An Exploration of Dutch Dermatologists' Experience and Satisfaction With Teledermatology: Sociotechnical and Complex Adaptive System Perspective.

BACKGROUND: Despite the global upscale of teledermatology during the COVID-19 pandemic, persistent barriers, such as the poor anamnesis and photo quality, hinder its effective use in practice. Understanding Dutch dermatologists' experiences and satisfaction with using the teledermatology system in the Dutch health care system is needed. A holistic evaluation may provide valuable insight to understand how barriers interrelate which is deemed necessary for the innovation of teledermatology in practice. OBJECTIVE: Guided by a complex adaptive system perspective, this study aims to understand Dutch dermatologists' experience and satisfaction with their training, support communication, interaction, and usage of a teledermatology platform of a Dutch digital hospital during the COVID-19 pandemic, uncovering insights to improve teledermatology services for the future. METHODS: A web-based questionnaire was sent in December 2021 to Dutch dermatologists who (1) had an active teledermatology platform account, and (2) responded to a teledermatology consultation between October 1, 2019, and September 30, 2021. The questionnaire consisted of the validated Store-and-Forward Telemedicine Service User-satisfaction Questionnaire (SAF-TSUQ) questionnaire, and new questions regarding; demographics of teledermatologists, the use of teledermatology during the COVID-19 pandemic, the performance of teledermatology by general practitioners (GP), and the role of dermatologists in the teledermatology process. The open-ended questions were analyzed by a grounded theory approach guided by a sociotechnical model and complemented by a complex adaptive system perspective. A panel discussion with 3 dermatologists was performed to provide additional insight into the responses to the questionnaire. RESULTS: We obtained responses from 25 out of the 249 (10%) invited dermatologists. Overall, dermatologists had a positive experience with teledermatology. Interestingly, teledermatology use frequency remained unaffected by the COVID-19 pandemic. However, the insufficient quality and incompleteness of the clinical content (photos and anamneses information) of the teledermatology consultation impacted the efficiency of the teledermatology workflow. Dermatologists expressed the need for improvement to avoid time-consuming processes or physical referrals. The panel discussion enriched and confirmed the responses, suggesting solutions like mandatory fields for the GPs for a complete anamnesis. CONCLUSIONS: Dutch Dermatologists view teledermatology as a valuable tool to provide access to dermatology care. However, improvements regarding the quality and completeness of the provided clinical content are necessary for the effectiveness and efficiency of the complex teledermatology system in Dutch health care. This could increase both the dermatologists' satisfaction and the quality of teledermatology services. Managing trade-offs, such as time investments versus image quality, is crucial for teledermatology implementation and should be assessed from a complexity perspective to understand trade-offs and prevent unintended consequences.

To Refer or Not to Refer in Teledermoscopy: Retrospective Study.

BACKGROUND: Challenges remain for general practitioners (GPs) in diagnosing (pre)malignant and benign skin lesions. Teledermoscopy (TDsc) supports GPs in diagnosing these skin lesions guided by teledermatologists' (TDs) diagnosis and advice and prevents unnecessary referrals to dermatology care. However, the impact of the availability of TDsc on GPs' self-reported referral decisions to dermatology care before and after the TDsc consultation is unknown. OBJECTIVE: The objective of this study is to assess and compare the initial self-reported referral decisions of GPs before TDsc versus their final self-reported referral decisions after TDsc for skin lesions diagnosed by the TD as (pre)malignant or benign. METHODS: TDsc consultations requested by GPs in daily practice between July 2015 and June 2020 with a TD assessment and diagnosis were extracted from a nationwide Dutch telemedicine database. Based on GP self-administered questions, the GPs' referral decisions before and their final referral decision after TDsc consultation were assessed for (pre)malignant and benign TD diagnoses. RESULTS: GP self-administered questions and TD diagnoses were evaluated for 6364 TDsc consultations (9.3% malignant, 8.8% premalignant, and 81.9% benign skin lesions). In half of the TDsc consultations, GPs adjusted their initial referral decision after TD advice and TD diagnosis. Initially, GPs did not have the intention to refer 67 (56.8%) of 118 patients with a malignant TD diagnosis and 26 (16.0%) of 162 patients with a premalignant TD diagnosis but then decided to refer these patients after the TDsc consultation. Furthermore, GPs adjusted their decision from referral to nonreferral for 2534 (74.9%) benign skin lesions (including 676 seborrheic keratosis and 131 vascular lesions). CONCLUSIONS: GPs adjusted their referral decision in 52% (n=3306) of the TDsc consultations after the TD assessment. The availability of TDsc is thus of added value and assists GPs in their (non)referral for patients with skin lesions to dermatology care. TDsc resulted in referrals of patients with (pre)malignant skin lesions that GPs would not have referred directly to the dermatologist. TDsc also led to a reduction of unnecessary referrals of patients with low complex benign skin lesions (eg, seborrheic keratosis and vascular lesions).

