91 TO REFER OR NOT TO REFER IN TELEDERMOSCOPY DISCUSSION Principal results This retrospective study assessed the impact of the availability of teledermoscopy on GPs’ self-reported decisions to refer patients to the dermatologist. GPs’ self-reported initial referral decisions before the teledermoscopy consultation were compared with their referral decisions after the teledermoscopy consultation for skin lesions diagnosed by the TD as (pre)malignant or benign. This study showed that for these lesions, GPs adjusted their initial referral decision after the TD assessment in half of the teledermoscopy consultations. For 26 (16%) of 162 patients with a premalignant TD diagnosis and for 67 (56.8%) of 118 patients with a malignant TD diagnosis, GPs adjusted their referral decision after the teledermoscopy consultation from nonreferral to referral. Therefore, without the availability of teledermoscopy, GPs would not have referred these patients with (pre) malignant TD diagnoses directly to the dermatologist. Furthermore, if the TD provided the diagnosis seborrheic keratosis, GPs adjusted their referral decision in 676 (86.2%) of the 784 teledermoscopy consultations from referral to nonreferral. For the TD diagnosis of vascular skin lesions, GPs adjusted their referral decision in 131 (80.4%) of the 163 teledermoscopy consultations from referral to nonreferral. Therefore, without the availability of teledermoscopy, GPs would have referred these patients with benign skin lesions to a dermatologist. Comparison with prior work In a Belgian teledermoscopy study, which included all patients with suspicious skin lesions for teledermoscopy, regardless of whether the GPs intended to refer the patients, GPs photographed all skin lesions as part of the teledermoscopy consultation [10]. The vast majority of these skin lesions were assessed by the TD as benign (n=91, 86.7%), malignant (n=8, 7.6%), and uncertain classified diagnoses (n=6, 5.7%). These percentages are comparable with the TD-assessed skin lesions in our teledermoscopy study, in which 81.9% (n=5211) were benign, 8.8% (n=561) were premalignant, and 9.3% (n=592) were malignant. In contrast to our study, a Danish and a Swedish teledermoscopy study included only patients with suspicious skin lesions that the GPs, without the availability of teledermoscopy, would have referred to the dermatologist [5,6]. All these patients were seen in-person by a dermatologist after the teledermoscopy consultation. These studies reported that 27.7% (n=166) and 28.1% (n=229) of the skin lesions were diagnosed by the TD as (pre)malignant and 72.3% (n=434) and 71.9% (n=587) were diagnosed as benign, respectively. For the same group of patients in our study, where the GPs indicated that they initially would have referred the patient to the dermatologist, we found a slightly 5
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