Whited 2013 — Clinical-course outcomes: store-and-forward teledermatology vs. conventional consultation RCT
Citation
Whited JD, Warshaw EM, Kapur K, Edison KE, Thottapurathu L, Raju S, et al. Clinical course outcomes for store and forward teledermatology versus conventional consultation: a randomized trial. J Telemed Telecare. 2013 Jun;19(4):197–204. DOI: 10.1177/1357633X13487116. PMID 23666440.
Study design and population
Two-site, parallel-group, superiority RCT. 392 randomised / 261 analysed. US Department of Veterans Affairs primary-care-to-dermatology referrals; 9-month clinical-course rating by blinded dermatologist panel on a 5-point scale.
Reported metrics
- No significant difference in clinical-course ratings between teledermatology and conventional consultation at 9 months (p = 0.88)
- No significant difference at first clinic visit (p = 0.65)
- Waiting time to intervention substantially shorter in teledermatology arm
- Among teledermatology referrals, subsequent in-person visit correlated with clinical course (p = 0.023) — suggests appropriate triage
Surrogate-to-outcome linkage
RCT-level evidence that store-and-forward teledermatology-based referral produces the same 9-month clinical-course outcome as conventional consultation — validating the referral pathway metric as a genuine proxy for clinical benefit rather than a pure process measure. Supports the non-inferiority leg of the Pillar-1 argument for AI-triage pathway redesign.
CRIT1–7 appraisal
| Criterion | Score | Justification |
|---|---|---|
| CRIT1 Relevance | 3 | Direct — SAF teledermatology pathway RCT with clinical-course outcome. |
| CRIT2 Methodology | 3 | Multi-site RCT; blinded outcome adjudication. |
| CRIT3 Reporting | 2 | Descriptive comparison; no 95 % CI for primary endpoint reported. |
| CRIT4 Applicability | 2 | VA predominantly male older population — EU-transferability requires care. |
| CRIT5 Evidence weight | 2 | RCT. |
| CRIT6 Risk of bias | 2 | Attrition (392 → 261 analysed); 5-point clinical-course rating is itself a surrogate. |
| CRIT7 Contribution | 3 | Core anchor — RCT-level outcome equivalence for skin-cancer referral pathway. |
Aggregate: strong.
Limitations and notes
VA population; attrition introduces selection bias; 9-month window may be insufficient for slow-evolving conditions.
Strength as anchor
Strong. Together with Eminović 2009 (EU cluster RCT on referral reduction) and Armstrong 2018 (chronic-disease equivalence RCT), provides the RCT-level evidence backbone for the referral-optimisation argument.