Moreno Ramirez 2005.

Study characteristics
Patient sampling	Study design: case series Data collection: retrospective Period of data collection: January to April 2004 Country: Spain
Patient characteristics and setting	Inclusion criteria: people with pigmented, circumscribed lesions fulfilling ≥ 1 of the following criteria: changing lesion ('ABCD changes'), recent lesion (< 3‐year history), multiple lesions (> 20 MN counted by the GP), symptomatic lesion (pain, itching, bleeding) or concerned about moles. Accuracy data reported only for those subsequently referred to the PLC and for whom pathology results were available. Setting: specialist unit (skin cancer/pigmented lesions clinic) Prior testing: most likely clinical examination (the reasons for teleconsultation were listed as concern about moles; recent pigmented lesion; changing lesions; symptoms; multiple lesions) Setting for prior testing: unspecified Exclusion criteria: Excluded difficult to diagnose Sample size (participants): number eligible: 219; number included: 108 referred to PLC, 57 participants included in the final analysis Participant characteristics: Age: mean: 43; range: 2–84 years Gender: male: 77 (35%); female 142 (65%) Lesion characteristics: NR
Index tests	TD Acquisition and transmission of images: 2 digital pictures were taken by the GP using a digital camera at a resolution of 1600×1200 pixels (Coolpix 4300, Nikon). A panoramic view of the lesion area and a close up of the lesion were taken. Images were inserted into a word document with relevant clinical information. This was transmitted via the intranet to an email account at the PLC. Nature of images used: clinical photographs Any additional participant information provided: clinical examination or case notes (or both) Diagnosis based on: unclear how many remote observers Number of examiners: NR Observer qualifications (remote diagnosis): dermatologist Method of diagnosis: at the teleconsultation, observers classified the lesions as being, "benign melanocytic naevus, multiple MN (>20 naevi as seen on teleconsultation), atypical naevus,7 congenital naevus, blue naevus, solar lentigo, lentigo maligna, melanoma, special melanocytic lesion (genital naevus, acral naevus, recurrent naevus), seborrhoeic keratoses, basal cell carcinoma (BCC), DF, vascular lesion, non‐pigmented lesion, or a 'difficult to diagnose' lesion." After evaluation of the pictures and clinical information, a report was returned to the GP at the primary care centre, with suggestions regarding the diagnosis and management of the case. Management options: limited to 'referral' or 'non‐referral' of the participant to the FTF clinic. Participants who had readily identifiable benign lesions such as benign melanocytic naevus, solar lentigo, SK, DF, vascular lesions and non‐pigmented lesions were not referred to the PLC. All other remaining categories were routinely referred to the PLC for FTF assessment.
Target condition and reference standard(s)	Reference standard: histological diagnosis Details: at the PLC, physical and dermoscopic examinations were carried out, as well as excisional biopsy in suspicious or malignant cases, and FU of participants with risk factors for melanoma (16/25 benign underwent histology) Target condition (final diagnoses) Melanoma (in situ): 1, BCC: 23; lentigo maligna: 3; dysplastic nevi: 16, common: nevi 8; blue nevi: 4
Flow and timing	Excluded participants: 13 difficult to diagnosis cases, plus 28 with 'malignant or suspicious lesions' were excluded from 2x2 tables Time interval to reference test: unclear – only mentioned, "Teleconsultation reports were sent to the GP in a mean time of 44 h [hours] (range 2–96 h). Patients referred to the face‐to‐face clinic were seen within the following two weeks (mean of 8 days, range 5–14). Dermatologists at the PLC spent an average of 2.3 h per week in evaluating the teleconsultations received." Time interval between index test(s): N/A
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?	Unclear
Was a case‐control design avoided?	Yes
Did the study avoid inappropriate exclusions?	No
Are the included patients and chosen study setting appropriate?	No
Did the study avoid including participants with multiple lesions?	Unclear
		High	High
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?	Unclear
		High	Unclear
DOMAIN 4: Flow and Timing
Was there an appropriate interval between index test and reference standard?	Unclear
Did all patients receive the same reference standard?	No
Were all patients included in the analysis?	No
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?
		High