181 GENERAL DISCUSSION care or in countries with long dermatology wait lists. This review further revealed that the Netherlands was, at the time of this review, the only country where teledermatology has been broadly integrated between primary GP care and secondary dermatology care and has been reimbursed in the healthcare system since 2006. Part II: Value of store-and-forward teledermoscopy in Dutch GP practice Part I provided an overview of teledermatology in general. Part II included three retrospective studies and zoomed in on teledermoscopy. These retrospective studies, focused on the added value of store-and-forward teledermoscopy consultations for GPs in Dutch primary care. We used data on the GP and TD self-reported teledermoscopy evaluation questions, teledermoscopy turnaround times and the provided optional GP and mandatory TD diagnoses embedded in the digital dermatology platform. Chapter 3 investigated the value of teledermoscopy by quality and performance outcomes based on data of eleven years of consultations (February 2009 – February 2020). Quality outcomes in this study were expressed as the percentage of GPs’ second opinion requests to teledermatologists (TDs), percentage of extra physical referrals after teledermoscopy, percentage of GPs following up on TDs’ referral advice, and percentages indicating whether the GP valued the teledermoscopy consultation as helpful and instructive. Performance outcomes were defined as the percentage of patients that would have been referred to the dermatologist if teledermoscopy would not have been available, the overall referral percentage in teledermoscopy, and the time GPs and TDs needed to send in and respond to a teledermoscopy consultation, respectively. We found that approximately 32% of the teledermoscopy requests concerned second opinion requests. In these consultations, GPs asked TDs for advice and indicated that they would initially not have referred these patients without the availability of teledermoscopy. In about 18% of these second opinion requests, patients were subsequently referred for a physical examination, whereas these patients would not have been seen by a dermatologist without a teledermoscopy consultation. Likewise, GPs indicated that in case the teledermoscopy service would not have been available, they would have referred about 68% of their patients to a dermatologist that GPs did finally not refer for a physical examination. These teledermoscopy consultations thus prevented unneeded physical referrals. In about 89% of the teledermoscopy consultations, the GP followed up on the TDs’ advice on patient referral, and GPs indicated that the teledermoscopy consultations were helpful (97%) and instructive (95%). Overall, about 59% of all patients were not referred by a GP after teledermoscopy consultation and GPs’ median time to send in a teledermoscopy consultation was 5.4 minutes. TDs’ median time to complete the teledermoscopy assessment was 2 minutes and their median response time to GPs was 2.4 hours. Furthermore, this study estimated that teledermoscopy halves the costs compared to a face-to-face consultation and saves €144.18 (in 2020: $164.65) in patient costs per teledermoscopy consultation. 8
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