Abstract
TeleDerm is a web-based service designed to provide general practitioners (GPs) with rapid assessment of dermatoscopic images of pigmented lesions and moles. During a 12-month period, GPs at the Hastings and Rother primary care trust referred a total of 660 lesion images from patients exhibiting less typical symptoms of cancer, who would otherwise have been routinely referred to hospital. The images were assessed by remote expert dermatologists. Of that total, 493 images (75%) were reported as displaying no suspect dermatoscopic structures, resulting in the GP discharging the patient. In addition, seven lesions (1%) were reported as displaying suspect dermatoscopic structures, resulting in the GP urgently referring the patient to hospital with a subsequent histological confirmation of melanoma. The overall costs per patient were reduced by 50%. In an independent survey, all 11 patients rated their experience as good to excellent. The results show that tele-dermatoscopy can provide GPs with an expert second opinion to increase the quality of diagnosis in primary care, reduce the costs of dermatology provision and provide a highly rated patient experience.
Introduction
According to the British Association of Dermatologists, most physicians have ‘limited experience of melanoma (and) the majority have not had the opportunity to develop diagnostic skills’. 1 As a result, a substantial number of benign lesions are referred inappropriately to secondary care. This may be 19 out of 20 cases in some areas. 2 According to the Dermatology Workforce Group 3 there are now more referrals to dermatology by general practitioners (GPs) than to all of the other medical specialities combined. Evidence also suggests that one patient in three with melanoma is initially misdiagnosed by their GP, leading to delay in referral to secondary care of more than a year. 4
The NICE Guidelines 5 hint at a possible solution, advising GPs that local investigations may be necessary in respect of patients with less typical symptoms and signs that might, nevertheless, be due to cancer. However, until recently, no local investigative process was available to GPs to assist with the diagnosis of melanoma.
Dermatoscopy and melanoma diagnosis
Dermatoscopy – skin imaging using a special hand-held skin contact microscope – is recommended by NICE Guidance 6 for melanoma diagnosis as it yields greater diagnostic accuracy than naked eye examination, although its use should be restricted to those expert in the technique.
Tele-dermatoscopy – remote interpretation of a dermatoscopic image – can link GPs with expert dermatoscopists. Scansol Ltd, an independent acute hospital registered by the Care Quality Commission for skin cancer screening, diagnosis and treatment, has developed a tele-dermatoscopy investigation service for primary care (TeleDerm). The service enables a GP or practice nurse to record patient history and images, including a dermatoscopic image, in a secure web-based Electronic Patient Record (EPR). This was described by the Care Quality Commission as an example of commendable practice. The case history and images are investigated by doctors who hold an international diploma in dermatoscopy and are experienced in the technique. The results are issued to GPs within three days.
Tele-dermatoscopy in the NHS
Hastings and Rother was the first primary care trust (PCT) in the UK to offer tele-dermatoscopy to its GPs, beginning with a pilot trial of the TeleDerm service. During the trial, from October 2008 to March 2009, 135 GPs had the option of referring patients with low risk pigmented lesions or moles to a local nurse, rather than directly and routinely to secondary care. The nurse recorded patient data and images on the EPR for dermatoscopic investigation and reporting. After the trial, the PCT continued to operate the service.
By September 2009 a total of 660 lesions from GPs had been dermatoscopically investigated using telemedicine. By using the dermatoscopic reports to augment their clinical decision, the GPs were able to discharge 493 patients (75% of the total) who would otherwise have been referred routinely to hospital. This resulted in a net cost saving to the PCT of 50%. In addition, GPs were able to identify seven lesions as suspect and requiring urgent referral (which histology subsequently confirmed as melanomas) of which only three would otherwise have been referred urgently by the GP. No melanomas were misdiagnosed by GPs using the TeleDerm service.
These results are similar to those from a controlled study in New Zealand, which showed that teledermatoscopy had a sensitivity of approximately 100% and a specificity of 90% for detecting both melanoma and non-melanoma skin cancers. 7 In this study, 74% of all lesions were thought to be manageable by the GP without needing to be seen face-to-face by a dermatologist.
A survey of GP users conducted by the PCT confirmed they found it ‘exceptional’, ‘fast’ and ‘useful’. An NHS survey (Dr Foster) of patient users confirmed that all 11 rated the experience as good to excellent.
Conclusion
Teledermatology can help GPs to reduce the high numbers of patients with benign lesions inappropriately referred routinely to secondary care and slightly increase the number of melanomas appropriately referred urgently to secondary care. This results in reduced waiting times and reduced anxiety for patients with benign lesions, earlier treatment for patients with melanoma and reduced costs to PCTs.
Footnotes
Acknowledgements
TeleDerm is a registered trademark.