62 CHAPTER 3 lesions [28], but this study was based on data of only 54 teleconsultations. Overall, these findings could suggest that despite the differences in teledermoscopy services platforms and healthcare settings, teledermoscopy seems to prevent most physical referrals of patients over the last years and is therefore a valuable service to healthcare professionals and their patients. We performed a limited cost evaluation and estimated a cost reduction of 50.2% for a teledermoscopy patient compared to the conventional healthcare costs. Despite this limited evaluation, these outcomes of teledermoscopy are promising for future (Dutch) healthcare cost savings. More extensive costs analyses were performed in other studies [29]. Surprisingly, teledermoscopy skin cancer referrals were more expensive compared to conventional care in these studies, but the time to establish a diagnosis was significantly reduced and therefore the costs were deemed worthwhile [30]. Although generalizability of economic analysis is limited, it was concluded by a systematic review from 2020 that teledermoscopy can be cost-effective in certain circumstances such as when the number of physical referrals can indeed be reduced [31]. Finally, timestamps were evaluated (performance outcome 7). GPs needed on average 5.4 minutes to create and send a teledermoscopy consultation, while a regular consultation at the GP is scheduled for ten minutes [32]. Some GPs spend more time on a teledermoscopy consultation than on a standard GP consultation. Yet, the time GPs and teledermatologists needed to send or answer a teledermoscopy consultation respectively decreased when they became more experienced in teledermoscopy. It is important to note that GPs could save the teledermoscopy consultation as a draft for an unlimited time, which we could not take into account for the analyses. We expect that GPs could have sent some teledermoscopy consultations faster if they would have continued their workflow by sending the teledermoscopy consultation immediately to a teledermatologist for advice. Teledermatologists answered 80% of the teledermoscopy consultations within one working day (9 hours) with a median response time of 2.4 hours (mean: 6.7 hours). These fast responses contribute to early reassurances of both the patients and GPs. This finding is especially relevant for patients with suspected malignancies in the context of the average patient waiting time of 2.8 weeks in the Netherlands for a dermatology outpatient clinic visit, with maximum waiting times for a patient referral of four weeks [33]. Reported teledermoscopy response times in our study were longer than the teledermatology response times by Börve et al. [17] who reported a median response time of 1.8 h. Kips et al. [28] reported a median response time of 17 h. However, this comparison of results should be interpreted with caution, since both study populations were much smaller and study settings were completely different from our study. Strengths and limitations So far, retrospective evaluation studies of teledermoscopy quality and performance outcomes are limited. By including over 18,000 teledermoscopy consultations sent by
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