Multicentre randomised control trial comparing real time teledermatology with conventional outpatient dermatological care: societal cost-benefit analysis

British Medical Journal, May 6, 2000 by R Wootton, S E Bloomer, R Corbett, D J Eedy, N Hicks, H E Lotery, C Mathews, J Paisley, K Steele, M A Loane

Abstract

Objectives Comparison of real time teledermatology with outpatient dermatology in terms of clinical outcomes, cost-benefits, and patient reattendance.

Design Randomised controlled trial with a minimum follow up of three months.

Setting Four health centres (two urban, two rural) and two regional hospitals.

Subjects 204 general practice patients requiring referral to dermatology services; 102 were randomised to teledermatology consultation and 102 to traditional outpatient consultation.

Main outcome measures Reported clinical outcome of initial consultation, primary care and outpatient reattendance data, and cost-benefit analysis of both methods of delivering care.

Results No major differences were found in the reported clinical outcomes of teledermatology and conventional dermatology. Of patients randomised to teledermatology, 55 (54%) were managed within primary care and 47 (46%) required at least one hospital appointment. Of patients randomised to the conventional hospital outpatient consultation, 46 (45%) required at least one further hospital appointment, 15 (15%) required general practice review, and 40 (39%) no follow up visits. Clinical records showed that 42 (41%) patients seen by teledermatology attended subsequent hospital appointments compared with 41 (40%) patients seen conventionally. The net societal cost of the initial consultation was 132.10 [pounds sterling] per patient for teledermatology and 48.73 [pounds sterling] for conventional consultation. Sensitivity analysis revealed that if each health centre had allocated one morning session a week to teledermatology and the average round trip to hospital had been 78 km instead of 26 km, the costs of the two methods of care would have been equal.

Conclusions Real time teledermatology was clinically feasible but not cost effective compared with conventional dermatological outpatient care. However, if the equipment were purchased at current prices and the travelling distances greater, teledermatology would be a cost effective alternative to conventional care.

Introduction

As part of the government's commitment to modernise the NHS, telemedicine is to be implemented within the health service where there is clinical need and evidence supporting its cost effectiveness.[1] In the United Kingdom dermatology accounts for about 15% of consultations in general practice, with 4% of these patients referred for specialist advice.[2] The ratio of dermatologists to population (1:217 000) is lower than for many other medical specialties in Britain[3] and three times lower than in the rest of Europe.[4] The UK multicentre teledermatology trial is evaluating the use of real time telemedicine for delivering dermatological health care.

The diagnostic accuracy and management efficacy of videolink consultations have been shown acceptable compared with conventional hospital consultations.[5-10] In our multicentre trial the videolink diagnosis agreed with the face-to-face diagnosis in two thirds of cases.[7] There was no diagnostic agreement in 6% of cases, which is comparable with the differences in diagnosis made by two practitioners with differing levels of experience in a normal dermatology outpatient clinic. Clinical management advice given by videolink agreed with the face-to-face advice in 64% of cases. The videolink management plan was judged to be inappropriate in 9% of cases, which again may reflect the differences that exist between dermatologists in normal outpatient departments. Patient satisfaction with teledermatology consultations has also been favourable.[11]

Real time teledermatology is less time consuming and less expensive for patients because they are seen at the local health centre rather than at hospital. Patients required less time off work to attend the appointment, travelled shorter distances, and were seen more quickly compared with those who were seen by the dermatologist at the outpatient clinic.[12] To date no studies have examined the cost effectiveness of real time teledermatology from a societal or healthcare provider's perspective.

The present multicentre randomised controlled trial aimed to evaluate the health outcomes and cost-benefits of teledermatology compared with conventional outpatient dermatological care from a societal viewpoint.

Participants and methods

Design

We conducted a randomised controlled trial designed to measure the cost effectiveness of real time teledermatology in Northern Ireland. Two hospital dermatology departments and four health centres took part. Two of the health centres were located in rural areas and two in urban areas. Patient outcomes and cost-benefits of teledermatology consultations were compared with patient outcomes and cost-benefits of hospital outpatient dermatology consultations. Each hospital allocated a weekly session for teledermatology and a similar session for conventional outpatient appointments. Ethical approval was obtained from the appropriate committee.

Sample size calculations showed that a sample size of 200 had a power of 80% to detect a standardised difference of 0.4 at the 0.05 significance level.[13]