LAUSR

patients subsequently had a face-to-face (FTF) consultation with consultant 1. For each case, consultants 1 and 2 both assessed (i) whether FTF consultation was required; (ii) clinical urgency of the referral; (iii) most likely clinical diagnosis; and (iv) whether a management plan could be formulated based upon the referral information provided. Twenty-five patients were recruited. Four patients were excluded (photographs unavailable because of computer malware attack, n = 3; patient declined clinical assessment, n = 1). Sixty-two per cent (n = 13) were male; mean age 55 years (range = 34–73 years). The clinical diagnoses determined after FTF consultation were categorised into infection (n = 7), skin cancer (n = 2), inflammatory dermatosis (n = 4), benign lesions (n = 3) and diagnosis uncertain following investigation (n = 5), (Table 1). When a letter-only referral was available to consultant 1, 100% of patients were assessed to require FTF consultation compared with 86% evaluated by teledermatology referral. When assessing concordance for urgency of review, observed agreement with clinical assessment was 83% for teledermatology referrals (Fleiss j coefficient value 0.64 [95% confidence interval 0.18 to 1.1]) and 62% for letter-only referral (Fleiss j coefficient of 0.2 [95% CI 0.20 to 0.65]). For letter-only referrals, a provisional diagnosis was made in 50% of cases compared with 95% of teledermatology referrals. For letter-only review, a management plan could be confidently formulated in 24% (n = 4) of cases, compared with 57% (n = 12) of cases for teledermatology referrals. Diagnostic concordance with subsequent FTF consultations was 76% for teledermatology referrals (Fleiss j coefficient value 0.67 [95% CI 0.52 to 0.82]) versus 52% for letter-only referrals (Fleiss j coefficient value 0.44 [95% CI 0.27 to 0.61]. In patients where a final diagnosis was confirmed after further diagnostic tests (n = 16), these were concordant with the teledermatology diagnosis in 13/16 (81%) of cases and 9/16 (56%) in letteronly referrals. In the case of 3 recruited patients, images were lost during a global malware attack. Our pilot study suggests that teledermatology is a safe means of triaging skin referrals in high-risk OTR. Compared with the general population where significant reductions of FTF consultations are reported, we found only a modest 15% reduction. The high risk of skin cancer, together with the complexity of the conditions encountered in the transplant population, probably accounts for the smaller effect that teledermatology had on reducing our FTF consults. We have not formally evaluated the costeffectiveness of this approach, and such health economic assessment would be an important consideration for future studies. Nonetheless, our results suggest that triage with referral letter accompanied by teledermatology image provides an efficient means of allocating urgent appointments and may enable physicians to initiate treatment prior to dermatology review and/or avoid FTF consultation in selected patients. We consider that such an approach will ultimately contribute to the optimal rationalisation of clinical service provision in this high-risk patient population. Zeeshaan-Ul Hasan | Ramia Mokbel | Rebeca Goiriz | Jessica Gale | Bjorn Thomas | Malvina Krupiczojc | Priya Dewan | Liza Mitchell-Worsfold | Jane McGregor | Catherine Harwood Dermatology Department, Royal London Hospital, Barts Health NHS Trust, London, UK