Six studies reported both primary and aggregated diagnoses. In the latter case estimation of the proportion of correct diagnoses takes into consideration any differential diagnoses therefore increasing the likelihood of the correct diagnosis when compared to the histopathology results. The rate of agreement between the teledermatologist and the clinical dermatologist is also higher when diagnosis accuracy is based on the aggregated outcome. Table 32 lists the 15 included studies on diagnostic accuracy of SAF teledermatology that formed an evidence basis for assessing the diagnostic accuracy of SAF teledermatology. Table 32: Studies included in assessment of diagnostic accuracy of SAF teledermatology Study ID SAF modality Type of outcome reported Number analysed Quality assessment* Face-to-Face Şenel 2013 Digital photography +dermatoscopy Aggregated 82 82 III-1, Q3, P2 Digital photography Aggregated 82 82 Warshaw 2009a Digital photography +dermatoscopy Aggregated 542 542 II, Q1, P2 Primary 542 542 Warshaw 2009b Digital photography +dermatoscopy Aggregated 716 716 II, Q1, P2 Primary 716 716 Digital photography Aggregated 728 728 Primary 728 728 Oakley 2006 Digital photography Primary 48 29 III-1, Q3, P2 Piccolo 2000 Digital photography +dermatoscopy Aggregated 43 43 III-1, Q3, P2 Rosendahl 2011 Digital photography +dermatoscopy primary 463 463 III-1, Q3, P2 Digital photography primary 463 463 Whited 1999 Digital photography Aggregated 79 79 III-1, Q2, P2 Primary 79 79 Piccolo 1999 Digital photography +dermatoscopy N/A 66 66 III-1, Q3, P2 Whited 1998 Digital photography Aggregated 9 9 III-1, Q2, P2 Primary 9 7 Barnard 2000 Digital photography Aggregated 25 25 III-1, Q3, P2 Braun 2000 Digital photography +dermatoscopy Primary 55 55 III-1, Q3, P2
Table 38 Selected characteristics of the studies assessing diagnostic accuracy of SAF teledermatology Study Sample size Population Skin conditions Blindness of the assessors* Who made the images Quality of images (% rejected) Patient data recording format Şenel 2013 82 patients patients referred to dermatology department skin tumors no yes technician Not reported Standardized form Warshaw 2009 a 542 patients with a single index lesion patients referred to dermatology department clinic of Veteran Affairs pigmented neoplasms yes yes research staff 0% standardized patient and lesion history collected by the research assistants Warshaw 2009 b 728 patients patients referred to dermatology department clinic of Veteran Affairs neoplasms yes yes research staff 4 unusable photos (0.5%) standardized patient and lesion history collected by the research assistants Oakley 2006 48 lesions patients referred to dermatology department skin lesions no yes Medical student Not reported standardized patient and lesion history collected by medical student Piccolo 2000 43 lesions patients referred to dermatology department pigmented difficult to diagnose skin lesions no yes Not reported Not reported Basic clinical data sex, age, site of lesion Rosendahl 2011 463 lesions Retrospective analysis of consecutive biopsied lesions pigmented skin lesions (melanocytic and yes yes Clinician at the skin cancer clinic 3/466 (0.7%) Not clear Whited 1999 79 lesions patients referred to veteran administration dermatology department Skin lesions no yes A research assistant (can repeat images) Not reported Standardized history Piccolo 1999 66 lesions patients referred to dermatology department pigmented skin lesions (melanocytic and no yes Not reported Not reported Basic clinical data sex, age, site of lesion Whited 1998 9 lesions patients referred to veteran administration dermatology department suspected skin cancer. No sample yes Not clear: In the office Not reported History: location, duration and size of the lesion was recoded Barnard 2000 25 lesions patients referred to dermatology Suspected cancer, benign lesions yes Not reported Not reported patient’s age, gender, location, melanocytic non-
availability of patient clinical data. Some studies limited it to the age, sex, location and duration of a lesion (eg. Piccolo 1999, 2000); or did not elaborate on the content of the patient clinical data; and other studies created a standardized form to be included in the package transmitted for the teledermatology assessment (Warshaw, 2009a,b; Senel, 2013). In one study, the clinical history was collected, but was not made available to the teledermatologist (Braun, 2000). Table 39 Selected characteristics of studies assessing diagnostic concordance of SAF teledermatology Study Sample size Population Skin of Who made the images Quality of images (% rejected) Patient data recording format Skin lesions Piccolo 1999 66 lesions patients referred to dermatology department skin lesions and no yes Not reported Not reported Basic clinical data sex, age, site of lesion Bowns 2006 230 patients patients referred to dermatology department patients of skin conditions no yes Clinical Not reported a one page proforma; symptoms, signs and initial diagnosis and treatment by the GP. Oakley 2006 48 lesions patients referred to dermatology department skin lesions no yes Medical student Not reported patient and lesion history collected by medical student Mahendran 2005 163 patients referred to dermatology department lesions of skin cancer. yes yes yes 24/163 (15%) relevant past history Barnard 2000 25 lesions patients referred to dermatology department cancer, benign tumour; lesions yes Not reported Not reported patient’s age, gender, location, duration and symptoms of the skin
