PracticeUpdate: Dermatology - Winter 2018

EDITOR’S PICKS 11

Cost-Effectiveness of Skin Cancer Referral and Consultation Using Teledermoscopy in Australia JAMA Dermatology Take-home message

Abstract IMPORTANCE International literature has shown that teledermoscopy referral may be a via- ble method for skin cancer referral; however, no economic investigations have occurred in Australia. OBJECTIVE To assess the cost-effectiveness of teledermoscopy as a referral mechanism for skin cancer diagnosis and management in Australia. DESIGN, SETTING, AND PARTICIPANTS Cost-effec- tiveness analysis using a decision-analytic model of Australian primary care, informed by publicly available data. INTERVENTIONS We compared the costs of teledermoscopy referral (electronic referral containing digital dermoscopic images) vs usual care (a written referral letter) for specialist der- matologist review of a suspected skin cancer. MAIN OUTCOMES AND MEASURES Cost and time in days to clinical resolution, where clinical resolution was defined as diagnosis by a der- matologist or excision by a general practitioner. Probabilistic sensitivity analysis was performed to examine the uncertainty of the main results. RESULTS Findings from the decision-analytic model showed that the mean time to clinical resolution was 9 days (range, 1-50 days) with teledermoscopy referral compared with 35 days (range, 0-138 days) with usual care alone (dif- ference, 26 days; 95% credible interval [CrI], 13-38 days). The estimated mean cost difference between teledermoscopy referral (A$318.39) vs usual care (A$263.75) was A$54.64 (95% CrI, A$22.69-A$97.35) per person. The incremen- tal cost per day saved to clinical resolution was A$2.10 (95% CrI, A$0.87-A$5.29). CONCLUSIONS AND RELEVANCE Using teleder- moscopy for skin cancer referral and triage in Australia would cost A$54.64 extra per case on average but would result in clinical resolution 26 days sooner than usual care. Implementation recommendations depend on the preferences of the Australian health system decision mak- ers for either lower cost or expedited clinical resolution. Further research around the clinical significance of expedited clinical resolution and its importance for patients could inform imple- mentation recommendations for the Australian setting. Cost-Effectiveness of Skin Cancer Referral and Consultation Using Teledermoscopy in Australia. JAMA Dermatol 2018 May 09;[EPub Ahead of Print], CL Snoswell, LJ Caffery, JA Whitty, et al. www.practiceupdate.com/c/68079

• This study compared the estimated cost as well as time to clinical resolution of patients referred to dermatologists by a traditional referral letter versus a teleder- moscopic referral. Clinical resolution was defined as either clinical diagnosis by a dermatologist or excision of the lesion in question by a general practitioner (GP). Referral via teledermoscopic images resulted in clinical resolution 26 days faster than traditional referral. However, teledermoscopic referral cost an average of AUD 54.64 more per case than traditional referral. The authors suggested that additional costs were likely avoided using teledermoscopic referral by preventing unnecessary excisions by GPs as well as better triaging patients who needed to be managed by a dermatologist versus those who could be managed well by their referring GP. • The authors found that teledermoscopic referrals to dermatologists by general practitioners can result in faster clinical resolution but higher referral costs for patients with suspicious skin lesions. Caitlyn T. Reed MD

COMMENT By Robin P. Gehris MD T his article acknowledges the need to more accurately triage dermatol- ogy referrals. Because melanoma represents more than 10% of all reported cancers in Australia, this was an ideal study population. This was also a great place to study the cost-effectiveness of teledermoscopy because the govern- ment health system places a high value on teledermatology, reimbursing live interactive tele-visits at a rate of 1.5% higher than in-office visits. The goal of teledermoscopy is to expedite in-office evaluation and man- agement of potentially atypical skin lesions and avoid wasting precious der- matology schedule slots for patients with benign-appearing skin lesions. Even though preferential reimbursement does not yet exist for asynchronous, or store- and-forward visits, the authors chose to use a store-and-forward system initiated by the primary care provider because of its efficiency. Dermoscopic images were sent along with clinical information to the dermatologist. The measurable endpoint they used was clinical resolution either by dermatology diagnosis or by excision of the lesion by the primary physician. In concordance with many other studies of

teledermoscopy, there was an increased cost per patient of $54. The study did succeed, however, in reducing the time to clinical resolution by a mean of 26 days. The other cost savings proposed, but not quantified, was the avoidance of biop- sying or excising benign-appearing skin lesions in the primary care offices. It is imperative to stress to government and private payers that a delay in diag- nosis or excision of almost 1 month could lead to poorer clinical outcomes. This would be expected to lead to an increase in morbidity to the patient and costs to the system. This must be weighed against not only the cost of teledermoscopy noted above but also the cost of training and providing dermatoscopes to primary care physicians. Thus, studies considering a broader range of costs and benefits will be needed before teledermoscopy can be broadly recommended.

Dr. Gehris is Chief of Pediatric Dermatology, Medical Director of Pediatric Teledermatology and Founding Member of the Pediatric Melanoma Group at UPMC Children’s

Hospital of Pittsburgh in Pittsburgh, Pennsylvania.

VOL. 2 • NO. 3 • 2018