title: Photograph-based diagnosis of burns in patients with dark-skin types: the importance of case and assessor characteristics.
abstract: OBJECTIVE
  This study assessed whether photographs of burns on patients with dark-skin types could be used for accurate diagnosing and if the accuracy was affected by physicians' clinical background or case characteristics.
  
  
  METHODS
  21 South-African cases (Fitzpatrick grades 4-6) of varying complexity were photographed using a camera phone and uploaded on a web-survey. Respondents were asked to assess wound depth (3 categories) and size (in percentage). A sample of 24 burn surgeons and emergency physicians was recruited in South-Africa, USA and Sweden. Measurements of accuracy (using percentage agreement with bedside diagnosis), inter- (n=24), and intra-rater (n=6) reliability (using percentage agreement and kappa) were computed for all cases aggregated and by case characteristic.
  
  
  RESULTS
  Overall diagnostic accuracy was 67.5% and 66.0% for burn size and depth, respectively. It was comparable between burn surgeons and emergency physicians and between countries of practice. However, the standard deviations were smaller, showing higher similarities in diagnoses for burn surgeons and South-African clinicians compared to emergency physicians and clinicians from other countries. Case characteristics (child/adult, simple/complex wound, partial/full thickness) affected the results for burn size but not for depth. Inter- and intra-rater reliability for burn depth was 55% and 77%.
  
  
  CONCLUSIONS
  Size and depth of burns on patients with dark-skin types could be assessed at least as well using photographs as at bedside with 67.5% and 66.0% average accuracy rates. Case characteristics significantly affected the accuracy for burn size, but medical specialty and country of practice seldom did in a statistically significant manner.
authors.affiliation: Department of Public Health Sciences, Karolinska Institutet, Widerströmska Huset Tomtebodavägen 18 A, 171 77 Stockholm, Sweden.
authors.forename: C
authors.initials: C
authors.lastname: Boissin
authors.affiliation: Department of Public Health Sciences, Karolinska Institutet, Widerströmska Huset Tomtebodavägen 18 A, 171 77 Stockholm, Sweden; Stellenbosch Institute for Advanced Study (STIAS), Wallenberg Research Centre at Stellenbosch University, Marais Street, Stellenbosch 7600, South Africa; University of South Africa, Preller Street, Pretoria 0002, South Africa.
authors.forename: L
authors.initials: L
authors.lastname: Laflamme
authors.affiliation: Division of Emergency Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Private Bag X24, Bellville 7535, South Africa.
authors.forename: L
authors.initials: L
authors.lastname: Wallis
authors.affiliation: Division of Emergency Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Private Bag X24, Bellville 7535, South Africa.
authors.forename: J
authors.initials: J
authors.lastname: Fleming
authors.affiliation: Department of Public Health Sciences, Karolinska Institutet, Widerströmska Huset Tomtebodavägen 18 A, 171 77 Stockholm, Sweden; Stellenbosch Institute for Advanced Study (STIAS), Wallenberg Research Centre at Stellenbosch University, Marais Street, Stellenbosch 7600, South Africa. Electronic address: marie.hasselberg@ki.se.
authors.forename: M
authors.initials: M
authors.lastname: Hasselberg
mesh_terms: D000328:Adult; D000368:Aged; D001830:Body Surface Area; D002053:Burn Units; D002056:Burns / Q000175:diagnosis* / Q000473:pathology; D002648:Child; D004635:Emergency Medicine; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D010781:Photography / Q000379:methods*; D010820:Physicians; D015203:Reproducibility of Results; D012867:Skin / Q000473:pathology*; D012880:Skin Pigmentation; D013019:South Africa; D013043:Specialties, Surgical; D011795:Surveys and Questionnaires; D013548:Sweden; D017216:Telemedicine; D015599:Trauma Severity Indices; D014481:United States
keywords: Burn complexity; Diagnostic accuracy; Inter-rater reliability; Intra-rater reliability; Telemedicine; mHealth