Teledermatología diferida: análisis de validez en una serie de 2.000 observaciones

Store-and-forward teledermatology in a Spanish health area significantly increases access to dermatology expertise

INTRODUCTION

Teledermatology is the practice of dermatology through communication technologies. The aim of this study is to analyze its implementation in a Spanish health area during its first two years.

METHODS

Cross-sectional descriptive study. It included interconsultations between dermatologists and family physicians in the Salamanca Health Area (Spain) after the implementation of the non-face-to-face modality over a period of two consecutive years. A total of 25,424 consultations were performed (20,912 face-to-face and 4,512 non-face-to-face); 1000 were selected by random sampling, half of each modality.

MAIN MEASURES

referral rate, response time and resolution time, type of pathology, diagnostic concordance, and quality of consultation.

RESULTS

The annual referral rate was 42.9/1000 inhabitants (35.3 face-to-face and 7.6 non-face- to-face). The rate of face-to-face referrals was higher in urban areas (37.1) and the rate of non- face-to-face referrals in rural areas (10.4). The response time for non-face-to-face consultations was 2.4 ± 12.7 days and 56 ± 34.8 days for face-to-face consultations (p < 0.001). The resolution rate for non-face-to-face consultations was 44%. Diagnostic concordance, assessed by the kappa index, was 0.527 for face-to-face consultations and 0.564 for non-face-to-face consultations. Greater compliance with the quality criteria in the non-attendance consultations.

CONCLUSIONS

Teledermatology appears to be an efficient tool in the resolution of dermatological problems, with a rapid, effective, and higher quality response for attention to skin pathologies.

REGISTRY

ClinicalTrials.gov Identifier: NCT05625295. Registered on 21 November 2022 ( https://clinicaltrials.gov/ct2/show/ NCT05625295).

Diagnostic reliability in teledermatology: a systematic review and a meta-analysis

OBJECTIVES

To compare teledermatology and face-to-face (F2F) agreement in primary diagnoses of dermatological conditions.

DESIGN

Systematic review and meta-analysis METHODS: MEDLINE, Embase, Cochrane Library (Wiley), CINAHL and medRxiv were searched between January 2010 and May 2022. Observational studies and randomised clinical trials that reported percentage agreement or kappa concordance for primary diagnoses between teledermatology and F2F physicians were included. Titles, abstracts and full-text articles were screened in duplicate. From 7173 citations, 44 articles were included. A random-effects meta-analysis was conducted to estimate pooled estimates. Primary outcome measures were mean percentage and kappa concordance for assessing diagnostic matches between teledermatology and F2F physicians. Secondary outcome measures included the agreement between teledermatologists, F2F dermatologists, and teledermatology and histopathology results.

RESULTS

44 studies were extracted and reviewed. The pooled agreement rate was 68.9%, and kappa concordance was 0.67. When dermatologists conducted F2F and teledermatology consults, the overall diagnostic agreement was significantly higher at 71% compared with 44% for non-specialists. Kappa concordance was 0.69 for teledermatologist versus specialist and 0.52 for non-specialists. Higher diagnostic agreements were also noted with image acquisition training and digital photography. The agreement rate was 76.4% between teledermatologists, 82.4% between F2F physicians and 55.7% between teledermatology and histopathology.

CONCLUSIONS AND RELEVANCE

Teledermatology can be an attractive option particularly in resource-poor settings. Future efforts should be placed on incorporating image acquisition training and access to high-quality imaging technologies.

TRIAL REGISTRATION NUMBER

10.17605/OSF.IO/FJDVG.

Perceptions of medical students toward teledermatology as an educational tool: a cross-sectional study

Introduction

Teledermatology consultations have recently been on the rise, especially due to the SARS-CoV-2 pandemic. The role of teledermatology has been extensively discussed as a mean for the education of dermatology residents. Nevertheless, little has been explored on its use as a pedagogical tool for medical students. The objectives of this study were to assess the level of satisfaction of medical students with teledermatology and to evaluate their opinion about its use as an educational tool.