referred to dermatology clinic conditions data Clinical history, current treatment Oztas 2004 163 patients patients referred to dermatology clinic All skin conditions yes Not clear Not reported Unspecified patient history Du Moulin 2003 117 patients Selected by GP as suitable All skin conditions Not clear yes GPs at their practices Unspecified patient history Rashid 2003 33 patients patients referred to dermatology department All skin conditions no yes Not clear 3/33=10% Medical records High 2000 92 patients patients referred to dermatology department All skin conditions no yes The primary Not reported location of the lesion(s), the temporal course, any related symptoms, medications medical history. Krupinski 1999 308 patients patients referred to dermatology department Malignant benign lesions yes Partly aware of the FTF diagnosis (TD=CD in 1/3 of cases) Not clear about histology results medical students trained in the use of the camera Not reported Unspecified patient history Whited 1999 168 lesions patients referred to veteran dermatology department All types of skin lesions no yes A research assistant (can repeat images) Not reported history Kvedar 1997 116 patients patients referred to dermatology department All types of skin lesions no yes A Not reported medical history Zelickson 1997 23 nursing patients requesting a All types of skin yes yes A nurse Not reported Unspecified medical Infections
Table 68: Number of patients referred to dermatologist from outside metropolitan areas 2014 2015 2016 2017 2018 source Current nos. Projected growth 2012-13 GP medicare claims 126,800,000 A Britt (2013) Pop growth 1.7% B ABS Skin conditions identified by GPs 16.9/100 encounter C Britt (2013) Nos of skin events seen by GPs across Australia 21,429,200 21,793,496 22,163,986 22,540,774 22,923,967 C*A*B=D GP divide Metro Rural 68.8% 31.2% E F Number of skin events across Australia seen by metro GP 14,743,290 14,993,926 15,248,822 15,508,052 15,771,689 E*D=G Number of skin events across Australia seen by rural GP 6,685,910 6,799,571 6,915,164 7,032,721 7,152,278 F*D=H GPs refer skin conditions to dermatologist 7% Britt (2013) Rural GPs refer to dermatologist 4% Britt, 2001 J Rural pts referred to dermatologist At 7% 468,013.73 475,969.96 484,061.45 492,290.50 500,659.43 I*H=K Rural patients referred to dermatologists At 4% 267,436 271,983 276,607 281,309 286,091 J*H=L From Table 68 above it is assumed that due to the shortage of dermatologists in rural areas, the barrier of length of travel and ability to travel large distances and workplace commitments that as noted above, currently rural GP only refer 4% of patients with a skin complaint requiring specialist dermatology services compared to the Australian average of 7% (Britt, 2001). To estimate the Medicare benefits paid for dermatology services to rural patients the following assumptions are included in Table 69. The take up of delivery of specialist dermatology services by videoconferencing has been very low which may reflect a number of issues: The need the sufficient bandwidth to enable adequate vision for the dermatologist. Expert advice is that Skype is not adequate
Total $ 26,488,478 27,078,796 27,681,530 28,296,931 28,925,255 **expert advice from ACRRM is that 2000 GPs out of workforce of 10,500 use service The total cost to the MBS of introducing SAF technology will be a small increase over the total costs of the current situation without SAF which is shown in Table 70. This is due to the substitution of patient currently being treated by their GP to being treated by SAF. The assumptions underlying Table 71 assumes that around 2,000 rural GPs out of a rural GP workforce of 10,500 (General Practice Statistics, 2014) will take up SAF in its first year of availability. This figure is based on the number of rural GPs who currently participate in the ACRRM run TELEDERM program. It is assumed that this proportion of GPs will refer all patients requiring specialist dermatology services to a dermatologist either for a FF consultation or a consultation via SAF; VC use will remain unchanged. The estimates in Table 71 may underestimate the costs to the GPs as they will still be required to refer the patient which incurs costs. The number of GPs that takeup SAF is assumed to increase by 1,000 GPs a year up till 6,000 rural GPs will be participating in this program. This figure is an assumption but takes into account that younger GPs are more likely to be comfortable with digital technology and over time this type of consultation may increase. One of the recommendations of the protocol and expert advice is that there may need to be a separate MBS item created for GP referrers to recognise the extra time they will incur to take an extensive clinical history, take the digital images with the requisite expertise and to upload this data to the dermatologist’s SAF portal. Expert advice is that obtaining this information could take between 15-30 minutes depending on how extensive the skin involvement is. Table 72 estimates this likely additional cost to the MBS as well as the substitution of VC technology to deliver specialist dermatology services by SAF.
plan) between the consultant who had managed the case and an independent blinded consultant who gave a second conventional face-to-face consultation in setting. (CardPort Swift) and viewed using Piccolo software at the dermatology department on two similar PCs, with 19-inch monitors clinical was achieved in 55% (51/92) of cases vs 84% (61/73) of cases in the control group. Difference (95% CI: -40% to -14%; p = 0.0001) Excluding 53 patients from TD group who were not suited for TD management agreement was achieved in 67% (26/39).
