapeutic level and identification of appropriate dosing weight. Other outcomes included tacrolimus coefficient of variation (CV), time in therapeutic range (TITR), adverse events, infections, donor specific antibodies (DSAs), and acute rejection. A total of 292 patients were included; 156 and 136 patients with a BMI < 30 and BMI ≥ 30 kg/m2 , respectively. Baseline characteristics were similar, except for pancreas transplant, diabetes, and HLA mismatch. IR to LCP conversion ratio ranged from .73 to .79. Mean LCP dose was similar (.08 vs. .07 mg/kg/day for BMI < 30 and BMI ≥ 30 kg/m2 , respectively); there was a significant difference in IR and LCP mg/kg dosing at steady state with TBW (.11 mg/kg vs.09 mg/kg and .08 mg/kg vs. .06 mg/kg, respectively). The most appropriate dosing weight was adjusted body weight (AdjBW), consistent across IR and LCP steady-state doses, and might yield more accurate steady-state dosing requirements. In multivariable modeling, BMI was a significant predictor of steady state mg/kg dosing at therapeutic goal for total body weight (TBW), but not ideal body weight (IBW) or AdjBW.

Confirmation of Insertion, Deletion, and Deletion-Insertion Variants Detected by Next-Generation Sequencing.

BACKGROUND: Despite clinically demonstrated accuracy in next generation sequencing (NGS) data, many clinical laboratories continue to confirm variants with Sanger sequencing, which increases cost of testing and turnaround time. Several studies have assessed the accuracy of NGS in detecting single nucleotide variants; however, less has been reported about insertion, deletion, and deletion-insertion variants (indels). METHODS: We performed a retrospective analysis from 2015-2022 of indel results from a subset of NGS targeted gene panel tests offered through the Mayo Clinic Genomics Laboratories. We compared results from NGS and Sanger sequencing of indels observed in clinical runs and during the intra-assay validation of the tests. RESULTS: Results demonstrated 100% concordance between NGS and Sanger sequencing for over 490 indels (217 unique), ranging in size from 1 to 68 basepairs (bp). The majority of indels were deletions (77%) and 1 to 5 bp in length (90%). Variant frequencies ranged from 11.4% to 67.4% and 85.1% to 100% for heterozygous and homozygous variants, respectively, with a median depth of coverage of 2562×. A subset of indels (7%) were located in complex regions of the genome, and these were accurately detected by NGS. We also demonstrated 100% reproducibility of indel detection (n = 179) during intra-assay validation. CONCLUSIONS: Together this data demonstrates that reportable indel variants up to 68 bp can be accurately assessed using NGS, even when they occur in complex regions. Depending on the complexity of the region or variant, Sanger sequence confirmation of indels is usually not necessary if the variants meet appropriate coverage and allele frequency thresholds.

Online Infectious Diseases Subspecialty Supplementary Curriculum for Medical Students and Residents: Moving Beyond "You Get What You Get".

OBJECTIVES: Students and residents rotating through infectious diseases (ID) electives are instructed primarily by participation in rounds and clinics, with teaching focused on diseases encountered. This "you get what you get" approach allows learners to apply knowledge directly to patient care, however, may miss topics encountered in standardized testing. This multisite study investigates the use of asynchronous web-based learning modules and its impact on student and resident knowledge. METHODS: Students and residents rotating through an ID elective were assigned to their standard elective (old) or asked to complete asynchronous web-based learning modules in addition to the standard curriculum (new). Learners submitted pre- and post-tests and scores were tabulated. In the following academic year, learners at the host site were provided the learning modules and a post-elective survey. RESULTS: Nine learners (100%) completed the pre-test and 5 (55.6%) completed the post-test in the standard (old) curriculum group, while 15 (100%) completed the pre-test and post-test in the new curriculum group. The mean percentage change in accuracy was 9% and 5.3% in the old and new curricula, respectively. Most (94%) survey respondents recommended continued use of the curriculum and expansion to other subspecialty electives. CONCLUSIONS: Subspecialty electives have multiple purposes including assisting learners in exploring careers, providing a well-rounded medical experience, or preparing learners for content in standardized tests. Consistent curricula are not always provided with electives to supplement the clinical experience. Our web curriculum was well-received with perceived knowledge gain, though with very small pre-post-test groups a score improvement could not be determined. An asynchronous online curriculum for learners in ID was feasible and well-received among faculty, and learners felt their knowledge was enhanced. Content areas supplemented those encountered during the ID elective. While an improvement in post-test scores was not demonstrated, learners and faculty felt modules were beneficial.