Methods

A cross-sectional study was carried out at the Dermatology Department, Hospital Universitario Virgen de las Nieves, Granada (Spain). Participants were fourth-year medical students. Every student would spend half of their internship in face-to-face consultations and the other half in teledermatology consultations. Data was collected via self-administered questionnaires.

Results

Eighty one students were finally surveyed, being 66.67% (73/81) female. A majority of students considered a mixed clinical internship model (face-to-face consultations combined with teledermatology) more suitable for obtaining higher marks in the subject of dermatology and in the Medical Intern Resident exam (p = 0.04). Nevertheless, face-to-face practice was considered more useful for their training as general practitioners (p = 0.04).

Conclusion

Despite the fact that students highly value doctor-patient relationship, teledermatology is considered a powerful educational tool.

[Teledermatology in the Health Center West Area of Granada: From primary to specialized care]

INTRODUCTION

Teledermatology (TD) is a health tool based on the application of information and communication technologies (ICT) for the care of skin diseases at a distance, allowing a better connection between primary care professionals (PCP) and specialized care. The objective of this study was to analyze the characteristics of the teleconsultations made to our service in a period of 2years (January 1, 2018 to December 31, 2019).

MATERIAL AND METHODS

The data was obtained from a TD system with dermoscopy that allows teleconsultations to be carried out asynchronously. Data were analyzed over 24months. The variables studied were the health centre of origin, the diagnostic suspicion of the PCP, the time and type of response, and the clinical judgment issued by the dermatologist.

RESULTS

Between January 1, 2018 and December 31, 2019, a total of 3,294 teleconsultations were received. 24.76% were referred to the dermatology consultation, while 25.63% required subsequent follow-up electronically. The most frequent diagnostic suspicion by the PCP was that of benign pathology (54.71%). The most frequent dermatological clinical judgment was that of seborrheic keratosis (20.19%), followed by actinic keratosis (14.02%), acquired common melanocytic nevi (13.24%) and basal cell carcinoma (8.98%).

CONCLUSIONS

The TD system is a useful tool that allowed a quick response to a high percentage of consultations, helping to avoid unnecessary referrals and easy communication between primary and specialized care. It also allows prioritizing those patients with malignant tumour pathology.

[Usefulness and efficiency of teledermoscopy in skin cancer management in primary care]

OBJECTIVE

To evaluate the usefulness of teledermoscopy as a diagnostic and triage method for suspected skin cancer lesions between Primary Care and Dermatology. To analyse the reduction in the number of referrals and estimate the savings achieved.

MATERIAL AND METHODS

Concordance study on a non-randomised case series. Descriptive observational study of teleconsultations sent from two Health Centres (urban and rural) to the reference Dermatology service in Cordoba (Spain) between January 2017 and April 2019. The diagnoses proposed by Primary Care before and after the use of dermatoscopy, and the diagnosis of the Dermatologist, along with other epidemiological variables were collected. Descriptive analysis and concordance study were performed.

RESULTS

A total of 395 teleconsultations were made. The coefficient of agreement between the diagnoses of both specialists without using dermoscopy was 0.486. Using this technique the concordance was 0.641. A reduction in the number of referrals to Dermatology was 58%. A savings of 2,475€ in transfers by ambulance and 550 working hours were made. The most common diagnoses were basal cell carcinoma (20%; n=79) and seborrheic keratosis (15.2%; n=60).

CONCLUSIONS

The addition of dermoscopy increases diagnosis concordance. Teledermatology is a useful system for patient triage and for decreasing the demand for hospital care, with an inherent resources saving.

Teledermatology in paediatrics: Health-care impact on the early treatment of infantile haemangiomas

INTRODUCTION

Teledermatology can solve diagnostic and therapeutic problems in paediatrics, for example in infantile haemangiomas (IHs) requiring early treatment with propranolol. This study aims to assess the impact of teledermatology following its implementation in a health area of Spain, specifically analysing its effectiveness in reducing the age of first propranolol treatment for IH.

