The acceptance of mobile teledermoscopy by primary care nurse practitioners in the state of Arizona

Acceptance of Teledermoscopy by General Practitioners and Dermatologists in Denmark

Background

Teledermoscopy can be used to triage referrals of suspected skin cancers, thereby reducing waiting time and number of face-to-face consultations with a dermatologist. However, the success of the implementation of this technology in part relies on the acceptance of the providers.

Objectives

This study assessed the attitudes towards teledermoscopy of referring general practitioners and consultant dermatologists.

Methods

General practitioners from 48 practices and 3 dermatologists in the region of Southern Denmark, who had previous experience with teledermoscopy, were invited to answer questionnaires on their acceptance of the technology.

Results

General practitioners from 23 practices responded. All domains of the questionnaire received high scores, indicating a high degree of acceptance of teledermoscopy among respondents. All 3 dermatologists agreed that teledermoscopy was useful for triaging referrals, but they were less confident in their diagnoses and management plans proposed by teledermoscopy than in traditional face-to-face evaluations of patients. Two of the 3 dermatologists were satisfied with using teledermoscopy as a consult method.

Conclusions

This study reports high levels of provider acceptance of teledermoscopy. However, a low response rate among general practitioners may limit its generalizability.

Dermoscopy for melanoma detection and triage in primary care: a systematic review

OBJECTIVE

Most skin lesions first present in primary care, where distinguishing rare melanomas from benign lesions can be challenging. Dermoscopy improves diagnostic accuracy among specialists and is promoted for use by primary care physicians (PCPs). However, when used by untrained clinicians, accuracy may be no better than visual inspection. This study aimed to undertake a systematic review of literature reporting use of dermoscopy to triage suspicious skin lesions in primary care settings, and challenges for implementation.

DESIGN

A systematic literature review and narrative synthesis.

DATA SOURCES

We searched MEDLINE, Cochrane Central, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and SCOPUS bibliographic databases from 1 January 1990 to 31 December 2017, without language restrictions.

INCLUSION CRITERIA

Studies including assessment of dermoscopy accuracy, acceptability to patients and PCPs, training requirements, and cost-effectiveness of dermoscopy modes in primary care, including trials, diagnostic accuracy and acceptability studies.

RESULTS

23 studies met the review criteria, representing 49 769 lesions and 3708 PCPs, all from high-income countries. There was a paucity of studies set truly in primary care and the outcomes measured were diverse. The heterogeneity therefore made meta-analysis unfeasible; the data were synthesised through narrative review. Dermoscopy, with appropriate training, was associated with improved diagnostic accuracy for melanoma and benign lesions, and reduced unnecessary excisions and referrals. Teledermoscopy-based referral systems improved triage accuracy. Only three studies examined cost-effectiveness; hence, there was insufficient evidence to draw conclusions. Costs, training and time requirements were considered important implementation barriers. Patient satisfaction was seldom assessed. Computer-aided dermoscopy and other technological advances have not yet been tested in primary care.

CONCLUSIONS

Dermoscopy could help PCPs triage suspicious lesions for biopsy, urgent referral or reassurance. However, it will be important to establish further evidence on minimum training requirements to reach competence, as well as the cost-effectiveness and patient acceptability of implementing dermoscopy in primary care.

TRIAL REGISTRATION NUMBER

CRD42018091395.

Dermoscopy use in UK primary care: a survey of GPs with a special interest in dermatology

Background

Melanoma accounts for 90% of skin cancer mortality and typically presents in primary care, where it can be challenging to distinguish from benign lesions. Dermoscopy is a tool for skin visualization that is routinely used for melanoma diagnosis in secondary care. However, the role of dermoscopy in primary care remains unclear.

Objectives

To determine views on, and use of, dermoscopy by dermatology‐interested general practitioners (GPs).

Methods

An online questionnaire was emailed to the UK Primary Care Dermatology Society members in February 2018, and responses collected over the following 4 weeks.

