Introduction of new technology and new working methods; from a successful pilot project to a region-wide implementation of teledermatoscopy in primary health care. (Preprint)

Abstract

BACKGROUND Teledermatoscopy (TDS) has successfully been incorporated into the healthcare system of Stockholm Region, serving a population of 2.4 million with nearly 240 Primary care units. The full implementation was preceded by a pilot project conducted in 2015-2021. The implementation has been complex as it involves several levels of care, several contractual structures, procurement of a technical solution integrated into the regional IT environment and a major training mission. Political initiatives played a critical role in making the system a reimbursed utility for healthcare providers. Approximately 1.500 referrals for suspected skin lesions are now sent monthly to Karolinska Hospital's dermatology unit for assessment. We expect a steady increase in the number of referrals as the implementation is still being completed in several primary care centers and as TDS is recommended in the Swedish melanoma guidelines. OBJECTIVE The aim of this analysis was to investigate the following aspects: the rate of excision recommendations, the detection of melanoma and other types of skin cancer, the proportion of lesions requiring no further action other than reassurance. Additionally, a study on lead times to excision was conducted 2016 to 2019 during the pilot project time to ensure the safety and effectiveness of utilizing TDS. METHODS A comprehensive review was conducted on the TDS platform by collecting pathology reports and linking them to tagged dermatoscopic diagnoses. To examine lead times to excision for urgent melanoma referrals, a comparison was made between TDS and traditional electronic referrals to a tertiary hospital. RESULTS Between June 1, 2021, and May 27, 2023, a total of 13,923 consultations were conducted. Excision recommendations were made for 18 percent of these consultations, resulting in the detection of 262 melanomas and several other malignancies. Furthermore, over 80 percent of patients received reassuring messages, eliminating the need for unnecessary surgeries or referrals to secondary care doctors. In the lead time study, 128 patients referred by TDS that met the criteria of double reader consensus for melanoma suspicion were compared with 53 patients referred for melanoma suspicion to a tertiary hospital (Södersjukhuset, Stockholm, Sweden) by traditionally electronic referral. Patients from primary care with suspected melanoma, regardless of the referral route, experienced a median lead time of 12 days (interquartile range [IQR] 6-19; mean 15.8) from their initial consultation to diagnostic excision. Notably, those who underwent TDS during their first visit and had excision performed in primary care achieved significantly faster lead times. The median lead time for patients who underwent surgery at a primary care unit (n=40) was significantly shorter (p=0.013) compared to those who had surgery at other facilities (n=87), with lead times of 7.5 days (IQR 3–19.5, mean 13.2) and 13 days (IQR 8–19, mean 15.2), respectively. CONCLUSIONS Teledermatoscopy enables dermatologists to diagnose skin malignancies at the patient's first visit to primary care, improving patient care by increasing diagnostic accuracy, reducing time to diagnostic surgery, and reducing unnecessary surgical procedures.