Impact of converting adult kidney transplant recipients with high tacrolimus variability from twice daily immediate release tacrolimus to once daily LCP-Tacrolimus.

BACKGROUND: The influence of converting to once daily, extended-release LCP-Tacrolimus (Tac) for those with high tacrolimus variability in kidney transplant recipients (KTRs) is not well-studied. METHODS: Single-center, retrospective cohort study of adult KTRs converted from Tac immediate release to LCP-Tac 1-2 years post-transplant. Primary measures were Tac variability, using the coefficient of variation (CV) and time in therapeutic range (TTR), as well as clinical outcomes (rejection, infections, graft loss, death). RESULTS: A total of 193 KTRs included with a follow-up of 3.2 ± .7 years and 1.3 ± .3 years since LCP-Tac conversion. Mean age was 52 ± 13 years; 70% were African American, 39% were female, 16% living donor and 12% donor after cardiac death (DCD). In the overall cohort, tac CV was 29.5% before conversion, which increased to 33.4% after LCP-Tac (p = .008). In those with Tac CV >30% (n = 86), conversion to LCP-Tac reduced variability (40.6% vs. 35.5%; p = .019) and for those with Tac CV >30% and nonadherence or med errors (n = 16), LCP-Tac conversion substantially reduced Tac CV (43.4% vs. 29.9%; p = .026). TTR significantly improved for those with Tac CV >30% with (52.4% vs. 82.8%; p = .027) or without nonadherence or med errors (64.8% vs. 73.2%; p = .005). CMV, BK, and overall infections were significantly higher prior to LCP-Tac conversion. In the overall cohort, 3% had rejection before conversion and 2% after (p = NS). At end of follow-up, graft and patient survival were 94% and 96%, respectively. CONCLUSIONS: In those with high Tac CV, conversion to LCP-Tac is associated with a significant reduction in variability and improvement in TTR, particularly in those with nonadherence or medication errors.

Diabetes is a significant and independent predictor for tacrolimus immediate release and LCP-tacrolimus conversion ratios.

Diabetes (DM) is a common comorbidity in transplant patients with known effects on gastrointestinal (GI) motility and absorption; however, DM's impact on immediate release (IR) tacrolimus to LCP-tacrolimus (LCP) conversion ratios has not been studied. This multivariable analysis of a retrospective longitudinal cohort study included kidney transplant recipients converted from IR to LCP between 2019 and 2020. The primary outcome was IR to LCP conversion ratio based on DM status. Other outcomes included tacrolimus variability, rejection, graft loss, and death. Of the 292 patients included, 172 patients had DM and 120 did not. The IR:LCP conversion ratio was significantly higher with DM (67.5% ± 21.1% no DM vs. 79.8% ± 28.7% in DM; P < .001). In multivariable modeling, DM was the only variable significantly and independently associated with IR:LCP conversion ratios. No difference was observed in rejection rates. Graft (97.5% no DM vs. 92.4% in DM; P = .062) and patient survival (100% no DM vs. 94.8% in DM; P = .011) were lower with DM. The presence of DM significantly increased the IR:LCP conversion ratio by 13%-14%, compared to patients without DM. On multivariable analysis, DM was the only significant predictor of conversion ratios, potentially related to GI motility or absorption differences.

Effectiveness of a "Suppression Bundle" to improve HIV virologic suppression in an outpatient infectious disease clinic: a pilot implementation study.

