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Experience and Evaluation of 2009 Teleconsultations

David Moreno-Ramirez, PhD; Lara Ferrandiz, MD; Adoracion Nieto-Garcia, PhD; Rafael Carrasco, MD; Pedro Moreno-Alvarez, PhD; Rafael Galdeano, MD; Esther Bidegain, MD; Juan J. Rios-Martin, PhD; Francisco M. Camacho, PhD

Arch Dermatol. 2007;143(4):479-483.

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 ( 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  = 0.91 (95% CI, 0.89-0.93) for the management decision and  = 0.95 (95% CI, 0.94-0.96) for the diagnosis. Interobserver concordance was  = 0.83 (95% CI, 0.78-0.88) for the management decision and  = 0.85 (95% CI, 0.79-0.91) for the diagnosis. Accuracy was  = 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.

Author Affiliations: Pigmented Lesion, Skin Cancer, and Teledermatology Clinic (Drs Moreno-Ramirez and Ferrandiz), Department of Dermatology (Drs Moreno-Ramirez, Ferrandiz, and Camacho), Surgical Area (Dr Carrasco), and Department of Pathology (Dr Rios-Martin), University Hospital Virgen Macarena; Department of Social and Health Sciences, Faculty of Medicine, University of Seville (Dr Nieto-Garcia); and Primary Care Center "San José" (Dr Moreno-Alvarez), Primary Care Center "Sevilla" (Dr Galdeano), and Primary Care Center "Sevilla Norte" (Dr Bidegain); Seville, Spain.

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