The Value of Teledermoscopy to the Expertise of General Practitioners Diagnosing Skin Disorders Based on ICD-10 Coding.

Early recognition of skin cancer is vital to enhance patient outcomes. Teledermoscopy (TDsc), a telemedicine service, supports general practitioners (GPs) in gaining fast access to dermatologists' feedback to detect skin cancer. This study aimed to assess if GPs gain expertise in diagnosing skin disorders after continued use of TDsc, based on diagnosis classification by the International Statistical Classification of Diseases and Related Health Problems (ICD-10). A retrospective study was conducted on TDsc consultations sent by GPs to teledermatologists in the Netherlands (July 2015 - June 2018). GP sensitivity and confirmed cases in diagnosing skin disorders slightly increased over time. However, the total positive predictive value showed a decrease. In three years, 43 melanomas were diagnosed by the TD for which the GP did not provide a (correct) pre-diagnose. Though GPs appear to improve their expertise in skin disorder detection after continued TDsc use, TDsc remains imperative to early melanoma detection.

Is Teledermoscopy Improving General Practitioner Skin Cancer Care?

Skin cancer incidences have tripled in the Netherlands for the last twenty years and are expected to increase even more in the coming years. Teledermoscopy (TDsc) is implemented in Dutch practice to support and enhance early skin cancer detection by general practitioners (GPs) through remote consultation with dermatologists. This study assesses the effect of TDsc consultation on the quality and efficiency of skin cancer care in the primary setting by analyzing 10,184 TDsc consultations.

Cow's milk allergy in Dutch children: an epigenetic pilot survey.

BACKGROUND: Cow's milk allergy (CMA) is a common disease in infancy. Early environmental factors are likely to contribute to CMA. It is known that epigenetic gene regulation can be altered by environmental factors. We have set up a proof of concept study, aiming to detect epigenetic associations specific with CMA. METHODS: We studied children from the Dutch EuroPrevall birth cohort study (N = 20 CMA, N = 23 controls, N = 10 tolerant boys), age and gender matched. CMA was challenge proven. Bisulfite converted DNA (blood) was analyzed using the 450K infinium DNA-methylation array. Four groups (combined, girls, boys and tolerant boys) were analysed between CMA and controls. Statistical analysis and pathway-analysis were performed in "R" using IMA, Minfi and the global-test package. Differentially methylated regions in DHX58, ZNF281, EIF42A and HTRA2 genes were validated by quantitative amplicon sequencing (ROCHE 454(®)). RESULTS: General hypermethylation was found in the CMA group compared to control children, while this effect was absent in the tolerant group. Methylation differences were, among others, found in regions of DHX58, ZNF281, EIF42A and HTRA2 genes. Several of these genes are known to be involved in immunological pathways and associated with other allergies. CONCLUSION: We show that epigenetic associations are involved in CMA. Although, the statistical power of our study is limited and our sample was based on whole blood, we were still able to detect feasible loci and pathways. Therefore our findings might contribute to future diagnostic or therapeutic interventions for specific CMA. Further studies have to confirm the findings of our study.

Genetic susceptibility for cow's milk allergy in Dutch children: the start of the allergic march?

BACKGROUND: Cow's milk allergy (CMA) is the most common allergic disease in infancy. It is not clear, whether infants with CMA have an increased risk of developing other allergic diseases later in life, the so-called "allergic march". We aimed to detect genetic associations of CMA using reported single nucleotide polymorphisms (SNP) in other allergic diseases and genetic mutations within the filaggrin (FLG) gene. Both to investigate possible causes of CMA, which also suggests an "allergic march". METHODS: Thirty children from the Dutch EuroPrevall birth cohort study with CMA in infancy and twenty-three healthy controls were studied. Six candidate SNPs were selected (minor allele frequency 10-50 % combined with a large effect) based on the literature. Thirteen FLG candidate mutations were selected spread over repeats 1, 3, 4, 5, 6, 7, 9 and 10 respectively. RESULTS: We found two SNP's, rs17616434 (P = 0.002) and rs2069772 (P = 0.038), significantly associated with CMA. One is located near the toll like receptor 6 (TLR6) gene, which functionally interacts with toll-like receptor 2, and is associated with an increased risk of other allergic diseases. One is located at the Interleukin 2 (IL2) locus. Twelve FLG amplicons were analyzed, but showed no significant enrichment. Nevertheless, we did observe more FLG mutations in the CMA-group compared to controls. CONCLUSION: We significantly associated two SNPs with CMA, suggesting that variation in the TLR6 and IL2 genes contribute to the expression of CMA. In addition, since TLR6 and IL2 were earlier associated with other later onset allergies, this also favours the "allergic march" hypothesis. We observed more FLG mutations in the CMA-group, albeit we found no statistical significant enrichment of FLG mutations. Further studies are necessary to investigate the role of common variants and FLG or other skin barrier gene mutations in CMA.