for inclusion. Ebner, et al Mobile teledermatology: a feasibility study of 58 subjects using mobile phones. Journal of Telemedicine and Telecare 2008Volume 14 Number 1, p2-7 Patients attending the outpatient clinic for an urgent-care dermatology visit: adults with visible skin lesions; willing to participate; and able to provide informed consent. Children, subjects with skin lesions that could not be visibly documented (e.g. phlebothrombosis) or subjects who were not willing to provide informed consent Edison, 2008 Diagnosis, diagnostic confidence, and management concordance in live-interactive and store-and-forward teledermatology compared to in-person examination Telemedicine Journal & 2008, 14 (9) 889-95 Head-to-head trial Enrolled subjected were a convenience sample of new patients who and subsequently presented to the dermatology clinic on a “study” day. Every patient was invited to participate Not reported Heffner VA, Lyon VB, Brousseau DC, Holland KE, Yen K. Store-and-forward teledermatology versus in-person visits: a comparison in pediatric teledermatology clinic. J Am Acad Dermatol 2009;60:956-61. Consecutive patients enrolled to the pediatric dermatology clinic with a rash or rash descriptors (bumps, spots, patches) Not reported High, et al Assessment of the accuracy of low-cost store-and-forward teledermatology consultation. J Am Acad Dermatol 2000;42: 776-83. Patients presented for FTF consultation at the Dermatology department. No specific inclusion criteria No specific exclusion criteria Kvedar et al. The substitution of digital images for dermatologic physical examination. Arch Dermatol Adult patients presenting with dermatologic symptoms in a university- based practice who consented to have their skin conditions documented with a still digital camera according to a standardized protocol. Patients with a presenting complaint of acne or warts were excluded because these conditions pose no diagnostic challenge and would favourably bias the study. Tucker 2005 New patients agreed to have a digital photograph taken of their lesions or a representative area of their eruption. Unclear Mahendran 2004 Patients with suspicious skin lesions being referred by GP to a dermatology department. Unclear Oztas 2006 Randomly selected outpatients from the department of dermatology Unclear Rashid 2003 Selective patients from the outpatient department of dermatology Unclear
Zelickson 1997 All nursing home resident consultations requests from the Walker Methodist Health Care Centre Unclear Videoconferencing with diagnostic accuracy as an outcome Lowitt et al. Teledermatology and in-person examinations: a comparison of patient and physician perceptions and diagnostic agreement. Arch Dermatol 1998;134:471-6. Consecutive dermatology patients at the Veteran Affairs Medical Centre Patients transported by stretcher and those who refused to participate Videoconferencing with diagnostic concordance as an outcome Edison, 2008 Diagnosis, diagnostic confidence, and management concordance in live-interactive and store-and-forward teledermatology compared to in-person examination Telemedicine Journal & 2008, 14 (9) 889-95 New self-scheduled patients presented at the Dermatology Clinic. N/R Gilmour et al Comparison of teleconsultations and face-to-face consultations: Preliminary results of a United Kingdom multicentre teledermatology study The British Journal Of Dermatology 1998 Jul; Vol. 139 (1), pp. 81-7; N/R N/R Lesher JL Jr, Davis LS, Gourdin FW, English D, Thompson WO. Telemedicine evaluation of cutaneous diseases: a blinded comparative study. J Am Acad Dermatol 1998;38:27-31. Patients at least 18 years of age with a skin problem were recruited randomly from among patients enrolled in the health system N/R Loane et al. Diagnostic accuracy and clinical management by real real time teledermatology: results from the Northern Ireland arms of the UK multicentre teledermatology trial. J Telemed Telecare 1998;4:95-100. Patients with dermatological conditions requiring a specialist referral N/R Lowitt et al. Teledermatology and in-person examinations: a comparison of patient and physician perceptions and diagnostic agreement. Arch Dermatol 1998;134:471-6. Consecutive dermatology patients at the Veteran Affairs Medical Centre Patients transported by stretcher and those who refused to participate Phillips 1997 Patients referred to the dermatology clinic N/R
Table 80: Baseline characteristics of the participants in SAF trials Study Age (mean, SD) Gender N, % male Ethnicity/ Skin type No. of rural residency (%) Skin cancer history (%) Other dermatological history (%) Duration of current skin disease (acute, subacute, chronic) Barnarda 2000 N/R N/R N/R N/R 25 tested lesions included 8 cancer cases N/R N/R Braun, 2000 N/R N/R N/R N/R N/R N/R N/R Coras, 2003 N/R N/R N/R N/R N/R N/R N/R Ferrandiz, 2007 70.25 (95% CI, 63.11–77.39) 82 (61.2%) N/R N/R Non-melanoma skin cancer (73%) N/R N/R Kroemer, 2011 median age 69 years, range 41 (46%) N/R N/R 113 skin tumours N/R Median duration 52 months Krupinski, 1999 N/R N/R N/R N/R N/R N/R N/R Barbieri, 2014 55.2 (16.2) 18 (36%) N/R N/R N/R N/R N/R Du Moulin, 2003 47 years N/R N/R N/R N/R N/R N/R Ebner, 2008 median age of 41 years (range 18–85 years) 34 (59%) N/R N/R N/R N/R N/R Edison, 2008 Mean=42 (range 7 -92 ) 34 (31%) 94 (85%) white, 13 (12%) 2 (2%) Asian, 1 (1%) Hispanic/Latino N/R N/R N/R N/R Heffener 2009 6.17 years (range 3 81 (60%) 38% African American; 13% N/R N/R N/R N/R
Table 82: Baseline characteristics of the participants in VC trials Study Age (mean, SD) Gender N, % male Ethnicity/ Skin type No. of rural residency (%) Skin cancer history (%) Other dermatological history (%) Duration of current skin disease (acute, subacute, chronic) Gilmour, 1998 Range (3 month – 83 years) 64 (51%) N/R N/R N/R N/R N/R Lesher, 1998 N/R N/R N/R N/R N/R N/R N/R Loane, 1998 43 years (SD 24) Range (5 months years) 92 (45% ) N/R N/R N/R N/R N/R Lowitt, 1997 Median 65 (range 23-85) 124 (95%) White 79 (60%) 52 (40%) 98 (75%) within 45 min driving distance 33 (25%) outside 45 min driving distance N/R N/R N/R 28 (21%) initial visit 103 (79%) follow-up Phillips 1997 The average age was 37 years (range, 1 to 68 years). 24 (40%) Black 15 (25%), white 44 (73%) "other."=1 (2%) 100% N/R N/R N/R Phillips 1998 The average age was 46.7 years. N=8 (16%) White 38 (75%), 3 (6%) 10 (20%) N/R N/R N/R N/R N/R Nordal 2001 mean age 40 57/116= 49% N/R N/R N/R N/R N/R