Despite effectiveness and accessibility of combined anti-retroviral therapy (cART), only 85% of people living with HIV (PLHIV) in the United States are virologically suppressed. Improving suppression is complex. Our objective was to consider unique factors in PLHIV with non-suppressed viral loads in clinic and improve the percentage of suppressed patients by implementing a "Suppression Bundle" consisting of three to five bundled interventions with the goal of improved suppression. Prior to the study, there were 567 HIV-positive patients receiving care in clinic. Of those, 89 had a measurable viral load (>40 copies/mL). In this pilot pre-post implementation, we focused on the 89 non-suppressed patients to (1) determine feasibility of implementing bundles and (2) increase the number of patients with suppressed viral loads pre- to post-intervention. Of non-suppressed patients, 65 were active in care immediately pre-intervention and participated in the pilot. At the completion of the 9-month intervention, 46 had viral loads <40 copies/mL, demonstrating substantial improvement with 70.1% of the previously non-suppressed patients achieving suppression. By considering unique patient factors, an individualized Suppression Bundle is acceptable, feasible, and may increase virally suppressed patients in an outpatient clinic. Next steps include determining whether suppression bundles can be implemented in differing practices.

Implementation of Effective Smoking Cessation Strategies for People Living with HIV: A Pilot Implementation Study.

Introduction: Use of tobacco products carries significant long-term health risks, and rates of smoking in persons living with HIV are as high as two to three times that of the general population. This study aimed to increase assessment of readiness to quit smoking and provide cessation counseling to patients receiving HIV care through an infectious disease clinic. Methods: This study was a pilot implementation in a single-center teaching hospital. In total, 603 active patients with HIV were followed in clinic at the time of the study start; of these, 79 were active tobacco smokers (13%) and eligible for the intervention. Providers were educated on recommendations for tobacco smoking cessation counseling, intervention strategies, and options for treatment. Patients who smoked tobacco were assessed for readiness to quit. Cessation counseling and tobacco cessation mediations or nicotine replacement were provided at the discretion of the patient and physician based on visit discussions. Primary outcome measures were increase in assessment of readiness to quit and in providing cessation counseling. Secondary measures included tabulation of the number of patients provided with a tobacco smoking cessation treatment and those with a successful quit episode. Results: There was a moderate increase in patients assessed for readiness to quit and who received tobacco smoking cessation counseling and treatment medications during the pilot. In total, 11 patients (8.7%) reported quitting smoking for at least two weeks. Conclusions: Additional work on streamlined mechanisms to identify tobacco use and provide efficient and effective tobacco smoking cessation counseling are needed in this high-risk population.

Assessing Provider Utilization of COVID-19 Inflammatory Marker Trends in Hospitalized Patients and Implications in Optimizing Value-Based Care During a Pandemic.

Introduction: Numerous inflammatory markers may serve a role in prognostication of patients hospitalized with COVID-19 infection. Early in the pandemic, our health system created an admission order set which included daily d-dimer, c-reactive protein (CRP), lactate dehydrogenase (LDH), and ferritin. Given more available outcomes data, limiting standing order of labs that do not affect daily management could result in significant cost savings to the health system without adverse patient outcomes. The purpose of this study was to determine ordering and utilization patterns of inflammatory markers by physicians caring for patients hospitalized with COVID-19 infection. Methods: An anonymous 10-question survey was distributed to 125 physicians (Infectious Disease, Hospitalist, Pulmonary and Critical Care faculty). Responses were tallied and values greater than 50% were identified as the majority of the surveyed group. Results: Of the 125 physicians surveyed, 77 (62%) responded. A total of 57.1% (44/77) of physicians reported ordering daily inflammatory markers for 3 - 10 days from admission. Another 31.2% (24/77) ordered markers until clinical improvement or hospital discharge. D-dimer was used for care decisions by 83.1% (64/77) of respondents; 93.8% (60/64) of those reported utilizing it in determining anticoagulation dose. CRP was used by 61% (47/77) of physicians to help identify a secondary infection or determine steroid dose or duration. LDH and ferritin were not used for management decisions by the majority of physicians. Inflammatory markers were not used routinely after isolation precautions had been discontinued, even when ongoing care required mechanical ventilation. Conclusions: Of the markers studied, both d-dimer and CRP were considered useful by most respondents. LDH and ferritin were used less frequently and were not considered as useful in guiding medical decision making. Discontinuation of standing daily LDH and ferritin orders is believed to have potential to result in cost savings to the health care system with no adverse patient outcomes.

