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Rural studies examine satisfaction with and cost-effectiveness of telecolposcopy for women with abnormal Pap smears

Rural women with abnormal Pap smears usually have to travel long distances for further evaluation by traditional colposcopy (examination of vaginal and cervical tissue by means of a magnifying instrument) to detect cervical cancer. Telecolposcopy allows local doctors to confer with distant experts by transmitting the image of a woman's vaginal and cervical tissue obtained with on-site colposcopy to the expert. Some high-speed transmission systems allow synchronous face-to-face communication between distant experts and patients or their local doctors.

Two recent studies supported by the Agency for Healthcare Research and Quality (HS08814) and led by Daron G. Ferris, M.D., of the Medical College of Georgia, examined women's satisfaction with and the cost-effectiveness of telecolposcopy. The first study found that rural women in Georgia were very satisfied with this approach. However, the second study found that this technology is not yet as cost effective as colposcopy done by local doctors.

Both studies are discussed here.

Ferris, D.G., Litaker, M.S., Gilman, P.A., and Lopez A.G. (2003, September). "Patient acceptance and the psychological effects of women experiencing telecolposcopy and colposcopy." Journal of the American Board of Family Practice 16, pp. 405-411.

This study found that women in rural Georgia felt that telecolposcopy saved them time and money, and they would recommend it to a friend. To examine attitudes toward this approach to cervical exams, the investigators administered questionnaires to 150 and 263 women living in rural Georgia who were scheduled for colposcopy or telecolposcopy, respectively. The researchers assessed the women's anxiety, depression, health beliefs and concerns, coping style, and examination acceptance and satisfaction. Both telecolposcopy and colposcopy groups had mean scores indicating mild anxiety and mild depression.

In general, women in both groups were highly satisfied with their examinations and care. Women in the telecolposcopy group were more satisfied with the time and money saved by that approach compared with women in the colposcopy group. In general, women thought that telecolposcopy improved the quality of their care, they felt better about their health after the exam, and they would recommend it to a friend. Based on these results, initial concerns that rural women would object to an unknown distant expert examining their genital region from afar seems unwarranted, conclude the authors. They point out, however, that Federal and private payers have been slow to reimburse for telemedicine examinations.

Bishai, D.M., Ferris, D.G., and Litaker, M.S. (2003, December). "What is the least costly strategy to evaluate cervical abnormalities in rural women? Comparing telemedicine, local practitioners, and expert physicians." Medical Decision Making 23, pp. 463-470.

Local practitioners performing colposcopy is the least costly way to evaluate cervical abnormalities in rural patients who would incur substantial time and travel costs to confer with a specialist, according to this study. In the study, women in rural Georgia who needed colposcopy were examined by an expert colposcopist on site, by a local practitioner, and by a distant expert colposcopist linked by telemedicine to establish the least costly strategy. The investigators calculated average costs in year 2000 dollars from a societal perspective to include medical costs, pain and suffering due to additional biopsies and curettage, telemedicine costs, and costs of potential diagnostic delay for a 1-year period.

The average cost per patient evaluated was $270 for patients seen by referral experts. The cost was $38 less ($232) for patients seen by local practitioners, and $35 more ($305) for patients seen by telemedicine. From the societal perspective, local practitioners were less costly than referral experts because of lower travel costs for patients. However, from the medical perspective, their average cost was $32 higher than referral experts because they performed more biopsies and curettage procedures than experts.

Telemedicine assistance by distant experts would have lowered the number of biopsies performed by local practitioners, but as of the year 2000, the costs of this technology could not be justified by the savings, explain the researchers. Since rural Georgia has a shortage of local doctors trained in colposcopy, they suggest that investing in developing local expertise among rural practitioners in performing colposcopy is a more promising strategy than investing in telemedicine at current costs. However, the costs of telemedicine are likely to come down, and telecolposcopy merits reevaluation once the incremental cost of establishing a telemedicine colposcopy program (including distant experts) is less than $10 per patient.

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