Can teledermatology meet the needs of the remote and rural population?

The Outer Hebrides is an archipelago of islands, 50 miles off the west coast of Scotland and has a total population of 28 000 (Scottish Government, 2020). Life in the Outer Hebrides can be challenging, especially regarding health service provision. With extreme weather conditions causing regular travel disruption, relying purely on visiting specialists is neither a dependable nor cost-effective answer. Geographical boundaries and the availability of consultant dermatologists have always been prevalent issues, especially in relation to providing equity of service to people living in the islands.

For the past 20 years, an experienced consultant dermatologist visited regularly from a mainland hospital, as part of a service link agreement, to carry out clinics once every 2 months. This was bolstered by a local GP with a special interest (dermatology), providing support and a half day clinic on the interim month. Some services were provided ‘off-island’, which meant considerable travel and inconvenience for the patients, with this 200-mile round journey costing the health-board £300 a time. The consultant dermatologist was the clinical lead for the Western Isles service and due to the extreme stresses on his time was not always able to provide ‘between clinics’ support or advice. With this level of service, 55% of all ‘urgent’ referrals were routinely breaching guideline timescales.

With the retirement of the consultant dermatologist, significant challenges were faced regarding service delivery due to the failure to find a successor.

An internal audit shows that in 2019 the Western Isles Dermatology Department received 500 referrals from primary care, with 125 of these sent as urgent. Could the introduction of teledermatology safely serve this patient group?

Introduction

In 2018, the Cochrane database of systematic reviews analysed 22 studies with this sole objective: ‘to determine the diagnostic accuracy of teledermatology for the detection of any skin cancer in adults, and to compare its accuracy with that of in-person diagnosis.’ The review states that correct diagnosis from photographs had a sensitivity rate of 94.9%, and referral accuracy, comparing teledermatology to face-to-face (F2F) consultation, had a sensitivity rate of over 90%. The conclusion suggests that ‘teledermatology can correctly identify the majority of malignant lesions’ (Chuchu et al, 2018), but that further evidence was required.

Skin cancer rates have risen by 66% for people aged 25 to 49 since the 1990s (Cancer Research UK, 2021). Malignant melanoma is responsible for most skin cancer-related deaths in the UK (National Institute for Health and Care Excellence (NICE), 2015), having an average annual mortality rate of 2500 (Melanoma UK, 2020), which equates to 7 people every day in the UK dying from a malignant melanoma skin cancer. If melanoma is diagnosed when still at the local stage, there is a 99% survival rate, but this drops to 65% if it has spread regionally and 25% if distally spread (American Cancer Society, 2021).

In March 2020, a nationwide survey found that more than 152 000 new cases of non-melanoma skin cancer (basal cell carcinoma (BCC) and squamous cell carcinoma (SCC)) were diagnosed in the UK annually (Melanoma UK, 2020), which is a 10.3% rise from the 136 000 recorded in 2018 (Mayers, 2018). This total of over 165 000 cases of skin cancer every year in the UK highlights the importance of early, accurate diagnosis and treatment. NHS England (2019) showed that 40% of dermatology departments were falling below the 2-week-wait target of 93%, highlighting the overwhelming failure to address the new demands.

GPs are constantly concerned about the risk of missing a malignancy, while being acutely aware that over-diagnosis can be a problem too, leading to inefficient use of resources and poor patient experience (Foot et al, 2010).

This suggests that any dermatology service not only has to meet the needs of the referred patients, but also provide support and continued education for those making referrals.

In the 26 years since Perednia and Brown (1995) coined the term ‘teledermatology’, very few health boards have encompassed it into their daily practice, despite its obvious benefits, specifically in remote and rural underserved areas. Since the SARS and COVID-19 pandemics, limitations on access to healthcare have been a driving force, pushing remote working methods into mainstream usage at a great speed.

Telemedicine has emerged as a ‘critical tool’ for practitioners to continue their work without increasing transmission risk (Hadeler et al, 2021), with store-and-forward teledermatology being a well-received and appropriate option. In the pandemic in the USA, Salamon (2020) reported that telemedicine has moved on 10 years in 2 weeks, enabling 90% of the workload to be carried out remotely using technology, whereas Adisen et al (2020) found that 71.2% of the total workload of patients could be managed via teledermatology. Turnbull, in the article ‘Telehealth in the time of COVID-19’ (2020), quoted UK health secretary, Matt Hancock, as stating that ‘we have moved to a principle of digital first in primary care and outpatients’. This may lead to innovations around healthcare that we would not have seen otherwise (Salamon, 2020), a sentiment echoed by Puri et al (2020), who remind us that ‘times of great crisis are also times of transformative change’.

Many health professionals changed their practice purely out of necessity, being forced by contact restrictions due to the pandemic. Considering the ideals of evidence-based practice, is evidence available supporting this sudden shift? Has the enforced use of teledermatology changed our practice long term, or do most hold the view that it is an inferior, temporary measure?