Acanthamoeba Keratitis: A Single-Institution Series of Four Cases With Literature Review.

Acanthamoeba species are free-living protozoa found pervasively in water and soil, which can cause infections of the central nervous system, skin, and eye. Amoebic keratitis (AK) is a vision-threatening, often chronic infection that is associated with the use of soft contact lenses due to corneal microtrauma and improper cleaning and storage. Although AK infections are rare, they cause significant morbidity including vision loss due to the diagnostic and therapeutic challenges they pose. The clinical course is determined by the organism's inherent pathogenicity, delay of diagnosis, and the paucity of data on effective therapeutic regimens. The case series and review of literature that follows examine current latest best practices in AK diagnosis including in vivo confocal microscopy (IVCM) and therapeutic interventions including miltefosine.

Internal Medicine Clerkship ID Curriculum Flip: Will They Prefer to Pre-learn?

Varying pedagogical approaches of undergraduate medical education are utilized in clerkships to supplement bedside teaching. The flipped classroom mode, in which self-paced study precedes the in-person session, is often used in pre-clinical education. This shift allows time with the instructor to focus on guided application of pre-learned concepts. At our institution, the Internal Medicine Clerkship Infectious Diseases lecture was substituted to a flipped classroom with two pre-learning videos. Student satisfaction scores were higher for the flipped classroom and comments were more negative for the traditional lecture. This suggests that senior medical students favor flipped classroom pedagogy despite pre-learning requirements.

Antibiotics and Imiquimod for Cutaneous T-Cell Lymphoma in Veterans: A Patient Population with Agent Orange Exposure.

LESSONS LEARNED: Staphylococcus aureus infection in cutaneous T-cell lymphoma (CTCL) is thought to contribute to disease progression; thus, adjunctive treatment with antibiotics warrants further investigation. This trial of antibiotic therapy followed by imiquimod in early stage CTCL was not completed because of difficulties with patient accrual. BACKGROUND: Cutaneous T-cell lymphoma (CTCL), a form of non-Hodgkin lymphoma, is a heterogeneous group of malignancies of mature memory T lymphocytes. It has an annual age-adjusted incidence of 7.5 per million persons in the U.S. population [1]. The etiology of CTCL is unknown, but epidemiological studies have reported potential associations with environmental and occupational factors, including Agent Orange exposure in Vietnam Veterans [2]. Both topical and systemic therapies have been identified as effective in CTCL; the choice of treatment is dependent on disease stage, with the overall goal of improving symptoms given the chronic and recurrent nature of the disease. Several studies have suggested that CTCL is exacerbated by the presence of Staphylococcus aureus in the skin and can be ameliorated by treatment with antibiotics [3]. METHODS: Our study was designed to assess the effects of antibiotics and imiquimod on early stage CTCL. Patients between the ages of 30-89 years with stage I and II CTCL were eligible for enrollment. They could not be receiving concurrent therapy, and the study design included a 14-day washout period after discontinuation of CTCL therapy. The washout period was followed by doxycycline 100 mg p.o. b.i.d. for 14 days and then two packets (250 mg per packet) of imiquimod 5% cream topically to the most clinically active lesions 3 days a week (Monday, Wednesday, and Friday) for 28 days. Skin lesions were measured using the modified Severity Weighted Assessment Tool (mSWAT). RESULTS: Our study enrolled only two patients with early stage CTCL because of difficulty locating patients with active CTCL able to discontinue all therapy. The two enrolled patients completed all therapy. One patient had a complete response after imiquimod, whereas the other patient had stable disease. CONCLUSION: Antibiotics and imiquimod have reported activity as single agents in CTCL; we did not enroll enough patients to assess value in the sequence of antibiotic therapy followed by imiquimod.