Table 83: Characteristics of the included SAF studies Author, year, country Study design, objective Intervention standard Technology (camera, IT system, quality of pictures, pixels) Who made the images Population (skin conditions) Outcomes reported Accuracy based on outcomes Safety outcomes (safety, repeated requests (%), refusals, Results (management) Conclusion as reported in the paper Store-and-Forward teledermatology with diagnosis accuracy based on histological analysis as an outcome Barnard, 2000 Evaluation of an system for diagnosis of skin cancer and other skin diseases. Telemed J E Health USA A study designed to assess the ability of dermatologists to evaluate digital images of skin cancers as well as other skin diseases using a store-and-forward application. SAF TD (the same images assessed by 5 TDs) In person FTF (by one of three the case) Results of biopsy, culture, or wet mount results digital camera with a 105-mm lens. A contained all 50 clinical cases. Each case was presented through a software application. It contained a number of digital images along with relevant text; the recipient opened and viewed the application on their personal desktop computers (Pentium 133MHz or N/R 8 cancer cases The noncancer cases include a variety of viral, fungal or bacterial skin infections, inflammatory dermatoses, reactive dermatoses, benign tumors, systemic diseases with skin vascular reactions, and one disorder of keratinization Concordance was determined by comparing primary and differential diagnoses made by the teleconsultants on all 50 cases with those made by the dermatologists who originally examined the patients in person. For eight skin cancers, the diagnostic accuracy for the in-person dermatologist was 88% versus 90% (range, 75–100%) for the teleconsultants. The concordance between the and teleconsultant diagnoses were in agreement 77% of the time (90% if differential diagnoses were For the 25 cases (including the 8 skin cancers) confirmed by either biopsy (20), culture (1), or wet mount (4), the accuracy was 84% compared to 73% (range, 65–88%) for the Not a part of the study Not a part of the study The results show that this application allows levels of accuracy and concordance equivalent to those obtained with live interactive teleconsultation systems person person
greater) with a 15-inch or larger colour VGA monitors for evaluating the images. This permitted full screen displays of colour with 480 X 640-pixel resolution. included). Braun et al. in Switzerland: a preliminary evaluation. J Am Acad Dermatol Switzerland To evaluate the feasibility and the benefit of teledermatoscopy in diagnosis of pigmented skin lesions as a form of telemedicine under routine conditions in private practice. performed by the physician experienced in FTF in person DELM diagnosis microscopy (ELM) is a noninvasive technique for the diagnosis of pigmented skin lesions (PSLs). commercially available as “dermanet” system (Arpage AG, Zürich, Switzerland) Digital microscopy (DELM) uses digital or digitized pictures of PSLs. The system is based on a commercially 6 private practice trained in DELM Pigmented skin lesions The diagnostic accuracy of the teledermatoscopic approach for benign lesions was superior to the conventional diagnosis (68% vs 53%). For the malignant melanocytic lesions it was 100% compared with 78% for the conventional approach The diagnostic accuracy for suspect melanocytic skin lesions for both approaches was 67%. Cohen’s κ. For the agreement of FTF diagnosis, we obtained a K value of 0.565 diagnosis accuracy was 75% (41/55) vs 64% of FTF (35/55) Picture quality was evaluated to be good or very good in 90% of the DELM pictures and in 95% of the macroscopic pictures. 9 benign lesions were by a assessment vs 13 in FTF assessment; no malignant lesions were by a Not a part of the study Clinical history was not made available to We have identified the feasibility of a consultation by teledermatoscopy but consider our study as exploratory for any other extrapolation, because it lacks many appropriate controls in this respect. Because clinical information such as age, sex, risk factors for melanoma, and phototype was only available in 15% of all cases, we are unable to comment on the impact of this on our study. Experience in the field
available PC (166 MHz MMX Intel Pentium processor, 32 MB RAM, 4 GB hard disk) that was equipped with a standard PCI graphic card (4 MB ram, 24-bit color depth at 600 × 800 resolution). A Mitsubishi CCD camera was added to the system. It has a physical resolution of 768 × 567 pixels and allows macro pictures as well as DELM examination. compared with 0.742 for teledermotoscopy diagnosis. of ELM seems to have more impact on the diagnosis than clinical information, particularly for nonpigmented lesions Coras B et al. in daily of the first 100 cases. Curr Probl Dermatol Germany and Switzerland To assess the possibility [diagnostic accuracy] of teledermatoscopy with computerized dermatoscopy system with video camera SAF (dermatoscopy images) sent to the Department of Dermatology of the University by one of 3 experiences dermatologists in private practice FTF with by private Histology diagnosis Hand-held camera (Dermogenius ® ultra) with resolution of more than 700 TV lines and 512x512 pixels. The pictures are stored using Dermogenius Software on the made the digital (clinical) pictures and images 45 of 100 pigmented lesions that were excised the diagnosis according to the protocol was benigh, atypical melanocytic nevi; malignant melanocytic skin lesion. teledermatoscopy Primary: 89% (40/45) For malignant vs benign: Sensitivity: 0.86 Specificity: 0.92 Face-to-face plus dermatoscopy Primary: 91% (41/45) In 45 lesions excision was performed See primary outcome vs histology 5 incorrect diagnoses Face-to-face 10% of digital images were rejected Not a part of the study Results demonstrated similar sensitivity and specific for teledermatoscopy and FTF consulations. The procedure of teledermatoscopy is simple and may be in high demand in the future CCD
dermatoscopic images to SAF teledermatology. dermatoscopy: TD A: 0.77 TD B:0.75 -with dermatoscopy TD A: 0.85 TD B: 0.86 TD A:2 SCC, 1 KS TD B:1 SCC dermatoscopy TD A: 0.73 (0.62-0.85) TD B: 0.76 (0.66-0.87) the reliability and the accuracy of teledermatology. Warshaw 2009a United States N=542 With images Observational, cohort study compare conventional, clinical dermatology with store-and-forward teledermatology for pigmented skin neoplasms, using the outcomes of diagnostic accuracy and appropriateness of management Clinical photographs and the standardized patient and lesion history FTF Nikon Coolpix 4500 Unclear Patients being referred to dermatology by health care providers for evaluation of a pigmented skin neoplasms. Aggregated: SAF=282/542 (52%) FTF=434/542 (80%) -Primary: SAF=271/542 (50%) FTF=320/542 (59%) Benign keratosis N=125 Dysplastic nevus N=115 Benign nevus N=82 Melanoma N=36 BCC N=66 SCC N=18 N=12 melanoma Without SAF N=7 FTF N=1 With (PLD) SAF N=3 FTF N/A With (CID) SAF N=6 FTF N/A Management accuracy SAF:383/542 (71%) PLD: 380/542 (70%) CID: 401/542 (74%) FTF:356/542 (66%) PLD: 356/542 (66%) CID: 357/542 (66%) The diagnostic accuracy of clinic dermatologists evaluating 542 veterans with pigmented skin lesions was superior to teledermatologists and the addition of dermatoscopic images did not significantly increase the diagnostic accuracy of teledermatologists. Despite the superiority of clinic dermatology for diagnostic accuracy, the two methods of care had overall equivalent rates of appropriate management; however, 7 index melanomas (19%) would have been mismanaged via teledermatology.
