Eminović 2009 — Cluster RCT: teledermatology reduces dermatology referrals
Citation
Eminović N, de Keizer NF, Wyatt JC, ter Riet G, Peek N, van Weert HC, et al. Teledermatologic consultation and reduction in referrals to dermatologists: a cluster randomized controlled trial. Arch Dermatol. 2009 May;145(5):558–564. DOI: 10.1001/archdermatol.2009.44. PMID 19451500.
Study design and population
Multicentre cluster RCT, 2 Dutch regions. 85 GPs from 35 practices randomised to teledermatology triage vs. usual referral. 5 dermatologists; 631 patients (327 intervention, 304 control).
Reported metrics
- Consultations judged preventable: 39.0 % (teledermatology) vs. 18.3 % (control)
- Absolute difference 20.7 pp (95 % CI 8.5–32.9)
- At 1-month dermatologist visit, 20.0 % of teledermatology patients had recovered
- Patient satisfaction high, no significant difference between arms
Surrogate-to-outcome linkage
Highest-tier evidence for referral reduction as a care-pathway outcome in a GP-level teledermatology triage context — the exact clinical scenario of a primary-care CDS. Preventable-visit rate is a direct system-level surrogate for specialist-capacity release and reduced wait times.
CRIT1–7 appraisal
| Criterion | Score | Justification |
|---|---|---|
| CRIT1 Relevance | 3 | Direct — GP teledermatology triage with referral-reduction primary outcome. |
| CRIT2 Methodology | 3 | Cluster RCT; pre-specified primary outcome; blinded adjudication. |
| CRIT3 Reporting | 3 | Absolute difference with 95 % CI; patient satisfaction reported. |
| CRIT4 Applicability | 3 | EU primary-care setting, directly applicable. |
| CRIT5 Evidence weight | 2 | Cluster RCT — highest tier available for care-pathway intervention. |
| CRIT6 Risk of bias | 2 | "Preventability" judged retrospectively by dermatologists (not hard endpoint); Dutch referral culture-specific. |
| CRIT7 Contribution | 3 | Core anchor — RCT-level evidence for the referral-reduction surrogate. |
Aggregate: very strong.
Limitations and notes
Pre-dates modern AI triage; retrospective "preventability" judgement; Dutch context.
Strength as anchor
Very strong. Highest evidence level (cluster RCT) for the referral-appropriateness surrogate in EU primary-care setting. Cited routinely in HTA evaluations (NICE, NIHR, HIQA).