Implementation of an Audience Response System in a Case Conference Curriculum: Results of a Placebo-Controlled Trial.

Audience response systems engage learners and facilitate the assimilation of the material. We assessed whether incorporation of one system into a resident case conference would increase retention of information and attentiveness. Pre-tests were administered prior to case conferences. The University Hospital incorporated Poll Everywhere into a conference and the Veterans Administration hospital did not. Participants rated self-perceived attentiveness and completed a post-test following conference. There was an increase in post-test scores compared to pre-tests. There was no significant difference in self-perceived attentiveness or post-test scores between sites. The use of audience response did not increase retention of material or perceived attentiveness when incorporated into the conference.

Life vs Loans: Does Debt Affect Career Satisfaction in Osteopathic Graduates?

BACKGROUND: The cost of undergraduate osteopathic medical education continues to grow. It is important to understand how the rising cost of matriculation negatively affects training and career satisfaction of entering students. OBJECTIVE: To better understand any association between level of educational debt and satisfaction with osteopathic medical education, career choice, and financial services. METHODS: Responses were analyzed from the American Association of Colleges of Osteopathic Medicine survey of pending medical school graduates from 2007 through 2016 regarding indebtedness and specialty selection. RESULTS: From 2007 to 2016, the mean educational debt level at graduation rose consistently among osteopathic graduates (from $155,698 to $240,331, respectively). In all years, there was no significant effect of debt quartile on satisfaction with choice of osteopathic medicine as a career. Quartile variable with debt did not show a significant effect on satisfaction with education experience in 2010, 2013, and 2016. Top quartile debt was associated with higher satisfaction with financial service departments in all years. CONCLUSION: Although debt has consistently increased for osteopathic medical graduates, it does not affect their satisfaction with either their educational experience or their choice of osteopathic medicine as a career.

How Trainees Finance Their Medical Education: Implications of Higher Education Act Reform.

CONTEXT: The Public Service Loan Forgiveness (PSLF) program is among several repayment programs currently available for recipients of federal student loans. Medical education debt has continued to expand at a rapid pace in the decade since PSLF was created. Proposed changes to the Higher Education Act would substantially transform how future medical trainees finance and repay medical education debt. OBJECTIVE: To better understand relationships between debt and personal stress, as well as between repayment- and forgiveness-program use, in the context of competing legislation. METHODS: Surveys were sent to all Accreditation Council for Graduate Medical Education-accredited internal medicine residency programs (osteopathic and allopathic). RESULTS: From a potential pool of 579 residents, data were obtained from 403 unique respondents (response rate, 69.6%) at 12 residency programs, for a program response rate of 2.2%. Of these respondents, 290 (71.9%) completed the demographic portion of the survey. Median education debt was $225,000. Residents with the top quartile of debt burden were more likely to use PSLF (odds ratio [OR], 3.27; P=.02), more likely to enter loan forbearance (OR, 2.14; P=.03), and indicated a higher level of stress (OR, 5.94; P<.001) compared with those in the second and third quartiles. CONCLUSION: Proposed legislative changes to the Higher Education Act would scale back loan repayment options and also eliminate PSLF for future borrowers. Our data suggest that higher debt burdens are associated with increased debt-related stress. Given program popularity and growing use, along with growing concerns of physician burnout, policy makers should weigh the potential downstream effects of policy change on prospective future physicians.

Choosing Primary Care: Factors Influencing Graduating Osteopathic Medical Students.