Method

Teledermatology is a service that provides access to specialist dermatologist care through digital health services and involves the use of digital dermatoscope images being sent for interpretation through store-and-send services (Muir and Lucas, 2008), in conjunction with general email support and video conferencing for both staff and patients. This supports the core principle of the Scottish Government (2017) policy on modern outpatients (2017-20), as it is ‘optimizing e-Health and digital opportunities at the primary/secondary care interface’.

Carrying out a literature review of journal articles regarding use of teledermatology in the diagnosis of skin cancers, provides an evidence base to inform the decision as to whether teledermatology is a safe and efficient way to diagnose and manage skin cancer.

Studies were identified by structured database searches: three electronic bibliographic databases were systematically searched to identify relevant articles. Cooper et al (2018) state that bibliographic database searches are the ‘first method of choice’ and that searches should be a ‘thorough, comprehensive and transparent process’.

Teledermatology does not have any MeSH terms appointed. Dermatology covers too broad a subject and does not have any relevant subheadings. A free text ‘key word’ search was carried out using ‘Boolean operators’ to combine search terms with connector words, as well as ‘wildcard’ to capture any articles with a spelling variation, as advocated by Ecker and Skelly (2010).

The final 30 potentially relevant articles were then sourced in their full text format and read in full, and second-level screening was undertaken. After reviewing the full text articles, 24 further exclusions were made according to relevance, leaving a final total of six.

Mays et al (2005) suggested narrative methods of data synthesis for systematic reviews where included studies are not ‘sufficiently similar’ for a meta-analysis to be appropriate; thus a narrative synthesis of systematically searched for and quality appraised evidence (Popay, 2006) will be conducted following the Preferred Reporting Guidelines for Reviews and Meta-Analysis (PRISMA), guidelines, as stated in the 2009 PRISMA checklist (PRISMA, 2009).

Discussion

The data collated through the completion of the Critical Appraisal Skills Programme (CASP) (2019) extraction forms showed that none of the available literature was of adequate quality to endorse replacing face-to-face consultation with teledermatology as a sole method of service provision.

All articles included advocated the use of teledermatology as merely a method of triage to reduce face-to-face consultations, despite favourable statistical results (see Table 1). For example, Marwaha et al (2019) reported a 95% confidence interval, 4% reduced probability of an unwarranted biopsy and 9% higher probability of cancer detection obtained through tele-dermoscopy. Creighton-Smith et al (2017) claimed that there were no significant differences in diagnostic accuracy between teledermatology and face-to-face consultation, but conclude that its potential is limited to triage, and all diagnostic decisions should be made in face-to-face consultations and thus does not advocate its use as a service alternative.

Bandic et al (2020) reported teledermatology reliability of over 90% for diagnostic accuracy and Finnane et al (2017) show teledermatology consultation diagnostic reliability at 51-85%, which appears poor until compared with the face-to-face results of 67-85%. Bandic et al (2020) addressed concerns with the use of F2F consultations as a ‘gold standard’, as studies have shown that even F2F mistakes can be made, with diagnostic discordance ranging from 2-7% (Morgensen and Jemec, 2007) up to 14.3% (Shoo et al, 2010).

In the included studies, the diagnostic accuracy results ranged from 36% to 95%. When study results show this huge level of discrepancy, it suggests that there were severe issues with the research methodologies, reporting and a lack of standardisation and comparability. The heterogeneity of the studies available prevents a direct comparison of results and thus further compounds the issue of collating a collective opinion of the available evidence. The lack of comparability is so severe that even narrative data synthesis found only one confluent theme, that the use of ‘high-quality’ and ‘dermatoscopic’ images improves diagnostic accuracy. All other aspects were devoid of thematic similarities of any note.

Limitations

• Due to the nature of the interventions, it was not feasible for participants in any of the studies to be blinded as to their individual treatment pathway, which is also true of the participating health professionals. This has implications of high levels of participation bias
• Only one study described its data collection as ‘intention to treat’ methodology, as used in randomised controlled trials (RCTs). This suggests high potential of attrition bias in the other five studies.

Conclusion

The name Cochrane is synonymous with the gold standard in systematic reviews. Its 2018 review, Chuchu et al, reported findings on the diagnostic accuracy of teledermatology methods used for the diagnosis of 4057 lesions. They declared that, despite concerns regarding study size, poor reporting quality, the applicability of study participants and lesion image acquisition in specialist settings, ‘our results suggest that teledermatology can correctly identify the majority of malignant lesions’. Although this publication was only 3 years ago, there has been a dramatic shift in healthcare to encourage remote consultations. With strict limitations placed upon F2F consultations since the pandemic restrictions came into place, how has use of teledermatology developed?

