Factors for not performing total body skin examinations in primary care in association with teledermoscopy

We conducted a retrospective cohort study to better understand the underlying factors for not performing TBSE in connection to TDS consultations in primary care. Not surprisingly, the reason that brought the patient to seek medical care impacted the risk of omitted TBSE most. Unfortunately, the risk of omitted TBSE was increased not only when the visitor’s primary purpose was non-skin related but also when patients sought consultation concerning one specific skin lesion. Furthermore, high age of the patient and female gender had a negative effect on the probability of receiving a TBSE.

The importance of performing TBSE is emphasized in several previous studies. Aldrige et al. [13] found through analysis of two prospective cohorts of patients referred from primary care to dermatology clinics, that more than 30% of detected melanomas were found upon TBSE. Similarly, a prospective, population-based cohort study in Australia found that 12% of all melanomas were incidentally detected and 35% were detected through routine skin checks [14]. In two studies from dermatology hospital clinics in Spain and the UK, as much as 26.6% and 21.7% of all detected skin cancers were detected incidentally [12]. However, these results might not be entirely applicable to the primary care setting, in which the populations are not selected on skin cancer risk. In a study from Belgium, the skin cancer detection rate per 100 screened participants did not differ between TBSE (2.3%), and LDS (3.2%) and LDS was found to be 5.6 times less time consuming [4]. Studies have also been performed on patients referred by TDS and found that 3.6–15.6% were found to have incidental skin cancers upon a face-to-face follow-up. The risk of missing skin cancers might also vary with different methods used for dermatologic teleconsultations. For example, real-time video teledermatology sessions compared with store-and-forward TDS referrals give different information. However, both these methods have in common that they will result in fewer TBSEs performed by dermatologists and thereby likely lead to a higher risk of missed skin cancer. Risk factors for having incidental skin cancers include older age (> 50), male gender, light skin phototype, having many nevi, living alone, lesion on the trunk, family history of skin cancer, personal history of skin cancer [11, 12, 15, 16].

With increasing age, this study found that the risk of omitting TBSE increased. This effect appeared in people over 59 years old, and in people over 80 years this risk was increased by 4.5 times compared to persons younger than 30 years. Furthermore, from our analyses of the referrals that lacked information on performed TBSE, this was more common for older patients, suggesting this might be an even greater risk factor than indicated by our results. In several previous skin cancer risk models, older age has been shown to be a significant factor [17, 18]. Therefore, it is particularly unfortunate that this patient group is at a higher risk of not receiving TBSE in primary care, especially in the setting of TDS which results in fewer TBSEs performed by dermatologists. We had no information on why a TBSE was more often omitted for older people. Speculatively, it might be due to time limitations since, on average, it takes longer time for older people to get undressed. To avoid missing skin cancers, this unfavorable situation must be addressed to stress the importance of TBSE already at the primary care level when managing older persons with TDS.

A performed TBSE includes examination of private body parts and the different gender combinations can influence if a TBSE is performed and whether examination of sensitive body parts is included in the TBSE. Kuraitis et al. found in a survey study of dermatology residents in America that male residents had lower exposure during training to female genital examinations, which might impact their future practice [19]. Their finding is in contrast with our study, which found that male physicians more often performed TBSE. There was neither a great impact on physician-patient gender discordance, even though the chance of having a TBSE was highest for male persons that was examined by male physicians. Importantly, male physicians were more likely not to record whether they had performed a TBSE. Therefore, these results should be cautiously interpreted. The underlying explanation for these gender differences is also difficult to discern and needs further study.

Not surprisingly, the primary reason for the visit to primary care significantly impacted the probability of getting a TBSE. We had no specific information about the possible influence of time pressure on primary care physicians during the visit that generated the TDS referral. However, the time pressure was probably higher in visits booked for other reasons than a specific skin lesion/ skin check. Time constraints are a substantial problem for most primary care physicians, with several underlying mechanisms. Firstly, the prevalence of multimorbidity and complexity of patients visiting primary care is high. In a prior study, nine out of ten persons had more than one chronic condition and the prevalence of multimorbidity increased with age [20]. Secondly, the organization of primary care with different financial incentives to reduce hospital-based health care, impacts primary care in different ways. In Sweden, the primary health care system was reformed in 2009, introducing a free choice of provider for the population in combination with freedom of establishment for private primary care providers [21]. Gradually all regions in Sweden now have a reimbursement system promoting that all health issues of a patient are managed during as few visits as possible. As a consequence, Swedish primary care physicians tend to deal with skin lesions brought to their attention during a visit for other primary purposes. Presumably, this results in too little time to perform TBSEs. In addition, to save time and if patients seek advice in primary care for one specific skin lesion, traditionally the standard care has been only to examine this particular lesion. In an era of increasing management of patients through e-health, the usual methods of examining patients must be re-evaluated and evidence-based. Failure to perform TBSE in primary care, especially in the setting of TDS, carries an obvious risk of missing skin cancer. This risk is particularly unfavourable for patients at high risk of skin cancer, for example persons with fair skin types, older age, male gender, living alone, prior skin cancer (including a malignant index skin lesion), severely sun damaged skin, many nevi, and heredity for skin cancer. However, suggesting performing a TBSE for all patients managed with TDS would not be cost-effective. We therefore argue that consideration of risk factors for incidental skin cancer should be taken into account when managing patients with TDS, to determine the need for TBSE. For high-risk patients (for example older patients with a suspicious index lesion or a history of skin cancer) that ask for an assessment of a skin lesion during a visit for another primary reason (such as hypertension), primary care physicians might serve the patient better by setting up a new visit that allows for TBSE in conjunction with TDS. These secondary effects on health care systems of implementing tele-health services, such as performing TBSE in primary care instead of in specialized dermatology care, should be considered during the implementation’s planning phase. Required resource allocation to the affected stakeholders should be analysed before implementing the system.