CONTEXT: Access to primary care (PC) improves health outcomes and decreases health care costs. The shortage of PC physicians and shifting physician workforce makes this an ongoing concern. Osteopathic medical schools are making strides to fill this void. Considering the critical need for PC physicians in the United States, this study aims to identify factors related to choosing a PC specialty. OBJECTIVE: To understand possible motivations of osteopathic medical students pursuing a career in PC specialties by examining the role of sex and the influence of 5 key factors in this decision. METHODS: Responses from the annual American Association of Colleges of Osteopathic Medicine graduate survey (2007-2016) were analyzed. Self-reported practice decision considerations of 5 key factors, including (1) intellectual and technical content, (2) debt level, (3) lifestyle, (4) prestige/income level, and (5) personal experience and abilities were summarized, and their subjective value was contrasted between osteopathic medicine graduates pursuing PC specialties vs those pursuing non-PC specialties. RESULTS: The mean percentage of graduates pursuing PC and non-PC specialties from 2007 to 2016 was 31.3% and 68.7%, respectively. Women were 1.75 times more likely to choose PC than men (95% CI, 1.62-1.89). Regardless of specialty choice, lifestyle was the most important factor each year (1027 for PC [75.3%] vs 320 for non-PC [63.3%] in 2016; P<.0001). Students entering PC were more likely to report prestige and income level to be "no or minor influence" compared with students entering non-PC specialties (P<.0001). Debt level was more likely to be a "major influence" to students choosing to enter non-PC specialties than to those entering PC (P<.0001), and the percentage of non-PC students has grown from 383 in 2007 (22.9%) to 833 in 2016 (30.6%). CONCLUSION: Sex was found to significantly influence a graduate's choice of specialty, and female graduates were more likely to enter practice in PC. Each of the 5 survey factors analyzed was significantly different between students entering PC and students entering non-PC specialties. Lifestyle was deemed a major influencing factor, and responses suggested that debt level is a strong influencing factor among students pursuing non-PC specialties.

Poll Everywhere to Encourage Learner Satisfaction and Participation in Internal Medicine Fellowship Didactics.

Active learning improves self-reported engagement and satisfaction in medical education. Audience response systems are one mechanism of encouraging participation, especially in a setting in which learners in varying educational levels are present. Three fellowships participated in this educational quality improvement project where Poll Everywhere® was incorporated into didactics. Attendees were invited to complete a 4-question retrospective pre-post satisfaction survey. Incorporation of the Poll Everywhere® audience response system resulted in a shift in more favorable satisfaction scores and self-perceived attentiveness compared to the pre-intervention responses.

Teledermatology as a Tool for Preoperative Consultation Before Mohs Micrographic Surgery Within the Veterans Health Administration.

BACKGROUND: Telemedicine is improving access to subspecialty care within the Veterans Health Administration (VHA). Mohs micrographic surgery (MMS) is a surgical modality used to treat nonmelanoma skin cancers. OBJECTIVE: This study evaluates the use of teledermatology for preoperative consultation for MMS. METHODS AND MATERIALS: A retrospective analysis of interfacility MMS referrals to the Bronx Veterans Affairs Medical Center (VAMC) was conducted. The consult failure rates (CFRs), treatment follow-through rates, time to treatment, and travel savings for "face-to-face" preoperative consults were compared with store-and-forward "teledermatology" preoperative consults. RESULTS: Although both "teledermatology" and "face-to-face" preoperative consults resulted in an equivalent percentage of treated lesions, teledermatology had a significantly decreased CFR. In addition, teledermatology decreased the time to treatment by 2 weeks, increased the percentage of lesions treated within 60 days, and resulted in average travel savings of 162.7 minutes, 144.5 miles, and $60.00 per person. CONCLUSION: This study demonstrates that teleconsultation is effective for preoperative consults for MMS within the VHA system. Teledermatology improved access measures such as time to treatment and travel burden. This program may serve as a model not only for other VAMCs that accept interfacility MMS consults, but also for VAMCs that provide other types of access-limited subspecialty care.