Internet-based skin cancer screening using clinical images alone or in conjunction with dermoscopic images: A randomized teledermoscopy trial.

BACKGROUND: Teledermoscopy involves the use of dermoscopic images for remote consultation and decision-making in skin cancer screening. OBJECTIVE: We sought to analyze the potential benefits gained from the addition of dermoscopic images to an internet-based skin cancer screening system. METHODS: A randomized clinical trial assessed the diagnostic performance and cost-effectiveness of clinical teleconsultations (CTC) and clinical with dermoscopic teleconsultations. RESULTS: A total of 454 patients were enrolled in the trial (nCTC = 226, nclinical with dermoscopic teleconsultation = 228). Teledermoscopy improved sensitivity and specificity (92.86% and 96.24%, respectively) compared with CTC (86.57% and 72.33%, respectively). Correct decisions were made in 94.30% of patients through clinical with dermoscopic teleconsultations and in 79.20% in CTC (P < .001). The only variable associated with an increased likelihood of correct diagnosis was management using teledermoscopy (odds ratio 4.04; 95% confidence interval 2.02-8.09; P < .0001). The cost-effectiveness analysis showed teledermoscopy as the dominant strategy, with a lower cost-effectiveness ratio (65.13 vs 80.84). LIMITATIONS: Potentially, a limitation is the establishment of an experienced dermatologist as the gold standard for the in-person evaluation. CONCLUSIONS: The addition of dermoscopic images significantly improves the results of an internet-based skin cancer screening system, compared with screening systems based on clinical images alone.

Economic evaluation of a store-and-forward teledermatology system for skin cancer patients.

We conducted an economic analysis of a store-and-forward teledermatology system for the routine triage of skin cancer patients. A cost-identification, cost-effectiveness and sensitivity analysis under a societal perspective was used to compare teledermatology with the conventional care alternative. In the period March 2004 to July 2005, a total of 2009 teledermatology referrals were managed from 12 Primary Care Centres (PCCs) of the public health system. The unit cost was of Euro 79.78 per patient in teledermatology, and Euro 129.37 per patient in conventional care (P < 0.005), with an incremental cost of Euro 49.59 per patient in favour of teledermatology. The cost ratio between teledermatology and conventional care was 1.6. There was a significant inverse relation between the unit cost in each participating PCC and the number of teleconsultations transmitted from them (P < 0.001). Teledermatology resulted in a more cost-effective, or dominant, methodology. In a public health system equipped with an intranet, the routine use of teledermatology in skin cancer clinics is a cost-effective method of managing referrals.

Teledermatology-based presurgical management for nonmelanoma skin cancer: a pilot study.

BACKGROUND: To date, no previous experiences of teledermatology (TD) as a preoperative management facility have been published. OBJECTIVE: The objective was to evaluate a store-and-forward TD (SFTD) system aimed at the presurgical management of nonmelanoma skin cancer patients. METHODS AND MATERIALS: This was a multicenter, longitudinal, descriptive, and evaluative pilot study. Patients included in the TD-based surgical referral system presented with a nonmelanoma skin cancer or a fast-growth vascular tumor suitable for surgery under local anesthesia. Waiting intervals and on-the-day cancellation rates were evaluated and compared with a sample of patients managed through the conventional system. The accuracy of the diagnoses yielded and of the surgical techniques planned through teleconsultation was also calculated. RESULTS: A total of 134 patients were enrolled in the study. The mean waiting interval was 26.10 days [95% confidence interval (CI), 24.51-27.70] in patients managed through TD and 60.57 days (95% CI, 56.20-64.93 days; n=92; p < .001) in the conventional system. On-the-day surgery cancellation was 2.99% (95% CI, 1.52%-4.46%) for the TD series and 8.85% (95% CI, 5.62%-11.81%; p<.005) in the conventional system. The accuracy of the telediagnoses was kappa=0.86 (95% CI, 0.83-0.89). The agreement rate between the surgical technique planned through teleconsultation and the technique finally performed was kappa=0.75 (95% CI, 0.04-0.79). CONCLUSION: SFTD has been demonstrated to be effective and accurate as a preoperative tool for nonmelanoma skin cancer, avoiding unnecessary visits to the hospital and shortening the waiting intervals to the surgical treatment.

Store-and-forward teledermatology in skin cancer triage: experience and evaluation of 2009 teleconsultations.

OBJECTIVE: To evaluate a store-and-forward teledermatology system aimed at the routine triage of patients with skin cancer. DESIGN: A multicenter, longitudinal, 4-phase, descriptive and evaluation study of a referred sample of patients attended through teleconsultation between March 2004 and July 2005 (n = 2009). Clinical and dermoscopical examination and histopathological study were considered the gold standard. SETTING: A skin cancer unit of a public university hospital and 12 primary care centers in southern Spain. PATIENTS: The study population comprised patients with circumscribed lesions fulfilling at least 1 of the following criteria: changes in ABCD criteria (asymmetry, border irregularity, color variegation, and diameter >6 mm), recent history, multiple melanocytic lesions, symptoms, and/or patient's application for surgical treatment and concern about moles. INTERVENTIONS: Diagnosis, diagnostic category (malignant lesions, high-risk lesions, benign lesions, special lesions, and other lesions), diagnostic confidence level on a 3-point scale, and management decision (referral vs nonreferral) were listed after the evaluation of each teleconsultation. A face-to-face evaluation and biopsy of selected patients were performed. MAIN OUTCOME MEASURES: The filtering percentage, as the percentage of patients not referred to the face-to-face clinic, as well as waiting intervals and pick-up or skin cancer detection rates were evaluated as effectiveness indicators. Reliability measures (kappa agreement), accuracy, and diagnostic performance indicators (validity) were also evaluated. RESULTS: The filtering percentage was 51.20% (95% confidence interval [CI], 49.00%-53.40%). The waiting interval to attend the clinic was 12.31 days (95% CI, 8.22-16.40 days) through teledermatology and 88.62 days (95% CI, 38.42-138.82 days; P<.001) for the letter referral system. Pick-up rates were 2.02% (95% CI, 1.10%-2.94%) for malignant melanoma and 27.94% (95% CI, 24.98%-30.90%) or 1:3.71 for patients with any malignant or premalignant lesion. Intraobserver agreement was kappa = 0.91 (95% CI, 0.89-0.93) for the management decision and kappa = 0.95 (95% CI, 0.94-0.96) for the diagnosis. Interobserver concordance was kappa = 0.83 (95% CI, 0.78-0.88) for the management decision and kappa = 0.85 (95% CI, 0.79-0.91) for the diagnosis. Accuracy was kappa = 0.81 (95% CI, 0.78-0.84). Sensitivity was 0.99 (95% CI, 0.98-1.00); specificity, 0.62 (95% CI, 0.56-0.69); pretest likelihood, 0.42 (95% CI, 0.37-0.47); positive posttest likelihood, 0.65 (95% CI, 0.61-0.69); and negative posttest likelihood, 0.01 (95% CI, 0.00-0.05). CONCLUSION: Store-and-forward teledermatology has demonstrated in this series to be an effective, accurate, reliable, and valid approach for the routine management of patient referrals in skin cancer and pigmented lesion clinics.