Family Practice Vol. 21, No. 1, 54-56
© Oxford University Press 2004, all rights reserved.
Article |
A randomized controlled trial using instant photography to diagnose and manage dermatology referrals
Departments of a General Practice and b Epidemiology and Public Health, Queen's University and c Department of Dermatology, Royal Victoria Hospital, Belfast, UK
Correspondence to Dr Paul Leggett, c/o Department of General Practice, Queen's University, 1 Dunluce Avenue, Belfast BT9 7HR, UK; E-mail: drpfl{at}doctors.org.uk
Received 17 February 2003; Revised 15 July 2003; Accepted 8 September 2003.
Leggett P, Gilliland AEW, Cupples ME, McGlade K, Corbett R, Stevenson M, O'Reilly D and Steele K. A randomized controlled trial using instant photography to diagnose and manage dermatology referrals. Family Practice 2004; 21: 54–56.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
Background. Fifteen percent of GP consultations are for dermatological conditions; 4% of these are referred to a dermatologist. There are long waiting lists for dermatology appointments. This study examines the value of instant photography in managing dermatology referrals.
Objective. The purpose of our study was to compare outcomes of referral for dermatology appointments between patients whose referral letters do or do not include instant photograph(s).
Methods. Patients (136), referred to a dermatologist by GPs in two urban health centres, were randomly allocated to study and control groups. Instant photographs, taken by the GP, were included in the referral letters. Control group patients were given out-patient appointments in the usual way. The numbers of study group patients needing an appointment for diagnosis or management and with a changed diagnosis after face-to-face consultation were recorded. Waiting time from referral to appointment or management plan was recorded for both groups.
Results. For 63% of the study group (45/71), a diagnosis and a management plan were made without the patient requiring an appointment. This included 38% (27/71) who, after diagnosis and initial management, needed an appointment and 25% (18/71) who did not. The remainder of the study group (37%; 26/71) required a face-to-face consultation. The mean time for formulation of a management plan for patients without an appointment was 17 days (SD = 11); waiting times for appointments in study and control groups were similar (mean 55 days; SD = 40).
Conclusions. Instant photography is helpful in managing dermatology referrals and offers the potential to reduce numbers requiring an out-patient appointment by 25%.
Keywords. Dermatology, instant photograph, telemedicine.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Approximately 15% of all GP consultations in the UK are for dermatological conditions; 4% of these need secondary referral.1 Several studies have demonstrated that real-time teledermatology using a video link is a feasible alternative to an out-patient appointment but not cost-effective or readily available.2,3 Instant photography, however, is readily available. Most studies testing its value in managing dermatological conditions have involved medical photographers and trainee dermatologists.4 We aimed to assess the value of including photographs taken by GPs with dermatology referral letters and to minimize selection bias by using a randomized controlled study design.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
All 20 GPs in five practices, located near a major teaching hospital, were invited to participate; all agreed. Patients were referred from 10 GPs, none of whom had special dermatological expertise. One camera (Instant Macro 3 SLR: £440; Defeatured Instant film: £1/photograph) was placed in each practice. GPs were trained for 15 min in its use.
All patients who required referral to a dermatologist were eligible for inclusion. Those who had attended hospital with the same condition previously or requested referral to a non-participating clinician, hospital removal of skin lesion(s) or a private appointment were excluded.
Written informed consent was obtained. The GP took photograph(s) of the skin condition and sent them with a referral letter to the dermatologist in a numbered, sealed envelope. The numbers previously were allocated randomly to study and control groups using a computer program. Group allocations were only revealed at hospital where photographs were removed from control group letters and appointments were made as usual.
Study group letters with photographs were sent to the dermatologist. If a diagnosis was not possible, patients were given an appointment. If diagnosis was possible, a letter was sent to the GP with advice on management: some patients were also given an appointment for further management.
The time from referral to appointment, or formulation of management plan if not given an appointment, was recorded for both groups. GP records of patients not seen by the dermatologist were reviewed by PL 6 months after referral to determine their well-being. Patients who had not consulted were contacted by their GP.
Pilot work suggested that 67 patients were required in each of two groups to detect a 30% reduction in numbers needing appointments (90% power; alpha level = 5%). SPSS (version 9) was used to compare time (days) from referral to management plan formulation/ appointment between groups: log transformation was used because of skewness of waiting times. The effect of age and gender on outcomes was tested using logistic regression.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Study and control groups were similar in age (range: 5 months–94 years; mean 38.5 years, SD 23.2), gender [55 (40%) male; 81 (60%) female], numbers of patients not attending appointments and range of diagnoses (Table 1).
|
Within the two largest practices, 104 of 120 referrals (87%) to dermatology during the study period were included. Most referrals included two photographs.