METHODS

This was a descriptive study of paediatric teledermatology from 2015 to 2018, studying age, sex, diagnosis, time and mode of resolution. All IHs referred via teledermatology were analysed, and age at propranolol initiation was compared to the period prior to implementation (2008-2014). We also analysed IHs according to referral pathways (teledermatology vs. conventional pathways).

RESULTS

We included 432 consultations (47.7% boys). The main diagnoses were IH, erythematous-desquamative diseases and infections. Concordance in diagnosis between paediatricians and dermatologists was good, and 48.12% of cases consulted via teledermatology were resolved remotely. Response time was 2.81 days on average. Children younger than two months of age showed the highest proportion of in-person visits. In 2015-2018, children with IHs began treatment with propranolol at a mean age of 4.5 months (1.9 months in those referred via teledermatology vs. 5.6 months in those using conventional referral pathways). In 2008-2014, the mean age at referral was 7.1 months. These differences were significant.

DISCUSSION

Teledermatology is a fast and effective tool to resolve paediatric cases, enabling a significant decrease in the age of treatment in infants with IH.

Multidisciplinary approach to psoriasis in the Spanish National Health System: A social return on investment study

Introduction

Psoriasis is a chronic disease in which patients feel stigmatization, social rejection, and suffer from low self-esteem. There are still unmet needs that make it necessary to define a new multidisciplinary approach to provide benefits not only to patients and their families but also to the Spanish National Health System (SNHS) and society. The aim was to define a new approach to better address the unmet needs of patients with psoriasis within the SNHS and to measure its impact from a social perspective, that is, in clinical, health care, economic, and social terms.

Methods

Multidisciplinary experts identified, agreed on, and selected several health care interventions that were feasible for implementation in the SNHS. This process was carried out in four different areas: diagnosis, mild psoriasis, moderate psoriasis, and severe psoriasis. To estimate investment and social return, the social return on investment (SROI) method was used.

Results

The new approach to psoriasis management in the SNHS comprised 18 proposals. The investment needed for the implementation of this new approach would amount to €222.77 million and its return to €1,123.11 million. This would yield a SROI ratio of €5.04 for every euro invested.

Conclusion

The new approach to psoriasis management would yield a positive social return. The results will allow optimal strategic planning adapted to each assistance situation, to achieve a comprehensive and multidisciplinary approach.

Teledermatology for diagnosing skin cancer in adults

BACKGROUND

Early accurate detection of all skin cancer types is essential to guide appropriate management and to improve morbidity and survival. Melanoma and squamous cell carcinoma (SCC) are high-risk skin cancers which have the potential to metastasise and ultimately lead to death, whereas basal cell carcinoma (BCC) is usually localised with potential to infiltrate and damage surrounding tissue. Anxiety around missing early curable cases needs to be balanced against inappropriate referral and unnecessary excision of benign lesions. Teledermatology provides a way for generalist clinicians to access the opinion of a specialist dermatologist for skin lesions that they consider to be suspicious without referring the patients through the normal referral pathway. Teledermatology consultations can be 'store-and-forward' with electronic digital images of a lesion sent to a dermatologist for review at a later time, or can be live and interactive consultations using videoconferencing to connect the patient, referrer and dermatologist in real time.

OBJECTIVES

To determine the diagnostic accuracy of teledermatology for the detection of any skin cancer (melanoma, BCC or cutaneous squamous cell carcinoma (cSCC)) in adults, and to compare its accuracy with that of in-person diagnosis.

SEARCH METHODS

We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, CPCI, Zetoc, Science Citation Index, US National Institutes of Health Ongoing Trials Register, NIHR Clinical Research Network Portfolio Database and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles.

SELECTION CRITERIA

Studies evaluating skin cancer diagnosis for teledermatology alone, or in comparison with face-to-face diagnosis by a specialist clinician, compared with a reference standard of histological confirmation or clinical follow-up and expert opinion. We also included studies evaluating the referral accuracy of teledermatology compared with a reference standard of face-to-face diagnosis by a specialist clinician.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where there were information related to the target condition of any skin cancer missing. Data permitting, we estimated summary sensitivities and specificities using the bivariate hierarchical model. Due to the scarcity of data, we undertook no covariate investigations for this review. For illustrative purposes, we plotted estimates of sensitivity and specificity on coupled forest plots for diagnostic threshold and target condition under consideration.

