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Photos may have limited value for remotely assessing wound infections

By Marilynn Larkin

NEW YORK (Reuters Health) - Wound photos may decrease a surgeon's ability to correctly identify a surgical site infection (SSI) while providing a false sense of confidence, a simulation study suggests.

"Our data suggest that wound photography, as it was created and employed in this study, may not improve upon current electronic message or telephone-based triage mechanisms (without images) for determining which patients require in-person wound assessment," Dr. Kristy Kummerow Broman of Vanderbilt University Medical Center in Nashville told Reuters Health by email.

Dr. Broman and colleagues compared surgeons' internet-based assessments of postabdominal surgery case vignettes with and without wound photography for the detection of SSIs.

As reported online October 24 in JAMA Surgery, 523 surgeons (mean age, 53; 22% women) completed a mean of 2.9 clinical vignettes. Participants were in practice a mean of 20 years, and most were general or vascular surgeons. Other specialties included colorectal, oncologic and trauma.

The addition of wound photography did not change accuracy for a diagnosis of SSI: 57% were correctly identified without and 58% with photographs. Specifically, surgeons gave a correct diagnosis in 58.4% cases with symptom reports alone and in 50.2% of cases with symptom reports plus wound photographs.

For cases without an SSI, surgeons made a correct diagnosis in 56.1% of cases based on symptom reports alone versus 63.4% of cases that also had wound photography. Therefore, photographs decreased sensitivity (from 0.58 to 0.50) but increased specificity (from 0.56 to 0.63).

The addition of wound photography in a subset of cases changed the surgeons' assessment from incorrect to correct in 14.2% and from correct to incorrect in 13.2%.

Surgeons reported greater confidence when vignettes included a wound photograph, regardless of whether they correctly identified an SSI; however, they were more likely to undertriage patients when vignettes included a wound photograph, again regardless of whether they correctly identified an SSI.

Specifically, the addition of wound photography decreased the frequency of care escalation from 69% to 59.1% for cases without an SSI, and from 86.2% to 75.9% in cases with an SSI.

"Remote evaluation of patient-generated wound photographs may not accurately reflect the clinical state of surgical incisions," the authors state. "Effective widespread implementation of remote postoperative assessment with photography may require additional development of tools, participant training, and mechanisms to verify image quality."

Dr. F. Thurston Drake of Boston University School of Medicine, author of an accompanying editorial, said in an email to Reuters Health, "I think it is important to highlight that these investigators have performed a study of what is already a common practice - using tools on smartphones, such as the camera, to assist in patient management."

"Sometimes," he said, "we might be tempted to say 'oh, everyone's already doing this; what's the point of a research project?' or 'of course, photographs make remote assessment more precise,' and we don't take the time to study widespread, common-sense practices."

"These authors didn't succumb to the temptation," he noted, "and their work generated a finding that many of us might have found surprising, which is that smart phone photographs do not improve accuracy but, in some circumstances, they may generate false confidence in the remote assessment."

"These tools are important, and not only for surgeons: sparing a post-operative patient an unnecessary clinic visit is a big deal," he added. "Providing them reassurance that everything is OK - when accurate - is also important for patient wellbeing."

"That said, the important result produced by this research project is that these tools (i.e., smartphone photographs) are not infallible," Dr. Drake concluded. "They are data points in the overall context of the patient's operation and baseline risk factors and should be considered as such."


JAMA Surg 2018.

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