85 TO REFER OR NOT TO REFER IN TELEDERMOSCOPY INTRODUCTION In the Netherlands, patients that are concerned about their skin lesion visit their general practitioner (GP) for advice. GPs assess the skin lesions and decide if a wait-and-see policy is justified, if they can manage the skin condition themselves in their practice, or if the patient should be referred to a dermatologist. In this way, GPs serve as gatekeepers and play a key role in deciding whether a patient is referred to Dutch dermatology care. However, GPs seem to find distinguishing between benign and malignant skin lesions a difficult task [1,2]. As a result, GPs frequently refer patients with suspicious skin lesions to a dermatologist that turn out to be benign (e.g., seborrheic keratosis, vascular lesions, and benign nevus) [1-4]. These mild benign skin conditions can be managed by the GP in the primary care setting, and no clinical or surgical dermatological intervention is required [1,2]. Teledermoscopy can provide diagnostic support to GPs to accurately triage people with suspicious skin lesions [5-8]. With teledermoscopy, more urgent cases can be correctly referred to a dermatologist, while unnecessary referrals of people with nonsuspicious skin lesions who can be managed in primary care are avoided [5-11]. In general, previous teledermoscopy evaluation studies in primary care settings included all eligible patients with suspicious (pigmented) skin lesions, patients who GPs regularly intend to refer, or patients who were already referred to a hospital or lesion clinic [57,9-11]. In addition, these previous teledermoscopy studies were often carried out in a study setting where the feasibility of teledermoscopy was examined with a simulated teledermoscopy service that was not yet integrated into GP daily practice. Furthermore, in some of these teledermoscopy studies, the GP did not act as a gatekeeper, the referral decision was made by a (tele)dermatologist and not by a GP, or the photos of the skin lesions were not acquired by the GP themself but, for example, by a trained nurse (also called a melanographer) [6-11]. In the Netherlands, teledermoscopy has been integrated into GP practices nationwide since 2009 by a Dutch telemedicine provider (Ksyos) and is fully reimbursed by Dutch health insurance companies [12]. The Ksyos teledermoscopy service is unique compared to other worldwide teledermoscopy services in primary care because this service (1) is implemented in GP general practice, (2) asks GPs to enter their initial referral decision in the Ksyos system at the start of a teledermoscopy consultation request, and (3) asks GPs to enter their final referral decision in the system after receiving the digital assessment of the teledermatologist (TD) based on the overview, detailed, and dermoscopic images. Our previously performed teledermoscopy evaluation in Dutch GP practices in the same context and the same Dutch teledermoscopy system showed that the GPs adjusted their referral decision after the TD assessment in 3722 (53.3%) of the 6977 teledermoscopy consultations [13]. 5
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