MAIN RESULTS

The review included 22 studies reporting diagnostic accuracy data for 4057 lesions and 879 malignant cases (16 studies) and referral accuracy data for reported data for 1449 lesions and 270 'positive' cases as determined by the reference standard face-to-face decision (six studies). Methodological quality was variable with poor reporting hindering assessment. The overall risk of bias was high or unclear for participant selection, reference standard, and participant flow and timing in at least half of all studies; the majority were at low risk of bias for the index test. The applicability of study findings were of high or unclear concern for most studies in all domains assessed due to the recruitment of participants from secondary care settings or specialist clinics rather than from primary or community-based settings in which teledermatology is more likely to be used and due to the acquisition of lesion images by dermatologists or in specialist imaging units rather than by primary care clinicians.Seven studies provided data for the primary target condition of any skin cancer (1588 lesions and 638 malignancies). For the correct diagnosis of lesions as malignant using photographic images, summary sensitivity was 94.9% (95% confidence interval (CI) 90.1% to 97.4%) and summary specificity was 84.3% (95% CI 48.5% to 96.8%) (from four studies). Individual study estimates using dermoscopic images or a combination of photographic and dermoscopic images generally suggested similarly high sensitivities with highly variable specificities. Limited comparative data suggested similar diagnostic accuracy between teledermatology assessment and in-person diagnosis by a dermatologist; however, data were too scarce to draw firm conclusions. For the detection of invasive melanoma or atypical intraepidermal melanocytic variants both sensitivities and specificities were more variable. Sensitivities ranged from 59% (95% CI 42% to 74%) to 100% (95% CI 48% to 100%) and specificities from 30% (95% CI 22% to 40%) to 100% (95% CI 93% to 100%), with reported diagnostic thresholds including the correct diagnosis of melanoma, classification of lesions as 'atypical' or 'typical, and the decision to refer or to excise a lesion.Referral accuracy data comparing teledermatology against a face-to-face reference standard suggested good agreement for lesions considered to require some positive action by face-to-face assessment (sensitivities of over 90%). For lesions considered of less concern when assessed face-to-face (e.g. for lesions not recommended for excision or referral), agreement was more variable with teledermatology specificities ranging from 57% (95% CI 39% to 73%) to 100% (95% CI 86% to 100%), suggesting that remote assessment is more likely recommend excision, referral or follow-up compared to in-person decisions.

AUTHORS' CONCLUSIONS

Studies were generally small and heterogeneous and methodological quality was difficult to judge due to poor reporting. Bearing in mind concerns regarding the applicability of study participants and of lesion image acquisition in specialist settings, our results suggest that teledermatology can correctly identify the majority of malignant lesions. Using a more widely defined threshold to identify 'possibly' malignant cases or lesions that should be considered for excision is likely to appropriately triage those lesions requiring face-to-face assessment by a specialist. Despite the increasing use of teledermatology on an international level, the evidence base to support its ability to accurately diagnose lesions and to triage lesions from primary to secondary care is lacking and further prospective and pragmatic evaluation is needed.

Telemedicine in dermatology: findings and experiences worldwide - a systematic literature review

