63 ELEVEN YEARS OF TELEDERMOSCOPY IN THE NETHERLANDS GPs from primary care practices in the Netherlands, this is, to our knowledge, the largest retrospective nationwide teledermoscopy evaluation study ever performed. All data on consultations and evaluation questions was part of the nationwide Ksyos teledermoscopy system flow. GPs and teledermatologists were unaware of this retrospective study at the moment of sending and responding on teledermoscopy consultation requests by which study outcomes reflect the actual general practice of teledermoscopy use in the Netherlands. Limitations of this study include that we were not able to report on patient’s histopathology diagnoses due to health record interoperability and privacy limitations. Therefore, we could not confirm the teledermoscopy diagnoses for extra and prevented physical referrals. The systematic reviews of Finnane et al. [34] and Warshaw et al. [35] both concluded that the management accuracy between in-person and teledermoscopy assessment is comparable by which both groups of patients as often received the accurate treatment. Due to privacy limitations, we could also not inspect the free text entries provided by the GPs and teledermatologists in the teledermoscopy consultation on further questions and information they provided. Second, not all teledermoscopy consultations had responses to the evaluation questions needed to quantify the teledermoscopy quality and performance outcomes, nor could we validate the GP-reported outcomes on patient referrals. As a result, we are unable to provide the actual reasons for which GPs reported not to refer the patient after the teledermoscopy consultation in contrast to the advice of the teledermatologist to physically refer the patient. Third, the cost evaluation was very limited and should be interpreted with caution as we only included the teledermoscopy consultation and weighted outpatient healthcare costs. Not all primary (e.g., GP reimbursement, costs of primary care consultation) and secondary healthcare costs (e.g., patient travel costs) were taken into account. And we did not correct for the different dermatology consultation rates per year. The weighted outpatient healthcare costs are thus a rough estimation of the actual costs since not all healthcare expenditures were included in this analysis. However, we believe that this cost estimation shows promising results for implemented teledermoscopy services used in real general practice. Future recommendations We observed that the majority of GPs followed the teledermatologists’ advice on patient referral. However, we did not assess for which teledermoscopy diagnosis groups the GP changed his referral decision. Therefore, we will assess the GP’s decision on patient referral before and after the teledermoscopy consultation per group of (pre-)malignant and benign teledermoscopy diagnosis provided by teledermatologists. 3
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