Delta 20 melanoma Whited 1998 United States Observational study Compared the precision and accuracy of digital image consultations with conventional consultations. Medical records and clinical images FTF Camera Fujix DS-515 (1280*1000 pixels) Unclear Convenience sample of patients at the Veterans Affairs Medical Center who were referred to the dermatology clinic for a suspected skin cancer. Diagnostic accuracy -Single diagnosis SAF TD1 7/9 (78%) TD2 2/9 (22%) FTF=6/7 (67%) -Single and differential diagnoses SAF TD1 8/9 (89%) TD2 7/9 (78%) FTF=7/9 (78%) Diagnostic concordance SAF vs FTF -Single diagnosis TD1 8/10 (80%) TD2 6/10 (60%) Mean=70% -Single and differential diagnoses TD1 9/10 (90%) TD2 10/10 (100%) Mean=95% BCC N=3 SCC N=2 N=2 Missed diagnosis for cancerous diseases (including differential diagnosis) TD 1 N=0 TD 2 N=0 Management concordance (vs FTF): TD1 10/10 (100%) TD2 9/10 (90%) This study suggest that teledermatologymay be a viable consultative technique for providing accurate diagnoses. Store-and-Forward teledermatology with diagnostic concordance as an outcome Barbieri, 2014 The reliability of to triage inpatient dermatology To evaluate whether a teledermatology system is reliable for the initial triage of inpatient consultations by two independent based on the information by a and plan by the AccessDerm smartphone platform (Vignet), with images captured by a smartphone camera. A medical student Inpatients of the US hospital Generalized lesion 22 (44%) The primary study outcomes were concordance of the triage plans and the decision to biopsy. Secondary outcomes included diagnostic N/A Concordance in a biopsy decision between and In-person dermatologist assigned 66% of consultations for the next day or later, with Regarding triage decisions, the teledermatologists rarely failed to triage a consultation to be seen the same day when the in-person
consultations JAMA Dermatol. USA dermatology consultations from the medical record and patient using the prompts in the AccessDerm smartphone platform (Vignet), with images captured by a smartphone camera. The form from the AccessDerm platform was filled by a medical student. dermatologic consultation note Most common dermatologic diagnoses: Drug reaction 7 (14%) Stasis dermatitis 4 (8%) Graft vs host disease 3 (6%) agreement between the in-person dermatologist and teledermatologists. There was complete, partial, and no agreement for 64%, 20%, and 16% of the consultations, respectively, between the dermatologist and teledermatologist1 and for 56%, 26%, and 18% of the consultations, respectively, between the dermatologist and teledermatologist 2. Comparing two teledermatologists, there was complete, partial, and no agreement between teledermato-logists for 58%, 30%, and 12% of consultations, respectively. Thus, there was 82% to 88% complete to partial diagnostic agreement. 1 and 2 was 94% and 96% respectively. 18% triaged to outpatient care. 1 triaged 60% of consultations to the next day or later, with 12% deferred to outpatient care. 2 triaged 60% of consultations to the next day or later, with 8% triaged to outpatient care. Concordance in a biopsy decision between and 1 and 2 was 94% and 96% respectively. Concordance in a biopsy decision between and dermatologist believed it was necessary (<10% of cases). On determining whether to biopsy, the teledermatologists rarely failed to request a biopsy when the in-person dermatologist requested one (<5%of cases).
J Am Acad Dermatol 2000;42: 776-83. USA and traditional face-to-face (FTF) office visits. Criteria for comparison included overall accuracy of diagnosis, as well as accuracy based on diagnostic confidence, image quality, and the type of skin lesion involved port interface and accompanying software. The Sony DSC-F1 camera displayed 640 × 480 pixel resolution with 24-bit colour. a PC with a Sony Trinitron Multiscan-15sf colour monitor set to display 24-bit colour at 864 × 480 pixels created all images. with only 3 patients classified as type V or VI. The study population contained a wide variety of dermatologic conditions. Most frequent Nevus, keratosis TD1 vs CD 70% (69/99) TD2 vs CD 64% (49/77) TD3 vs CD 77% (76/99) evaluation. FTF final diagnoses was in excess of 81% for each of the 3 teledermatologists. Kvedar et al. The substitution of digital images for dermatologic physical examination. Arch Dermatol USA To investigate the diagnostic accuracy of clinicians viewing a patient's history and static digital image set compared with clinicians who conducted office based physical examinations of the same patients. SAF diagnosis provided by 2 dermatologists independently; Patient record FTF by one of 13 FTF a digital camera (Kodak DCS 420) equipped with a macro lens (Nikkor 50 mm). The digital images were stored on optical disks as PICT files and viewed using a software program (Adobe Systems Inc, San Jose, Calif) on a Macintosh computer (Apple Macintosh PowerMac Two Malignant or premalignant Pigmented lesions disorders 2 TDs aggregated diagnoses : 70% 67% Primary diagnoses: 61% 64% Not a part of the study design 27% of the images taken by this method had a Q-index rating of less than 4, indicating a significant number of unacceptable images interspersed with the images. Not a part of the study design Still digital images can substitute for the dermatologic physical examination in up to 83% of cases. This study provides validation of the store-and-forward concept of telemedicine as applied to dermatology.
