背景:需要长期监测的黑色素瘤患者的数量越来越多,超过了皮肤科劳动力的能力,特别是在大都市以外。使患者能够进行皮肤自我检查并将关注的病变的皮肤镜图像发送给皮肤科医生的数字技术(移动远端皮肤镜)是一种潜在的解决方案。如果要将这些技术和黑色素瘤远程监测纳入常规临床实践,它们需要被提供黑色素瘤治疗的临床医生接受,例如皮肤科医生和全科医生(GP)。
目的:本研究旨在探讨对移动皮肤镜检查的潜在益处和危害的看法,以及这项技术的经验,参与一项以患者为主导的黑色素瘤监测的随机对照试验(RCT)的临床医师.
方法:这项定性研究嵌套在新南威尔士州皮肤科医生和皮肤专家GP主导的黑色素瘤诊所进行的试点RCT中,澳大利亚。我们对参与试验的11名临床医生中的8名进行了半结构化访谈,包括4名皮肤科医生(3名提供了远程皮肤科,2名正在治疗临床医生),1名外科肿瘤学家,和3名具有皮肤癌筛查资格的全科医生(其余3名全科医生拒绝面试)。参考“医疗过度使用”和“高价值护理”的概念,使用主题分析来分析数据。\"
结果:临床医生发现了几个潜在的好处,包括增加获得皮肤科服务的机会,早期检测到黑色素瘤,在预定的就诊之间为患者提供安慰,减少不必要的诊所就诊。然而,他们还发现了一些关于使用该技术和远程监测可能导致诊断不确定性的潜在问题.这些包括图像质量差,难以从2D数字图像进行评估(即使质量很好),提供的临床病史不足,并担心患者可能遗漏了可疑病变。临床医生认为这些担忧带来的不确定性,加上错过诊断的潜在法医学后果,可能导致不必要的诊所就诊和程序增加。建议实现高价值护理的策略包括管理临床不确定性,以减少医疗过度使用的可能性,并确保在现有临床护理路径中最佳放置患者主导的远程皮肤镜检查,以增加潜在的收益。
结论:临床医生对移动皮肤镜检查的潜在和经验益处充满热情;然而,管理临床不确定性对于在试验环境之外的临床护理中实现这些益处并将医疗过度使用的潜在危害降至最低是必要的.
背景:澳大利亚和新西兰临床试验注册ACTRN12616001716459;https://anzctr.org。au/Trial/Registration/TrialReview.aspx?id=371865。
BACKGROUND: The growing number of melanoma patients who need long-term surveillance increasingly exceeds the capacity of the dermatology workforce, particularly outside of metropolitan areas. Digital technologies that enable patients to perform skin self-examination and send dermoscopic images of lesions of concern to a dermatologist (mobile teledermoscopy) are a potential solution. If these technologies and the remote delivery of melanoma surveillance are to be incorporated into routine clinical practice, they need to be accepted by clinicians providing melanoma care, such as dermatologists and general practitioners (GPs).
OBJECTIVE: This
study aimed to explore perceptions of potential benefits and harms of mobile teledermoscopy, as well as experiences with this technology, among clinicians participating in a pilot randomized controlled
trial (RCT) of patient-led melanoma surveillance.
METHODS: This qualitative
study was nested within a pilot RCT conducted at dermatologist and skin specialist GP-led melanoma clinics in New South Wales, Australia. We conducted semistructured interviews with 8 of the total 11 clinicians who were involved in the
trial, including 4 dermatologists (3 provided teledermatology, 2 were treating clinicians), 1 surgical oncologist, and 3 GPs with qualifications in skin cancer screening (the remaining 3 GPs declined an interview). Thematic analysis was used to analyze the data with reference to the concepts of \"medical overuse\" and \"high-value care.\"
RESULTS: Clinicians identified several potential benefits, including increased access to dermatology services, earlier detection of melanomas, reassurance for patients between scheduled visits, and a reduction in unnecessary clinic visits. However, they also identified some potential concerns regarding the use of the technology and remote monitoring that could result in diagnostic uncertainty. These included poor image quality, difficulty making assessments from a 2D digital image (even if good quality), insufficient clinical history provided, and concern that suspicious lesions may have been missed by the patient. Clinicians thought that uncertainty arising from these concerns, together with perceived potential medicolegal consequences from missing a diagnosis, might lead to increases in unnecessary clinic visits and procedures. Strategies suggested for achieving high-value care included managing clinical uncertainty to decrease the potential for medical overuse and ensuring optimal placement of patient-led teledermoscopy within existing clinical care pathways to increase the potential for benefits.
CONCLUSIONS: Clinicians were enthusiastic about the potential and experienced benefits of mobile teledermoscopy; however, managing clinical uncertainty will be necessary to achieve these benefits in clinical care outside of trial contexts and minimize potential harms from medical overuse.
BACKGROUND: Australian and New Zealand Clinical Trials Registry ACTRN12616001716459; https://anzctr.org.au/
Trial/Registration/TrialReview.aspx?id=371865.