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Societal cost-benefit analysis of teledermatology

BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7265.896/a (Published 07 October 2000) Cite this as: BMJ 2000;321:896

Costs were understated

  1. Paul Jacklin (paul.jacklin{at}lshtm.ac.uk), research fellow,
  2. Jenny Roberts, reader in economics and public health
  1. Department of Public Health Policy, London School of Hygiene and Tropical Medicine, London WC1E 7HT
  2. Centre for Online Health, Royal Brisbane Hospital, Herston 4029, Australia

    EDITOR—The article by Wootton et al is a valuable addition to the limited literature on the cost effectiveness of telemedicine applications.1 But we have some reservations about their calculations of the net societal cost of a teledermatology consultation.

    Wootton et al are comparing outpatient dermatology, current clinical practice, with real time teledermatology in terms of clinical outcomes, cost benefit (which should theoretically include the monetary valuation of clinical outcomes), and patient satisfaction.

    Having calculated a total cost of £201.88 for a teledermatology consultation, Wootton et al subtracted two values from this total to arrive at the net societal cost. Firstly, they deducted the “savings” that would be made from reduced dermatology referrals, which they attribute to the learning benefits and increased confidence in managing patients obtained from the joint videolink consultation.

    Our point of contention is that they were wrong to subtract a further £69.78 for the “benefits” of the programme. These “benefits” do not reflect clinical outcomes, as Wootton et al found no major differences in the two approaches in terms of clinical outcomes. Rather it is an imputed measure of the training cost necessary to achieve the same educational impact as the experience obtained using telemedicine. This would, presumably, lead to a similar reduction in dermatology referrals as achieved by telemedicine. This then begs the question of who exactly in society would actually benefit to the tune of £69.78, as this training is not currently provided in current clinical practice.

    This result, as presented in the paper, seems to be a form of double counting. Real time teledermatology may or may not be cost effective, but its societal benefits surely cannot include the savings from reduced referrals and the cost of training necessary to obtain a similar pattern of referrals from general practice in the absence of telemedicine.

    References

    1. 1.

    Authors' reply

    1. Richard Wootton (r.wootton{at}pobox.com), professor of online health,
    2. Maria Loane, senior research officer
    1. Department of Public Health Policy, London School of Hygiene and Tropical Medicine, London WC1E 7HT
    2. Centre for Online Health, Royal Brisbane Hospital, Herston 4029, Australia

      EDITOR—Jacklin queries the rationale for showing the value of the knowledge transfer as a benefit to society. Transfer of knowledge from the expert who is consulted to the person who is making the consultation is commonly said to occur in large real time telemedicine programmes. It is also widely acknowledged as being very difficult to quantify.

      As stated in our paper, there are a number of additional benefits from teledermatology, such as the psychological impact on patients and their avoiding paying for interim treatments while waiting for a specialist appointment. The general practitioners in the trial also mentioned increased job satisfaction. These are all difficult to measure, and we omitted them from the analysis.

      The general practitioners also mentioned gaining considerable benefits from the learning effect in terms of managing their own and their colleagues' patients. The general practitioners estimated the value of the knowledge they had gained during the project as being of equivalent worth to attending a certain number of study days—a one off benefit that they had gained as a result of participating in regular teledermatology consultations. This is not double counting because the knowledge gained was used by the general practitioners for the management of all their dermatology patients, not just the 5% who would normally have been referred for hospital treatment. The knowledge transfer (assuming that the general practitioners estimated it correctly) was simply an additional benefit for the general practitioners that they would not otherwise have received; if it was overestimated in our study, then the magnitude would be of the order of 100/95.

      The original economic analysis was done by a well known British economics consultancy. Since Jacklin raised the point we have consulted two independent academic health economists in different countries outside the United Kingdom. One disagreed with Jacklin's point entirely, and one partially. From the remarks they made it is clear that there is scope for debate about what benefits should be included and how. Economics does not seem to be an exact science in this respect, which is a pity.

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