56 CHAPTER 3 Teledermoscopy quality outcomes were defined as the percentage of (1) second opinion request, (2) resulting in extra teledermoscopy referrals, (3) GPs following teledermatologists’ advice on patient referral and (4) GP valuation of teledermoscopy. Teledermoscopy performance outcomes were defined as (5) the teledermoscopy referral percentage of patients otherwise referred, (6) the overall teledermoscopy referral percentage and (7) the time needed of GPs to create and send a teledermoscopy consultation, and teledermatologists’ answering and response time (time between sending and receiving answer). Healthcare perspective costs of an average teledermoscopy patient were assessed for all teledermoscopy consultations with responses to evaluation question Q3. The healthcare perspective costs only included the teledermoscopy consultation costs and weighted mean outpatient conventional healthcare costs. No other costs were included (such as patient travel time and costs). We compared the teledermoscopy costs to the weighted mean outpatient conventional healthcare costs for teledermoscopy patients who were either referred (Q3 = Yes) or not (Q3 = No) after the teledermoscopy consultation (Formula 3.1 (Appendix 3.1)). Since 2009, Ksyos declared teledermoscopy consultation costs at the patients’ healthcare insurance company. These costs covered a dermatologist’s compensation, plus all technical, operational and legal overhead costs, for example, maintenance and innovation of the Ksyos platform, training of GPs, etc. The weighted mean outpatient conventional healthcare costs were derived from the Dutch Healthcare Authority and based on the weighted average price of the Diagnosis Treatment Combination [24]. This was done for 12 (85%) of the most reported ICD-10 code diagnoses in the Ksyos database. These costs were based on prices from 2020 price levels (European currency, Euro €). Euro values were multiplied by 1.142, which was the mean exchange rate in 2020, to convert to US dollars [25]. The intended purpose of the “NA” answer options has not been evaluated before. Instead of just treating these responses as missing data, we therefore performed a sub analysis to gain insight if the current use for providing the “NA” response (Q2) by teledermatologists still matches the intended purpose. A questionnaire was sent by email to thirty random teledermatologists who had been involved in teledermoscopy consultations. Responses to this questionnaire were anonymous. The time needed by teledermatologists to answer the teledermoscopy consultation requested by the GP was measured in time intervals on working days (8.30 am to 5.30 pm) of a 5-day working week, excluding national holidays and weekends. These timestamps were stored since July 2011. For the assessment of the third performance outcome, the time needed by GPs to create and send a teledermoscopy consultation was analyzed for consultations completed within one working day (9 hours) and consultations that were created on a working day but send the day after.
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