Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
University of Cambridge School of Clinical Medicine, Cambridge, UK.
BMJ Open. 2019 Aug 20;9(8):e027529. doi: 10.1136/bmjopen-2018-027529.
Most skin lesions first present in primary care, where distinguishing rare melanomas from benign lesions can be challenging. Dermoscopy improves diagnostic accuracy among specialists and is promoted for use by primary care physicians (PCPs). However, when used by untrained clinicians, accuracy may be no better than visual inspection. This study aimed to undertake a systematic review of literature reporting use of dermoscopy to triage suspicious skin lesions in primary care settings, and challenges for implementation.
A systematic literature review and narrative synthesis.
We searched MEDLINE, Cochrane Central, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and SCOPUS bibliographic databases from 1 January 1990 to 31 December 2017, without language restrictions.
Studies including assessment of dermoscopy accuracy, acceptability to patients and PCPs, training requirements, and cost-effectiveness of dermoscopy modes in primary care, including trials, diagnostic accuracy and acceptability studies.
23 studies met the review criteria, representing 49 769 lesions and 3708 PCPs, all from high-income countries. There was a paucity of studies set truly in primary care and the outcomes measured were diverse. The heterogeneity therefore made meta-analysis unfeasible; the data were synthesised through narrative review. Dermoscopy, with appropriate training, was associated with improved diagnostic accuracy for melanoma and benign lesions, and reduced unnecessary excisions and referrals. Teledermoscopy-based referral systems improved triage accuracy. Only three studies examined cost-effectiveness; hence, there was insufficient evidence to draw conclusions. Costs, training and time requirements were considered important implementation barriers. Patient satisfaction was seldom assessed. Computer-aided dermoscopy and other technological advances have not yet been tested in primary care.
Dermoscopy could help PCPs triage suspicious lesions for biopsy, urgent referral or reassurance. However, it will be important to establish further evidence on minimum training requirements to reach competence, as well as the cost-effectiveness and patient acceptability of implementing dermoscopy in primary care.
CRD42018091395.
大多数皮肤病变首先出现在初级保健中，在那里区分罕见的黑色素瘤与良性病变具有挑战性。皮肤镜检查可提高专家的诊断准确性，并被推荐用于初级保健医生（PCP）。然而，当未经培训的临床医生使用时，准确性可能并不优于目视检查。本研究旨在对文献进行系统回顾，报告在初级保健环境中使用皮肤镜检查对可疑皮肤病变进行分诊的情况，以及实施过程中的挑战。
系统文献回顾和叙述性综合。
我们检索了 MEDLINE、Cochrane 中心、EMBASE、护理学和联合健康文献累积索引以及 SCOPUS 书目数据库，检索时间为 1990 年 1 月 1 日至 2017 年 12 月 31 日，无语言限制。
包括评估皮肤镜检查准确性、患者和 PCP 接受程度、培训要求以及皮肤镜检查模式在初级保健中的成本效益的研究，包括试验、诊断准确性和可接受性研究。
23 项研究符合审查标准，代表 49769 个病变和 3708 名 PCP，均来自高收入国家。真正在初级保健中开展的研究很少，所测量的结果也多种多样。因此，异质性使得进行荟萃分析变得不可行；数据通过叙述性综述进行综合。经过适当培训的皮肤镜检查与提高黑色素瘤和良性病变的诊断准确性相关，并减少了不必要的切除和转诊。基于远程皮肤镜检查的转诊系统提高了分诊准确性。只有三项研究检查了成本效益；因此，没有足够的证据得出结论。成本、培训和时间要求被认为是重要的实施障碍。患者满意度很少得到评估。计算机辅助皮肤镜检查和其他技术进步尚未在初级保健中进行测试。
皮肤镜检查可以帮助 PCP 对可疑病变进行活检、紧急转诊或缓解。然而，建立进一步的证据来确定达到胜任力所需的最低培训要求，以及在初级保健中实施皮肤镜检查的成本效益和患者可接受性非常重要。
CRD42018091395。
