Telemedicine for the Initial Evaluation and Management of Infantile Hemangiomas

Objective:

This internet-based survey will capture information regarding specific use of telehealth for the initial evaluation and management of infantile hemangiomas.

Background and Significance:

The World Health Organization (WHO) declared a pandemic in 2020 caused by COVID-19, an infection caused by the novel coronavirus SARS-CoV-2.  Due to mandated limitations in the ability to evaluate patients in the ambulatory setting, much of pediatric dermatology has shifted to the almost exclusive use of telemedicine for the care of their patients. 

Infantile hemangiomas (IH) are the most common tumor in infancy, occurring in as many as 5% of infants. Many require no treatment, however a significant minority can be considered high risk, and therefore subspecialty evaluation is required in order to determine the need for pharmacologic intervention and additional workup.  High risk features may include those that have or pose a risk of life threatening complications, functional impairment, disfigurement, ulceration, and associated structural anomalies.1  Given the known growth characteristics of IH with most superficial IHs undergoing accelerated growth at around 5-7 weeks of age, the ideal time for subspecialty consultation is at 4 weeks of age.1, 2, 3  Given the circumstances surrounding COVID-19, deferring in person evaluation for IH is not recommended and therefore telemedicine has become the predominant platform for initial evaluation and management of IH.  To date, few studies have evaluated the effectiveness of telemedicine with regards to IH, however the focus of these studies was on triage, not management.4, 5

Collecting information regarding telemedicine experiences from a provider standpoint, for the initial evaluation of patients with IH will allow for clinicians to identify the effectiveness of this platform in managing IH as well as to identify any barriers to treatment that may arise.

Study Methods:

Pediatric patients with IH who have been referred for subspecialty care for the initial evaluation of IH, whose consultation was performed via a telemedicine platform (defined as either synchronous video, Synchronous video with asynchronous store and forward photographs, or audio with asynchronous pictures) will be identified by treating clinicians.  De-identified patient data will be entered into a web-based survey developed and hosted by UCSF using the secure REDCap database.  A unique study identifier will be assigned to each patient at the time of data entry.  Information collected will include demographic details including age at the time of first visit, race, gender, as well as IH characteristics, and treatments recommended.  In addition, information regarding if at the time of video visit, still photographs were available for review, the quality of video and photographs used in physical examination, whether there was a need for translator, as well as a provider assessment of the relative success of the visit.

Data will be analyzed to identify the following outcomes: if active treatment was needed, whether this treatment could be performed via telemedicine, including ability to initiate topical or systemic therapy at home, and whether in person evaluation would have changed prescribed treatments, and whether in person treatment was needed to proceed with management. 

Potential Study Risks:

This study poses minimal risk.  There is a very small risk of a breach of confidentiality of medical record information and associated privacy, which is mitigated by 1) collecting de-identified data, 2) assigning a unique study identifier to each reported patient, and 3) hosting the data on a HIPAA compliant web-based server such as REDCap.

Human Subjects Research Determination:

As this study is aimed at quality improvement and not human subjects research, and the database will only use de-identified data, we do not feel that consent would be required for participation in the study and therefore request a waiver from the IRB.

Potential Future Data Uses

With future IRB review, this data may be used to evaluate outcomes associated with telemedicine management of IH compared to those of in person evaluations.

References:

  1. Krowchuck DP, Frieden IJ, Mancini AJ, et al. Clinical Practice Guideline for the Management of Infantile Hemangiomas. Pediatrics. 2019 Jan;143(1).
  2. Chang LC, Haggstrom AN, Drolet BA, et al. Growth Characteristics of Infantile Hemangiomas: Implications for Management. Pediatrics August 2008, 122 (2) 360-367
  3. Tollefson MM, Frieden IJ. Early growth of infantile hemangiomas; what parents’ photographs tell us. Pediatrics. 2012 Aug;130(2):e314-20
  4. de Graaf M, Knol MJ, Totté JE, et al. E-learning enables parents to assess an infantile hemangioma. J Am Acad Dermatol. 2014 May;70(5):893-8
  5. Léauté-Labrèze C, Baselga Torres E, Weibel L, et al. The Infantile Hemangioma Referral Score: A Validated Tool for Physicians. Pediatrics. 2020 Apr;145(4).