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Industry: Email Alert RSS FeedMulticentre 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
The actual costs of the teledermatology consultation were calculated over one year, thus the high capitol cost of the equipment and the low use (an average of 25.5 patients per health centre in one year) did not make the system economically viable in this trial.
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The sensitivity analyses showed that increased use of the system improved its cost effectiveness. The equipment used in the study was purchased in 1995, and these were the prices used for analysis. Current prices for similar equipment of the same standard have fallen by almost 40%, which would reduce costs. In the trial the patient was always presented to the dermatologist by a general practitioner, which increased the costs of the teledermatology consultation. One possibility for reducing costs would be to use a nurse practitioner instead of the general practitioner. Sensitivity analysis showed that if each health centre in the trial allocated one morning session a week to telemedicine and a nurse practitioner presented the patients to the specialist using equipment at current prices, the cost of the teleconsultation was 54.18 [pounds sterling] per patient compared with the conventional cost of 48.73 [pounds sterling] per patient. The cost of teleconsultation is still higher because if a nurse practitioner is used because the general practitioner could not apply knowledge gained in the teleconsultations to other patients. If the average round trip distance to hospital was increased from 27 km to 38 km, the costs of the nurse practitioner presenting the patient over the videolink would have been equal to the conventional hospital outpatient appointment.
Factors not included in study
Some of the factors affecting the cost of teledermatology were not included in the trial design (box). For instance, long hospital waiting lists are common for non-urgent skin appointments. This implies that patients may be paying for interim treatments and losing time from work while waiting for specialist consultations. In addition, not all benefits can be measured in monetary terms--for example, greater convenience for the patient and greater job satisfaction for the general practitioner. The teleconsultations offer unique educational benefits as continuing medical education training courses do not normally use real patients. Finally, we have considered the costs of only the initial consultation; we have not taken into account the costs of the return visits or the fact that there were fewer return visits in the teledermatology group. All these factors bias the results against telemedicine.
In the context of this research trial, teledermatology was not cost effective for society in comparison with the conventional alternative. However, distances to hospital were relatively short and use of the equipment was low; had each health centre seen 12 patients a week and the patients lived an average of 40 km from the hospital, teledermatology would have been as cheap. Other factors, such as cheaper equipment, would also improve the relative economics for telemedicine. Nevertheless it is clear that, although real time teledermatology is both clinically effective and economic in the appropriate circumstances, it is not likely to be useful in large cities, except possibly for secondary-to-tertiary consulting or for educational use. Its place in the overall management of dermatology patients from primary care, and indeed the place of pre-recorded teledermatology ("store-and-forward") remains to be established in future trials.
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