Results

A total of 205 responses were analysed. Most respondents were GPs (94%), aged over 50 (53%), had a postgraduate dermatological qualification (67%) and used dermoscopy regularly when reviewing pigmented skin lesions (97%). Dermoscopy use was commoner amongst GPs who had worked longer in primary care and had experience of secondary care dermatology. Most had undertaken training in dermoscopy (91%), although one‐fifth (20%) had not updated their training in over 5 years. Most of those who had received only 1 day of face‐to‐face training reported feeling confident using a dermatoscope. Few respondents (11%) reported access to teledermatology or teledermoscopy for urgent or routine referrals.

Conclusions

UK GPs with a special interest in dermatology are routinely using dermoscopy in the primary care setting. More research is needed to establish optimal approaches to training and updating GP dermoscopy skills. When dermoscopy has been shown to be safe, effective, acceptable and cost‐effective in this setting, more GPs may also be able to gain and maintain the skills to implement dermoscopy into routine primary care. Technological advances, including incorporation of artificial intelligence (AI) and algorithms to guide GPs, could also contribute to widening use of dermoscopy among GPs.

Evaluating healthcare practitioners' views on store-and-forward teledermoscopy services for the diagnosis of skin cancer

Objective

The aim of the study is to evaluate healthcare practitioners’ views on and satisfaction with (i) digital image acquisition and storage and (ii) store-and-forward teledermoscopy services for the diagnosis of skin cancer in their clinical practice.

Methods

An online survey was conducted among 59 healthcare practitioners (GPs (n=17), dermatologists (n=22), dermatology registrars (n=18), a dermatology research fellow (n=1) and a plastic surgeon (n=1)) to assess usability of digital image acquisition and storage for when the imaging process is conducted by the healthcare practitioners themselves, or by their patients. The study identifies the enablers and barriers of this emerging mode of medical practice. A thematic analysis was used to extract key themes from open-ended responses, which involved identifying themes and patterns within and across participants.

Results

Thirty-four healthcare practitioners (58%) had previously used a mobile dermatoscope within their practice. Participants most appreciated its use in their practice for lesion monitoring (59%) and record keeping (39%). Challenges reported were the increased time to support the additional workload (45%), technical issues (33%) and cost of equipment (27%). Practitioners were unsure (36%) or did not advocate teledermoscopy for direct-to-consumer use (41%). Only 23% supported the use of direct-to-consumer teledermoscopy.

Conclusion

While most practitioners are receptive to mobile teledermoscopy, there was less support for patient-initiated use, whereby the patient controls the imaging process. As technology improves rapidly it is important to evaluate practitioners’ acceptance and satisfaction of evolving telehealth services, moving forward with models of practice where healthcare practitioners and other healthcare providers will feel comfortable engaging in telehealth services.

Recent trends in teledermatology and teledermoscopy

Teledermatology is a useful alternative where specialized dermatological assistance is not available and has been used successfully to support health professionals in a wide range of settings worldwide, in either an asynchronous store-and-forward format or a real-time video conferencing format. Teledermoscopy, which includes dermoscopic images in the teleconsultation, is another addition that improves remote assessments of pigmented lesions. A more recent variant is mobile teledermoscopy, which uses a smartphone to deliver the same type of service.

Teledermoscopy’s greatest strength may be as a triage and monitoring tool, as it can reduce the number of unnecessary referrals, wait times, and the cost of providing and receiving dermatological care. While face-to-face (FTF) care remains the gold standard for diagnosis, drawbacks of not using FTF care as the primary method can be mitigated if teleconsultants are willing to refer to FTF care whenever there is uncertainty. Teledermatology has generally been well accepted by patients and practitioners alike.

Barriers to the large-scale use of teledermatology remain. Assigning medicolegal responsibility and instituting a reimbursement system are critical to promoting widespread use by medical professionals, while privacy and security features and a mechanism to link teleconsultations to patients’ existing health records are essential to maximize patient benefit. Direct-to-consumer services also need attention from regulators to ensure that consumers can enjoy the benefits of telemedicine without the dangers of unregulated or untested platforms.