Telemedicine has become an important element of health care in many countries and profited from the technological progress of the last two decades. Due to the visual character of the dermatological specialty, teledermatology in particular participated in that development and is becoming a major tool in dermatological consultation. The objective of this article was to identify the use of teledermatology across the world based on published original articles. A systematic literature search of the MEDLINE and Embase databases for eligible publications (predefined inclusion and exclusion criteria) and a cross-validation search were conducted. Search results were reviewed systematically. The search resulted in 204 publications meeting the inclusion criteria for analysis. The highest number of published studies on teledermatology was performed in the United States, followed by the United Kingdom, Spain, the Netherlands, Italy and Austria. The majority of dermatological indications for telemedical consultations were not specified or included various kinds of skin diseases, followed by skin cancer and wounds. Research questions predominantly focused on concordance, effectiveness and cost-effectiveness to determine the value. Teledermatology proved to be a reliable consultation tool in the majority of studies. If specified, telemedicine was used in daily dermatological routine for patient management purposes, to consult patients in peripheral locations, or for medical support in nursing homes or home care settings. The application of teledermatology worldwide is highest in North American and European countries, while countries with poor geographical distribution of physicians seem to be under-represented in teledermatological use, as concluded from publication output. Regarding indications, comparison with classic consultation and area of application, most studies were of general nature. For precise determination of the value, systematic studies would be needed. However, teledermatology is already accepted as a valid tool.

[Teledermatology in Paediatrics. Observations in daily clinical practice]

INTRODUCTION

Teledermatology is a technique that is increasingly being developed. There are many studies that assess this discipline in the general population, but few studies analyse the paediatric population exclusively. The aims of this study are to describe the distribution of diseases consulted through teledermatology, the use of this technique to avoid face-to-face consultations, and the agreement between virtual and face-to-face diagnoses, in the paediatric population.

MATERIAL AND METHODS

The work consisted of an observational and retrospective study of the virtual consultations made between May 2011 and January 2015 through a store-and-forward teledermatology programme, involving patients from 0 to 15 years. We collected demographic data, as well as the diagnoses made by the paediatrician who made the virtual consultation, and by the dermatologists who assessed the virtual and the face-to-face consultations, the indication given by the dermatologist who assessed the virtual consultation (discharge or referral), reason for referral, and diagnostic agreement rate.

RESULTS

A total of 183 virtual consultations were analysed. The most frequent diagnoses were inflammatory diseases (39%), benign pigmented lesions (23%), and infectious diseases (20%). Almost half of the virtual consultations (48%) were referred for a face-to-face diagnosis. Diagnostic agreement between the dermatologist who evaluated the virtual consultation and the dermatologist who evaluated the face-to-face consultation was 89%, and 66% between the paediatrician who made the virtual consultation and the dermatologist who assessed it.

CONCLUSIONS

Virtual consultations have a similar disease distribution to conventional (face-to-face) referrals. Approximately half of the virtual consultations do not require a subsequent face-to-face visit. The agreement rate between the diagnoses given by both dermatologists (virtual and face-to-face diagnoses) is high.

Diagnostic agreement between a primary care physician and a teledermatologist for common dermatological conditions in North India

BACKGROUND

Primary care physicians (PCPs) encounter a large number of patients with dermatological diseases. However, delivering appropriate management is a challenge considering the inadequate dermatology training offered during the undergraduate medical curriculum. Teledermatology is the clinical evaluation of skin lesions by dermatologists and allows patients to be diagnosed and treated from a distant site. It is seen as a potential solution to the shortage of specialists and providing equitable service in remote areas.

AIM

The study was aimed at estimating the diagnostic agreement of common dermatological conditions between a PCP and a teledermatologist.

MATERIALS AND METHODS

Consecutive patients with dermatological ailments who attended a primary health care clinic were recruited into the study, examined by the PCP and offered a diagnosis. The clinical images and patients' history were collected and transferred to a dermatologist at a tertiary center who also made a diagnosis. Agreement between diagnosis made by the PCPs and the teledermatologist was measured using kappa (κ) statistics.

RESULTS

Overall agreement between the diagnoses made by a PCP and the dermatologist was found to be 56%. Poor κ agreement (<0.4) was seen in the diagnosis of psoriasis and eczema.

CONCLUSION

Teledermatology can supplement specialist dermatology service in remote areas. There was poor agreement in the diagnosis of psoriasis, classifying various types of eczematous conditions and fungal infections. Scarce manpower in dermatology at the primary health care level compounded by the burden of skin ailments necessitates training of PCPs in common dermatological conditions.