Diagnosis was possible for 63% (45/71) of the study group, but 27 of these required a face-to-face consultation for further management (e.g. for surgical excision). Of these, 20 attended their appointment and the diagnosis changed for only one (from psoriasis to eczema). ‘Photo-diagnosis’ was possible for the majority of cases of eczema, naevi, psoriasis and skin cancers, but for a minority of keratotic, infective and miscellaneous conditions (Table 1). A diagnosis and management plan was made for 25% (18/71) without a need for direct consultation. Logistic regression confirmed that this finding was not related to the patient's age or gender.
For 37% (26/71) of the study group, a diagnosis was not possible without a consultation because of insufficient clarity of photographic or clinical detail.
The mean waiting time for appointments was 55 days (SD 40), with no significant difference between the various categories of patients (P > 0.05, Table 1). For patients not needing an appointment, the time for formulation of a management plan was significantly less (17 days, SD 11; P < 0.001).
GP records of the 18 patients who were not offered an appointment were reviewed 6 months after referral. Records were not available for four who had moved to another GP; in all other cases, the condition requiring referral had resolved.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
This study shows that referrals which include instant photographs taken by a GP allow a dermatologist to advise appropriate management in >60% of cases without seeing the patient face-to-face. Of the study group, 25% were managed without an appointment; a further 38% may have been saved at least one out-patient attendance as initial management was advised without a consultation.
The randomized controlled design minimized selection bias and allowed comparisons with a control group of ‘normal’ referrals. The quality check indicates the applicability of the findings. However, whilst the study allowed follow-up by the dermatologist, it involved only one dermatologist: this avoided inter-observer variability but limits the generalizability of the findings.
Our study is complementary to that of Loane et al.5 who reported that 31% of GP referrals could be managed using instant photography without a face-to-face consultation. They used a repeated measures design and did not allow follow-up by the dermatologist or provide a measure of selection bias.
A recent review of teledermatology concluded that store and forward systems using digital images offer high levels of diagnostic accuracy but involve delays in obtaining information and are costly.6 Our findings indicated that when ‘photo-diagnosis’ was possible but patients required a face-to-face consultation, the diagnosis was confirmed in most cases. This suggests that accurate diagnosis is possible using clinical information supplemented with photography. Furthemore, if a ‘photo-diagnosis’ is possible, the time to formulation of a management plan is significantly shorter than if an appointment is required. No time delay was found in comparison with the conventional referral process.
We suggest that instant photography offers a straightforward alternative for GPs who have not embraced digital technology. The inclusion of instant photograph(s) with dermatology referral letters offers a potential reduction in the numbers of patients needing out-patient appointments. Further studies are required to determine the generalizability of these findings and their applicability to different clinical conditions.
|
Acknowledgments |
|---|
PL was supported in this work by a research grant from the Royal College of General Practitioners. The instant cameras and film were provided free of charge by Polaroid (UK) Ltd.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
1 Royal College of General Practitioners. Morbidity Statistics from General Practice. Fourth National Study 1991–1992. London: HMSO; 1995: 54–56.
2 Oakley AM, Astwood DR, Loane M et al. Diagnostic accuracy of teledermatology: results of a preliminary study in New Zealand. NZ Med J 1997; 110: 51–53.
3 Wootton R, Bloomer SE, Corbett R et al. Multicentre randomised controlled trial comparing real time teledermatology with conventional outpatient dermatological care: societal cost benefit analysis. Br Med J 2000; 320: 1252–1256.
4 Lyon CC, Harrison PV. Diagnostic imaging and teledermatology: educational and diagnostic applications of a portable digital imaging system for the trainee dermatologist. Clin Exp Dermatol 1997; 22: 163–165.[Medline]
5 Loane MA, Bloomer SE, Corbett R et al. A comparison of real-time and store-and-forward teledermatology: a cost–benefit study. Br J Dermatol 2000; 143: 1241–1247.[CrossRef][Web of Science][Medline]
6 Eedy DJ, Wootton R. Teledermatology: a review. Br J Dermatol 2001; 144: 696–707.[CrossRef][Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  F. Sullivan, C. Butler, M. Cupples, and A.-L. Kinmonth Primary care research networks in the United Kingdom BMJ, May 26, 2007; 334(7603): 1093 - 1094. [Full Text] [PDF]
|
|
|
|
 |
|
 B. Starfield, K. W. Lemke, R. Herbert, W. D. Pavlovich, and G. Anderson Comorbidity and the Use of Primary Care and Specialist Care in the Elderly Ann. Fam. Med, May 1, 2005; 3(3): 215 - 222. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 V. English, R. Mussell, J. Sheather, and A. Sommerville Ethics briefings J. Med. Ethics, June 1, 2004; 30(3): 329 - 330. [Full Text] [PDF]
|
|
|
|
|
|
R. Dobson Photo diagnosis can cut waiting times for dermatology BMJ, February 14, 2004; 328(7436): 367. [Full Text]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||