7100/66) Tucker 2005 United Kingdom N=75 (number of lesions=84) Skin Lesion Observational cohort study To test the efficacy of the teledermatology screening of referrals, and thereby to triage the patients to appropriate care. Medical records and clinical images FTF N/A Camera Fujifilm zoom *two took pictures for two batches of patients and then the pictures were read by the other Patients seeing in general dermatology clinics. Diagnostic concordance SAF vs FTF -complete 37/84 (44%) -partial 47/84 (68%) N/A Quality of images Poor N=18 N/A Teledermatology is not likely to have a great impact on reducing waiting lists. It is possible that it may help to prioritize referrals from remote areas. Mahendran 2004 UK N=163 *unclear that if the TD1 was the served as the clinical Skin Lesion Observational cohort study To investigate the value of a teledermatology system in the diagnosis and management of lesions suspicious of skin cancer. Medical records and clinical images FTF N/A Camera Nikon Coolpix 950 (1200*1600 pixels) GPs Patients with suspicious skin lesions referred by GPs to dermatology department. Diagnostic concordance TD1 vs FTF 78/163 (48%) TD2 vs FTF 72/163 (44%) N/A Missed diagnoses including BCC, melanoma, basal cell papilloma. Quality of image Insufficient quality N=24 Management concordance TD1 90/163 (55%) TD2 85/163 (52%) This study illustrates that the store-and forward type telemedicine system has limited diagnostic accuracy for skin lesions. However, our results suggest that teledermatology may be suitable and safe for screening out clearly benign lesions but the study casts doubt on its efficiency. Oztas 2006 Turkey Observational cohort study Medical records and FTF N/A Camera Cannon Unclear Randomly selected Diagnostic concordance: N/A N/A N/A A Web-based system appears to
Telemed Telecare North Ireland was connected to the unit at each health centre to enable the general practitioner (GP) to transmit images to the dermatologist. (JVC KY-F55B) dermatologist assessed the patients in a FTF consultation. dermatologist recorded in 29% of 252 cases equipment Lowitt et al. and examinations: a comparison of patient and physician perceptions and diagnostic agreement. Arch Dermatol USA To compare physician and patient impressions and inter-physician diagnostic agreement between live teledermatology and in- person examinations. Nurse-assisted with a dermatologist FTF with every biopsy N=11 VC were conducted over a dedicated data line (T1) at the rate of 1.554 megabytes per second (64% of patients) and at ¼ T1 (384 kBT per second) for the of patients Nurse in VC N=104 Acne, dermatitis fungal Benign tumour premalignant tumour Malignant tumour Aggregated: 80% (104/130) 84% for T1 and 78% for ¼ T1. See Table 4 in the paper for diagnostic agreement by condition VC 73% (8/11) FTF 64% (7/11) On 6 occasions a premalignant or Malignant tumour was mentioned by TD but not CD or vice versa Not a part of the study Physicians and patients were satisfied with examinations. Diagnostic agreement between and video was high. Phillips 1997 Prospective, observational study. To determine the reliability of videoconferencing in evaluating skin tumors, the impact of the technology on the clinician’s degree of suspicion that a Diagnosis was made by physician and via N/A FTF CLI CODEC (Panasonic or Canon 1- chip) plus digital camera with dermatoscopic camera. Not Patients enrolled in the screening at the community hospital or physician offices with suspected skin tumors. -Diagnostic concordance: Primary diagnosis 63/107 (58.9%) -Decision to biopsy the lesion: Agreement ĸ=0.47, p<0.025 N/A N/A N/A The concern about the malignancy of a particular skin lesion and the whether to do a biopsy were not significantly affected by telemedicine
skin tumor is malignant, and the recommendation to do a biopsy. technology. Phillips 1998 Prospective, observational study. To measure the degree of concordance between a dermatologist seeing a patient in a clinic and another dermatologist seeing the same patient over a commercially available videoconferencing system Diagnosis was made by physician and via N/A FTF Picture Tel System 4000 plus digital camera (Elmo model MN401X). Not Patients being referred by another physician. Diagnostic concordance: -Primary diagnosis 61/79 (77.2%) -Type of problem Lesions 82.7% Rashes 74.1% Other 75% N/A N/A N/A There was a reasonable degree of agreement between the two examining physicians. Despite the relatively high degree of concordance the had a significantly lower degree of confidence in his diagnoses. Nordal 2001 Prospective, observational study. The aim of the present study was to evaluate teledermatology in a comparative study of videoconferences versus consultations The same patients underwent a consultation and then a face-to-face consultation. N/A FTF The same systems were used at both sites (Titan, Philips); they were connected at 384kbit/s. The magnified still images had a resolution of 720 pixels6576 lines. A camera Sony) was used for patient Not Patients from primary care being referred for dermatology consultations. Diagnostic concordance: -Primary diagnosis 81/112 (72.3%) -aggregated diagnosis 97/112 (86.6%) Dermatologist evaluation -favour VC= 14% -favour face-to-face consultation= 22% Average duration of consultation (minute) N/A N/A N/A with a participating general practitioner may be useful in dermatology, but the technique should be used only for selected patients.
Appendix E Review of economic literature Economic evaluations Table 87: Review of economic evaluations time Type of Resource use/ outcomes Results Comments* 2010 The objective was to the of using to provide a Patient from primary care in -The stated that a societal was -The time The were and the usual care. consisted The analysis was based on a model. -The effectiveness data were mainly from the Primary care Electronic Referrals: Focus on Efficient Consultation using in (PERFECT -The total mean costs were EUR 387.0 (95% CI 281.0 to 502.5) for teledermatology and EUR 354.0 (95% CI 228.0 to 484.0) for usual care; a difference of EUR 32.5 (95% CI -29.0 to 74.7). -When the Interventions: The selection of the comparators was appropriate and the usual care was included. The interventions were well described.
