The long term objective of this project is to address the disproportionate prevalence of cervical premalignant and malignant disease in minority, rural, poor women. The high prevalence may be explained by cost and access to care problems as well as a lack of trained expert rural colposcopists able to evaluate women with abnormal Pap smears. These barriers amplify the probability that underserved women will develop cervical neoplasia. This project proposes to use telemedicine, the active application of telecommunications and computer technology to medical services, to provide colposcopic diagnostic services to patients in rural communities. Knowing that one third of women with an abnormal Pap smear fail to complete diagnostic evaluation, treatment and follow-up, this study proposes to use telecolposcopy as a means of reducing the geographic barriers to the diagnosis and management of cervical neoplasia in a minority rural population. Telemedicine has been proposed as a method to provide a quality standard of care to communities without readily available access to certain expertise. The success of telemedicine is contingent upon sufficient and adequate information transfer to generate clinically correct decisions which ultimately lead to satisfactory patient outcomes. Telemedicine must deliver care equivalent to direct, in-person traditional care that is accepted by patients. The proposed study permits a scientific analysis of telecolposcopy in comparison with live expert examination. The specific objectives of this investigation are to determine the clinical impact of telecolposcopy in regard to 1) diagnostic accuracy and patient management decisions, 2) different technological approaches of information transfer and 3) patient acceptance of this technology. Subjects (N=240) with an abnormal Pap smear report or lower genital disease will be colposcopically examined by a family physician or registered nurse clinician at one of two rural study sites. """"""""Real time"""""""" and """"""""off-line"""""""" images of the examination will be transmitted to a tertiary care Telemedicine Center for interpretation by an expert colposcopist. Rural practitioners and the expert colposcopist will independently identify pathology and biopsy sites, formulate colposcopic impressions, and select appropriate patient management options prior to consultation. These long distance judgements will be compared, within three months time, with blinded cross validation colposcopic examinations of all subjects at the respective rural sites by another expert colposcopist. Two types of telemedicine, real time or live video and """"""""off-line"""""""" PC modem image transfer, will be compared with respect to diagnostic accuracy, patient management decisions and image resolution. Finally, patient acceptance will be evaluated using satisfaction questions based on the Health Belief Model and simulated case scenarios administered after the initial and cross validation colposcopy sessions. Barriers to quality health care for the prevention, diagnosis and treatment of cancer continue to exist for women who are poor, rural and of minority populations. The strength of this study evolves from the application of an innovative procedure and technologically informed, immediate consultation to address these difficult problems. The efficacy of telecolposcopy will be determined from this comprehensive evaluation and unique cross validation design.
