Borve 2015.

Study characteristics
Patient sampling	Study design: case series Data collection: prospective Period of data collection: January 2011 to December 2012 Country: Sweden
Patient characteristics and setting	Inclusion criteria: adults > 18 years of age with ≥ 1 skin lesions of concern requiring referral to a dermatologist using the TD referral system Setting: primary (20 primary healthcare centres in western Sweden) Prior testing: N/A Setting for prior testing: N/A Exclusion criteria: did not attend FTF visit(s), did not comply or skin lesions were located on a body part that could not be photographed. Sample size (participants): number eligible: 902; number included: 816 Participant characteristics: Age: mean 54; range: 18–93 years Gender: 474 (61.3%) women Lesion characteristics: NR
Index tests	TD Acquisition and transmission of images: GPs used the smartphone TD referral system. The GP took 1 clinical and 1 dermoscopic image using an iPhone 4 with a FotoFinder Handyscope app, and completed a standardised query form including all the relevant clinical information. This was then sent through a secure web‐based TD platform (Tele‐Dermis) with a secure socket layer encryption. Simultaneously the participating dermatologists received an email that a new referral was ready for assessment. Nature of images used: clinical photographs and dermoscopic images Any additional participant information provided: clinical information Diagnosis based on: single; number of examiners: 4 Observer qualifications (remote diagnosis): 3 specialists in dermatology and 1 resident in dermatology Method of diagnosis: dermatologists logged onto the Tele‐Dermis platform to review the referrals on a 17‐ or 19‐inch liquid crystal display monitor. They chose from standardised triage responses including an assessment of the nature of the lesion (benign, malignant or unclear), ≥ 1 possible diagnoses, the priority given (high, within 2 weeks; medium, within 4 weeks or low, within 8–12 weeks), suggested management (none, medical therapy, destructive therapy or surgery) and, finally, a dermoscopic description.
Target condition and reference standard(s)	Histological plus expert diagnosis Histology: 551 Details: All MMs and SCCs (keratoacanthomas were classified as SCCs) were confirmed histopathologically. Final diagnosis confirmed histopathologically in 292 TD referrals (36%) and 259 paper referrals (35%) Expert diagnosis (FTF diagnosis at dermatology clinic): 265 Method of diagnosis: dermatologists used dermoscopy to evaluate the study lesions and carried out full body skin examination Prior test data: all relevant clinical information (FTF visits were not blinded to the results of the teledermoscopists) Diagnostic threshold: NR Diagnosis based on: single Number of examiners: NR Observer qualifications: dermatologists (specialists in dermoscopy) Experience in practice: high Experience with index test: high Target condition (final diagnoses) Malignant: MM: 19 (2.3%); MiS: 16 (2.0%); SCC: 17 (2.1%); SCC in situ: 7 (0.9%); BCC: 109 (13.4%); AK: 61 (7.5%); other malignant: 0 Benign: dysplastic nevi: 89 (10.9%); BN: 236 (28.9%); SK: 125 (15.3%); other benign: 137 (16.8%)
Flow and timing	Excluded participants: none reported Time interval to reference test: all participants were called to attend an FTF visit at the corresponding department of dermatology. A suspicion of MM or SCC was triaged within 2 weeks. After the triage process, all participants were managed according to standard protocols at the hospitals independently of the referral method.
Comparative
Notes	—
Methodological quality
Item	Authors' judgement	Risk of bias	Applicability concerns
DOMAIN 1: Patient Selection
Was a consecutive or random sample of patients enrolled?	Yes
Was a case‐control design avoided?	Yes
Did the study avoid inappropriate exclusions?	Yes
Are the included patients and chosen study setting appropriate?	Yes
Did the study avoid including participants with multiple lesions?	Unclear
		Low	Unclear
DOMAIN 2: Index Test Teledermatology
Were the index test results interpreted without knowledge of the results of the reference standard?	Yes
If a threshold was used, was it pre‐specified?	Yes
Was the test applied and interpreted in a clinically applicable manner?	Yes
Were thresholds or criteria for diagnosis reported in sufficient detail to allow replication?	Unclear
Was the test interpretation carried out by an experienced examiner?	Yes
		Low	Unclear
DOMAIN 3: Reference Standard
Is the reference standards likely to correctly classify the target condition?	No
Were the reference standard results interpreted without knowledge of the results of the index tests?	Unclear
For studies comparing TD/FTF clinical diagnosis to histology, was histology interpretation carried out by an experienced histopathologist or by a dermatopathologist?	Unclear
For studies comparing TD to FTF diagnosis, was the clinical diagnosis carried out by an experienced observer?
		High	Unclear
DOMAIN 4: Flow and Timing
Was there an appropriate interval between index test and reference standard?	Yes
Did all patients receive the same reference standard?	No
Were all patients included in the analysis?	Yes
If the reference standard includes clinical FU of borderline/benign appearing lesions, was there a minimum FU following application of index test(s) of at least: 3 months for melanoma or cSCC or 6 months for BCC?	Yes
		High