skin for patients who did not need an urgent with a was six of the general (GP) two to four digital images and a of the skin problem to a secure website. The received an email and consulted these images and then provided the GP with advice on further D) trial. This was a cluster randomised trial of 631 patients, with 85 GPs, and five From this trial, the authors determined that there was no difference in the clinical outcomes between the This was supported by another published study. The main clinical effectiveness estimate was patient recovery. - No distance to a dermatologist is greater (75km or more) or when more consultations can be prevented by teledermatology (37% or more), teledermatology resulted in cost savings. -The probabilistic sensitivity analysis demonstrated that usual care was less expensive than teledermatology in 89% of simulations. Authors' conclusions The authors concluded that The effectiveness data were from a randomised trial, which appears to have been of good quality. The authors assumed equal effectiveness for the two interventions based on this trial and validated this assumption using the results of another study. Costs: The perspective was clearly stated and the cost categories were consistent
or referral. The usual care consisted of a GP referral to a for a summary benefit measure was used because the interventions were assumed to be clinically equivalent. A analysis was carried out. -The economic analysis included the costs of GP care, dermatology care, expenses for patients including travel costs, and productivity losses due to teledermatology was unlikely to be cost saving, unless patients had to travel long distances to see dermatologists or they were likely to be able to be treated in a GP practice without needing a dermatological consultation. with this perspective. The unit costs and quantities of resources used were clearly and separately presented. The sources of costs were reported and appear to have been of good quality. The price year was not reported, making it unclear if the costs were adjusted for inflation. Discounting was not required as the time horizon was six months. Analysis and
GP or visits. The cost of investments, including the digital camera, website, and training for the GPs and was included for The resource use was based on data from the PERFECT D trial. The unit costs were mainly from the Dutch Manual for Costing, while market prices and expert opinion results: A synthesis of costs and benefits was not carried out, as a analysis was conducted. The authors justified this type of analysis on the grounds of the equal efficacy of the two interventions. The sensitivity analysis used both a deterministic and a probabilistic approach and extensively investigated the uncertainty. The authors compared their findings minimisation
were used for some investment costs. All costs were presented in Euros (EUR). with the results of another published study and discussed some limitations of their study. Loane 2000 To evaluate the clinical efficacy and of real-time and along with a clinical trial. Patients with a referral in the view of their treating GP. -Time the same as the length of the clinical trial versus real-time for patients with all skin The effectiveness and cost evidences were both from a part of randomised controlled trial conducted in the first 12 months of the UK trial. Patient clinical outcomes and costs of the RT consultation Diagnostic concordances: -Primary diagnosis 51/84 (60.7%) -Aggregated diagnosis 74/84 (88.1%) Clinical outcomes (hospital appointment required) Real-time: N=43 SAF: N=66 Consultation time (mean±SD) Real-time: Comparator: The selection of the comparator was appropriate. Validity of estimate of measure of effectiveness The effectiveness evidence came from a clinical trial, which was appropriate for the study question. The
were compared with patient clinical outcomes and costs of the SAF consultation. The concordance between the diagnostic and management decisions made at both was determined later by the third consultant Costs 15.7±4.6 SAF: 1.6±0.7 Costs: -Variable costs Real-time: £76.96 SAF: £20.15 -Fixed costs Real-time: £49456*50 SAF: £2380 -Savings Real-time: £9.74 SAF: 0 -Benefits (equivalent cost of GP training) use of a randomised trial is able to ensure a high internal validity. Validity of estimate of measure of benefit The benefit measure was specific to the intervention considered in the study. However, it is not enough to reflect all the benefits derived from the intervention (e.g. saved waiting time to receive treatment).
-variable cost: by consultation time (2) cost of travel (not reported in the current study) -fixed cost: Equipment cost for and Benefits: Avoided hospital referrals by GPs. Real-time: £ 60.04 SAF: 0 -Net societal cost Real-time: £132.10 SAF: £26.90 Authors' conclusions The consultation was cheaper, but less clinically efficient, compared with the real-time consultation. The absence of interaction in a store-and-forward consultation limits the dermatologist's ability to obtain clinically useful information in order to diagnose Validity of estimate of costs The authors stated explicitly the perspective that was adopted in the study. Detailed information on the cost items included was provided, although the cost for travelling was published in previous study (the detailed results were not reported here). Sensitivity analysis was not
and manage a patient satisfactorily. performed. 2009 To conduct an analysis of a system for the routine triage of skin cancer patients. A and analysis under a societal Patients being referred from primary care centres with skin cancers. -Time March 2004 and July 2005. versus care for patients with skin cancers. The effectiveness evidence was from a comparative study conducted between March 2004 and July 2005. Cost components include fixed costs (Equipment, e.g. computer, digital camera) and variable costs (Preparation and submission of Average total cost per patient SAF teledermatology: €79.78 Conventional: €129.37 (p < 0.005) Average cost for travel per patient SAF teledermatology: €6.01 Conventional: €13.2 Average lost productivity cost per patient Comparator: The selection of the comparator was appropriate. Validity of estimate of measure of effectiveness The effectiveness evidence came from a clinical trial, which was appropriate for the study question. Validity of estimate of measure of benefit
was used to compare with the care at primary care centre, evaluation of by FTF visit at local FTF visit at skin cancer clinic, travel to skin cancer clinic by patient, working time lost by patient. cost over the intranet considered negligible and not included in the cost SAF teledermatology: €12.6 Conventional: €27.5 Statistically significant inverse relationship between average unit cost of teleconsultation and the number of teleconsultations (p < 0.001). Average waiting interval (days) SAF ICER The benefit measure was specific to the intervention considered in the study. However, it is not enough to reflect all the benefits related to those two interventions. Validity of estimate of costs The authors stated explicitly the perspective that was adopted in the study. Detailed information
analysis. Cost-saving of €0.65 per waiting day avoided. Authors' conclusions SAF teledermatology is cost-effective for managing referrals in skin cancer clinics in a public health system equipped with an intranet. on the cost items included was provided. van der 2011 This study the effect of on quality The study patients referred for a -The system -time versus care for patients with all skin The efficiency data were from the prospective cohort study. Efficiency of SAF was measured by Efficiency Teledermatology prevented 74% (n=19741/26596) of physical referrals. Quality -A TDC was performed for Comparator: The selection of the comparator was appropriate. Validity of estimate of costs
and costs of care when in daily practice and applied following patient selection by the general (GP). with all skin was not clearly the number of physical referrals prevented. Quality was expressed as the number of TDCs performed for second opinion, as physical referrals resulting from these response time of the and the educational effect experienced by the GP. Costs: Cost of physical second opinion in 29% of the cases (n=10611). Among those, 16% (n=1723) were referred to the dermatologist on the dermatologist’s advice. -mean response time TDC 4.6 h (median 2.0, range 1.5 min-49 days) -GP’s learning experience A lot (17%)/substantial (39%)/slightly (29%)/not at all (15%) -helpfulness to dermatologist The authors stated explicitly the perspective that was adopted in the study. Only the consultation costs were included in the cost analysis. The cost components included were not enough.
