A provider survey was designed to document the learning curve of the computer-based digital colposcopic system in an office with limited computer support available (site 1). A 23-question patient satisfaction survey was administered in 2 parts to assess the acceptability of telecolposcopy to women undergoing a colposcopic examination.
Implementation of the Telecolposcopic System
Any woman 18 years or older and scheduled for colposcopy was eligible for enrollment in the study between October 1997 and May 1998. There were no other inclusion or exclusion criteria. After consent was obtained, the woman was given patient education materials to read and asked to complete the first part of the survey. The colposcopic examination was completed as usual, except that images were focused and captured throughout the examination to document the visualization of the entire squamocolumnar junction (SCJ), transformation zone, and any visible lesions in the anogenital area. The colposcopist entered a follow-up plan in the computerized patient record. The images and history were then printed for the patient’s chart. The patient was asked to complete the second part of the satisfaction questionnaire before dismissal, and the physician was asked to complete the provider satisfaction questionnaire. The woman’s cytology and histology results were processed and read by the site’s routine pathology laboratory and were entered into the study database. The review site colposcopist was blinded to the primary colposcopist’s impressions, the woman’s cytology and histology, and any information on the questionnaires.
Statistical Analysis
Our study has a 90% power to determine a statistically significant k correlation, at the 0.05 2-tailed level, between the remote and review site colposcopists’ identification of the SCJ and their impressions of lesion severity and between each colposcopist’s impression and pathology. We used k correlation, independent and paired t tests, and descriptive statistics in this study. All statistics were calculated with Statistica (StatSoft, Tulsa, Oklahoma).24
Results
A total of 79 women participated in our study. Sites 1 and 2 captured images of 39 and 40 women, respectively, representing 100% of the women scheduled for colposcopy at each site during the study. All women were white and ranged in age from 18 to 57 years, with a mean age of 29.5 years (standard deviation=11.5). Thirty-five percent of the women received their colposcopy at their usual site of gynecologic health care; the others were referred from outside offices where colposcopy was not available. The [Table] shows the descriptive data of the women participating in the project: 79% had a history of previous abnormal anogenital lesions; 65% presented with either atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion (LSIL) cytology, and approximately 20% had a CIN 2/3 lesion histologically.
Technical Feasibility
The number of images captured for each patient varied from 3 to 20, and the details of the patient’s gynecologic history varied from the current visit data to an extensive past medical and gynecologic history. The average time for transmission of one patient’s images was 6 minutes.
Technical feasibility was measured by the percentage of agreement between the review and both remote sites for colposcopic impressions and histology correlates. A k value greater than 0.75 denotes excellent agreement, between 0.4 and 0.75 is good agreement, and below 0.4 is marginal agreement.25 For all examinations, the physician at the remote sites attempted to capture the SCJ for transmission. The SCJ was noted as “completely visualized” or “not visualized.” There was 86% agreement in complete visualization of the SCJ between the review and the remote sites (k=.533; 95% confidence interval [CI], 0.276-0.791; P=.019).
Both remote and review site physicians classified the colposcopic cervical impression as normal, LSIL, or high-grade-squamous intraepithelial lesion (HSIL). The interobserver agreement for colposcopic impressions was 86% (k=.684; 95% CI, 0.544-0.825; P <.001), and 66% for colposcopic impressions with exact histology (k=.416; 95% CI, 0.323-0.509; P <.001). If agreement between colposcopic impression and histology was relaxed to within 1 degree of severity, there was an 86% interobserver correlation (k=0.78; 95% CI, 0.697-0.861; P <.001). The distinction between normal metaplastic epithelium and low-grade changes accounted for all the discrepancies.
In our study, the implementation of a telecolposcopy system within the current office structure was easily accomplished, and most women accepted the telecolposcopic examination.* A total of 90.5% of the women surveyed travel 25 miles or less to their usual site of general health care; 88.1% traveled 25 miles or less for their colposcopy appointment. When the women were asked to choose whether they would prefer to have a colposcopy done locally and have the images electronically sent to another physician to be reviewed or drive farther than usual to the nearest experienced colposcopist, 95.2% of the women stated that they would have their colposcopy locally with electronic submission if the experienced colposcopist were more than 25 miles away. For the 12% of women who traveled more than 25 miles for their scheduled colposcopy, all stated they would have colposcopy locally if the experienced colposcopist was farther away than their current colposcopist.