The aim of this literature review is to determine how teledermatology has developed since the publication of the Cochrane review (Chuchu et al, 2018), a reconsideration of its use and potential within the new work parameters. The limited search date of this review is an attempt to demonstrate recent developments in teledermatology and promote inclusion of contemporaneous studies, with the expectation of recent studies reflecting the upsurge of teledermatology as a response to the global pandemics. The lack of robust research in the form of RCTs or meta-analysis has raised questions regarding teledermatology feasibility and accuracy, with most still using teledermatology merely as a tool for triage.

But with the ‘Third phase of NHS Response to COVID-19’ (NHS England, 2020) urging clinicians to consider avoiding physical appointments when a ‘clinically appropriate alternative’ is available, the role of triage cannot be underestimated. Mehrtens et al (2019), in their 14-year review, found that 50% of cases were discharged to the GP with advice and a further 14% booked directly for surgery, leaving only 36% to attend F2F clinic appointments. ‘Transforming elective care services: dermatology’ (NHS England, 2019) found that use of e-referral services has increased from 55% in 2017 to 73% in 2018, with only 29% of teledermatology requests resulting in a referral to secondary care. Advice and guidance support the primary care team without burdening the patient with a further appointment to secondary care, streamlining the patient pathway. This is a valuable service, but it also highlights the desperate need for education within the primary care sector.

The one aspect that all studies, both past and present, do agree on is that good quality, macroscopic and dermoscopic images are imperative to aid accurate diagnosis.

Skin cancer guidelines all look for accurate and contemporaneous diagnosis, followed by appropriate referral and discussion at the multidisciplinary team meeting. Tele-dermoscopy, when used by skilled professionals, can expedite this pathway in a manner that is agreeable for the patient and uses the local skill set supported by a remote specialist, allowing for a safe, speedy, and patient-centred service in a remote location. By adopting a digitally enhanced, resilient local delivery model, the threat to service continuity posed by operational, geographical and recruitment challenges can be reduced.

Providing a ‘complete service’ for 2-week-wait patients via remote methods is not possible, as there is the necessity for some physical examinations and procedures to be carried out. These include lymph node checks, full skin examinations, lesion biopsies and of course lesion removal, but its use can certainly reduce the number of visits to clinic appointments, streamline care and expedite those that require the most immediate attention.

In the Western Isles, the specialist nurse will clinically vet all 2-week-wait referrals, with the aim to:

• Discharge—if images provided by GP/patient are adequate to make a firm benign diagnosis
• Refer direct for excision—if images provided are adequate
• Bring the patient in for a face-to-face appointment for a physical examination and for dermoscopic images to be taken.

Images will be stored to assist in identification for treatment and future comparison if a wait-and-watch approach is deemed appropriate.

At any point of this process, if the nurse is unsure of a diagnosis, images are forwarded to a remote consultant for review via secure email.

This initial contact with the specialist nurse starts a relationship that will support the patient through diagnosis, and potentially treatment. This central nurse role is imperative to the success of the service and provides a single point of contact for patients, improving continuity of care and patient confidence, as well as reducing waiting times. We can now meet the 2-week-wait guideline timescale for 100% of urgent referrals, in contrast to the 55% that breached using the previous system.

As is the nature of research, this study will likely be outdated before the save key is struck. With many projects, such as ‘The York experience’ (Thompson, 2020), working towards formalising the optimal use of teledermatology and a more collaborative medical environment post COVID-19, the remote way of working in dermatology will soon benefit from a clearer pathway and agreed methodologies, which will lead to a safer standardised way of working remotely for all.

There is no doubt that teledermatology is part of the solution for the 2-week-wait dermatology patients, but how big a part will it play? That requires further research.

Further reading and resources

• National Outpatients Transformation Programme. Implementing safe and effective teledermatology triage pathways and processes. A teledermatology roadmap for 2020-21 v1 (via Google)
• NHS England Elective Care Transformation Programme. Transforming elective care services: dermatology. 2019. https://www.england.nhs.uk/publication/transforming-elective-care-services-dermatology/
• Scottish Government Health Delivery and Performance Directorate. The modern outpatient: a collaborative approach (2017–2020). https://www.gov.scot/publications/modern-outpatient-collabortaive-approach-2017-2020/

KEY POINTS

• COVID-19 has shone a spotlight on the use of telemedicine and has shown that remote access to healthcare is our present and our future
• Specialist nurses play a critical role in the provision of telemedicine, including in the area of dermatology and, specifically, skin cancer
• Standardisation is required to ensure quality and equality

CPD reflective questions

• Has your patient contact method changed through COVID-19, and if so, how?
• What is the evidence base to support this change?
• How do you and your patients feel about this change—what have been the advantages and disadvantages?
• Do you feel safe as a practitioner with this change?