of referral to secondary care. Whited 2003 To the clinical from a clinical trial with cost estimates to report a cost analysis and a analysis to compare a consult The study patients referred for a -The Affair Health Care system -The setting was care. The study was in the USA. A (TD) service for patients referred for a was The reviewed a digital image and a history, Clinical trial based -The study sample 275 of which 140 were in the UC group and 125 in the TD group. Other -The effectiveness evidence came from a prospective, randomised clinical trial that was carried out at a single centre. Of the 110 TD patients who were scheduled for a clinic visit, 21 (19.1%) did not present for their visit. One patient was not scheduled but showed for a clinic visit anyway. Of the 140 -In the base-case analysis, the median time to initial definitive intervention was 137.5 days for UC and 50 days for TD (p=0.0027). This resulted in an incremental effectiveness of 87.5 days. Variations performed in the sensitivity analysis did not alter substantially the base-case results, and the incremental effectiveness of TD ranged from 86 to 87.5 days. -Cost results In the base-case analysis, the Selection of comparators The selection of the comparator was appropriate as it reflected the conventional approach to patient management. The authors made an extreme comparison in the model, because exclusive use of TD was compared with exclusive use of UC. Validity of estimate of
with a system. in addition to a request, and then evaluated whether to schedule the patient for a or to relay a diagnosis and treatment plan back to the referring clinician. on the study sample was not UC patients, 27 (19.3%) did not present. Further details on the study design were not 2002) -The analysis of the clinical study used actual clinic visit data. These data were derived from clinic visit occurrences and accounted for no-show rates or with clinic visit annual cost of treating 5,440 patients was $198,016 with TD and $116,416 with UC. Thus, the average cost per patient was $21.40 for UC and $36.40 for TD. The incremental cost per patient was $15. The sensitivity analysis showed that the incremental cost per patient did not vary substantially in the alternative scenarios (the incremental cost varied from $10.50 to $13.85). measure of effectiveness The effectiveness evidence came from a clinical trial, which was appropriate for the study question. However, the study had been published already and limited information on the methods, study sample and results was provided. The use of a randomised trial ensures a high internal validity. However, it was not
-The summary benefit measure was the median time to the initial definitive intervention. This was obtained using a modelling approach. -Indirect cost was only accounted for in the sensitivity analysis. -It was assumed that a dermatology clinic visit would take a Similarly, unrealistic variations in the base-case model inputs were required for TD to be cost-saving over UC. The two-way sensitivity analysis revealed that the three variables that showed the potential of having thresholds (although at very extreme values) were the probability of a TD patient being scheduled for a clinic visit, clinic visit cost, and travel cost. The inclusion of possible to draw any conclusions on the robustness of the estimate measures, owing to the lack of information. Validity of estimate of measure of benefit The summary benefit measure was specific to the intervention considered in the study and is not comparable with the benefits of other health care interventions.
half-day off from work for the patient or a family member. The price year was 2001 in US dollars. indirect costs did not alter the results, although the TD costs were more comparable with UC costs. -An incremental cost-effectiveness ratio was calculated to combine the costs and benefits of the alternative diagnostic strategies. In the base-case analysis, the incremental cost per patient per day of time to initial definitive intervention saved with TD over UC was $0.17. The results of the sensitivity analysis did not vary in comparison with the base-case Validity of estimate of costs The authors stated explicitly the perspective that was adopted in the study. Detailed information on the cost items included was provided, although the costs were presented as Therefore, the unit costs were not given. This reduces the possibility of replicating the analysis. Similarly,
results (ranging from $0.12 to $0.16 per patient per day saved). Authors' conclusions The teledermatology service decreased the time to initial definitive intervention, but was more costly than usual care (UC) for a dermatology consultation. TD could be considered in settings requiring long waiting periods for routine dermatological care. information on the source of the costs was limited for some items. Some costs were estimated in 2001 but the price year was not reported, which makes reflation exercises in other settings difficult. The costs were treated in the but extensive variations of the base-case costs were investigated in the sensitivity analysis. The indirect costs were also included in the sensitivity
analysis and the method of calculation was explicitly reported. The authors noted that the variable costs could have been because the time spent by clinicians for other duties was not taken into consideration. Pak 2009 The aim of this study was to perform a cost analysis of subjects who were being referred from a Primary Care Clinic to a of -Time 4 SAF versus care. analysis (a part of a trial) From a previously published randomised controlled trial Direct Costs Comparator: The selection of the comparator was appropriate. Validity of estimate of costs control
to a referral process (usual care). Because clinical were found, a analysis incurred costs between yet Clinic with various consultation, consultation, primary care visit, laboratory tests, laboratory preparations, procedures (including biopsies, laser therapy, UV therapy, and surgery), radiological tests, and medications. Indirect Costs Lost productivity cost for seeking Sensitivity analysis Not performed The authors stated explicitly the perspective that was adopted in the study. A series of cost components were included in the analysis. However, the start-up fee, on-site training, internet access fee and annual maintenance fee were not considered.