61 ELEVEN YEARS OF TELEDERMOSCOPY IN THE NETHERLANDS Linear regression modelling indicated that GPs and teledermatologists with more experience in performing a teledermoscopy consultation needed significantly less time to perform a teledermoscopy consultation with each consecutive consultation reducing the needed time by 0.5% (p < 0.01) and 0.05% (p < 0.01), respectively. DISCUSSION This study showed that the availability of teledermoscopy in the GPs’ practices is a useful service for requesting dermatologist advice in order to resolve any doubts from the GPs and support them in the diagnosis and management of a patient’s abnormal lesions. As a result of the sent second opinion request (quality outcome 1), patients were afterwards referred to dermatology care (quality outcome 2). For some of these cases, teledermatologists provided a teledermoscopy diagnosis for skin cancer. This suggests that these patients suspected of skin cancer had better access to secondary care, and a patient and doctor’s delay might be prevented due to teledermoscopy so that patients are treated as soon as possible. Early detection and adequate treatment of patients with skin cancer are key to decrease mortality, especially for melanoma [15]. For the majority of teledermoscopy consultations, the GP followed the teledermatologist’s advice on patient referral (quality outcome 3). Interestingly, teledermatologists reported “NA” as their response to patient referral for a third of teledermoscopy consultations. It seems that teledermatologists prefer to write their advice on referral management in free text for some cases. Teledermatologists are cautious in their decision-making and just want to fulfil an advisory role concerning the referral and treatment decisions of patients with skin lesions. The “NA” response option is thus still used as intended. We believe that these findings were very insightful. In addition, almost all GPs said that the teledermatologists’ responses were helpful and instructive (quality outcome 4). The majority of GPs followed the teledermatologists’ advice on patient referral, possibly indicating that they were satisfied with the reaction and advice. Hence, GPs could be provided with more dermatological knowledge by teledermoscopy [26]. Our study reported that GPs would have referred the majority of patients if teledermoscopy was not available (performance outcome 5 and 6). This reflects that the teledermoscopy consultation provided the GP with enough information to no longer consider a referral of his patient to a dermatologist necessary. This has also been evaluated in another Dutch teledermoscopy study with a data set ranging from 2009 to 2016 [27]. This study reported a comparable outcome that 69.4% of the physical referrals were prevented by teledermoscopy. The implementation of the Ksyos teledermoscopy service during a Belgium pilot study resulted in 71% reduction of the referral rate of patients with skin 3
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