207 APPENDICES In Chapter 4 we examined the added value of teledermoscopy for GPs in terms of expertise gained in diagnosing skin disorders after three years of teledermoscopy use in practice. Teledermoscopy consultations sent by GPs to teledermatologists (July 2015 – June 2018) and the corresponding GP and teledermatologist diagnoses were studied. This preliminary study showed that after continued use of teledermoscopy, GPs somewhat developed their expertise in diagnosing skin conditions. This implies that the teledermoscopy service has limited added value for GPs as a learning tool. After three years of teledermoscopy use, GP diagnosis sensitivity for skin disorders slightly improved, as well as the number of pre-diagnoses given by the GP and confirmed by the teledermatologist, while the total positive predictive value of skin diagnoses given by the GP slightly decreased. In 50 teledermoscopy consultations in this study, the teledermatologist diagnosed the skin lesion as melanoma and in 43 of these 50 consultations the skin lesions were not pre-diagnosed by the GP as melanoma. This indicated that even after prolonged and repeated use of teledermoscopy consultation by GPs, the teledermatologists’ advice is valuable for the early detection of melanoma. In Chapter 5 we measured the added value of teledermoscopy in terms of the availability of the service in general practice. We examined whether GPs changed their final referral decision after a teledermoscopy consultation compared to their initial referral decision prior to the consultation. Teledermoscopy consultations initiated by GPs in daily practice (July 2015 – June 2020) were included, as well as the related GPs’ referral decisions and teledermatologists’ diagnoses. In half of the teledermoscopy consultations studied, GPs adjusted their initial self-reported referral decision after assessment of the teledermatologist. This means that the availability of teledermoscopy aids GPs in deciding whether or not to refer patients to a dermatologist. Subsequently, the skin lesions diagnosed by the teledermatologist were classified in this study as benign, premalignant, and malignant. GPs’ referral decisions were specifically examined for these three diagnosis groups. In total, data of 6364 teledermoscopy consultations were included (9% malignant, 9% premalignant, and 82% benign skin lesions). This study showed that GPs changed their referral decision from referral to nonreferral in 75% of the cases with a benign teledermatologist diagnosis. This implies that without the availability of the teledermoscopy service, the GP would have referred these patients with benign skin lesions to a dermatologist. Additionally, in 57% of the cases with a malignant teledermatologist diagnosis and in 16% of the cases with a premalignant teledermatologist diagnosis, GPs reversed their referral decision from nonreferral to referral after teledermoscopy consultation. This indicates that teledermoscopy also led to referrals of patients with (pre)malignant skin lesions that GPs would not have referred directly to the dermatologist. Thus, the availability of teledermoscopy is of added value for GPs in their referral decision for patients with benign, premalignant and malignant skin lesions. A
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