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.


METHODS
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.


METHODS
A skin cancer unit of a public university hospital and 12 primary care centers in southern Spain.


METHODS
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.


METHODS
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.


METHODS
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).


CONCLUSIONS
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.
Moreno-Ramirez
David
D
Pigmented Lesion, Skin Cancer, and Teledermatology Clinic, University Hospital Virgen Macarena, Seville, Spain. dmoreno@e-derma.org
Ferrandiz
Lara
L
Nieto-Garcia
Adoracion
A
Carrasco
Rafael
R
Moreno-Alvarez
Pedro
P
Galdeano
Rafael
R
Bidegain
Esther
E
Rios-Martin
Juan J
JJ
Camacho
Francisco M
FM
D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D019114:Remote Consultation; D015203:Reproducibility of Results; D012871:Skin Diseases / Q000175:diagnosis; D012878:Skin Neoplasms / Q000175:diagnosis* / Q000473:pathology; D014218:Triage