95 TO REFER OR NOT TO REFER IN TELEDERMOSCOPY forward telemedicine provider in the Netherlands, the overall number of teledermoscopy consultations in the Netherlands might be higher. The fourth limitation is that no data concerning the histopathological diagnoses were available for our study. In practice, it is considered unethical to acquire, purely for research purposes, the histopathology of patients with benign skin lesions who not have been referred by the GP to the dermatologist (Q1=No and Q2=No; Q1=Yes and Q2=No). Vestergaard et al [6] showed in a pilot study that patients are reluctant to travel to the dermatologist for assessment of a supposedly benign skin lesion, and GPs are not willing to refer these patients to a dermatologist. Due to the retrospective nature of our study, it was not possible to obtain histopathological data of patients with skin lesions that were referred to dermatology care after the teledermoscopy consultation (Q1=Yes and Q2=Yes; Q1=No and Q2=Yes). We can only presume that GPs would have immediately referred patients to the dermatologist if patients had skin lesions that were highly suspect of melanoma or dubious. CONCLUSIONS This study showed that GPs adjusted their initial referral decision of patients with skin lesions in half of the studied teledermoscopy consultations after the TD assessment. The availability of teledermoscopy remains thus of added value to support GPs in gatekeeper health care systems in their decision to refer patients to a dermatologist for an in-person consultation. This study has shown that GPs initially did not intend to refer patients with (pre)malignant skin lesions for an in-person dermatological consultation and that the availability of teledermoscopy aids in the referral of these patients. In addition, teledermoscopy supports GPs in the prevention of unnecessary physical referrals to the dermatologist for patients with low-complex benign skin lesions (e.g., seborrheic keratosis and vascular skin lesions), easing the burden on dermatology care. ACKNOWLEDGMENTS The authors would like to thank Dr JP van der Heijden for reviewing the manuscript. 5
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