The DIADERM study was performed in 2016 to report on outpatient dermatology care in Spain.1 The study revealed that most patients were referred to the dermatology clinic via the dermatologist (34% of cases), followed by the primary care physician. Similarly, the most common destination after the consultation was the dermatologist, and most visits resulted in discharge.1 However, these referral routes may depend on other variables, such as patient age, whether the clinic is private or public, and whether the clinic is a specialist center. In terms of health care management, it is particularly interesting to study referral routes with respect to these variables and the percentage of consultations that lead to discharge. The destination of dermatology patients has been reported in other countries2; however, equivalent data are lacking in Spain.

In teledermatology, that is, distance health care using telecommunication technology,3 knowledge of referral routes can serve as an indicator of the use of this care modality in Spain. Many studies have shown that teledermatology can reduce waiting lists, act as a triage service for referrals from primary care, and ensure easy access to specialized care from remote locations.4–10 Spain has one of the highest frequencies of publications on teledermatology,11 which is a growing modality for consultation in Spain. In 2014, it was used by 70 centers, ie, more than 25% of all public dermatology clinics in Spain.12 Data from DIADERM enabled us to report on teledermatology referral routes and their characteristics.

The objective of the present study was to describe referral routes for patients seen in dermatology outpatient clinics in Spain and to report on the frequency and characteristics of teledermatology consultations in Spain.

Table 1 shows the patients’ destinations according to the study variables. There were no differences in referral route according to patient age or how the consultation was funded, although significant differences were observed between specialist and general consultations, with discharges being less frequent in specialist consultations (Table 1). We also found significant differences between the origin and subsequent referral (Table 2).

The DIADERM study made it possible to obtain a representative national overview of the origin and referral of patients attending dermatology outpatient clinics and of the use of teledermatology in Spain. The main origin for consultations at public centers was primary care and the dermatology clinic itself, since, in theory, direct access is not possible in this setting. Notwithstanding, it is striking that the origin was direct in 10%: some cases may correspond to patients referred from the emergency department (variable not collected). In private clinics, most patients were referred directly, and only 16% were from the dermatology department. This figure includes check-ups. Since direct access is—in theory—impossible in the public health system, it is important to remember that the difference we observed with private clinics is structural and necessarily imposed by the system. The high percentage recorded for direct origin in private clinics points to a high demand for dermatologic care in Spain, and we can assume that some of these patients have been seen by primary care physicians in the public health system.

The successive/first index—successive consultations divided by first consultations—is an indicator that is frequently used in health care management to evaluate the activity of outpatient clinics.13 This index helps to estimate the ability of a clinic to resolve cases, although it does not take into account possible re-entries of unresolved problems. In our study, if we assumed that all patients referred from the dermatologist are patients undergoing check-ups, we would have an index of 0.8 for public clinics and 0.2 for private clinics. These values point to a high ability to resolve cases, although it is striking that they do not agree with referrals, where, in both areas, 2 of every 3 patients undergo a check-up in the dermatology department. We cannot explain this observation, although it could be due to the fact that many check-ups are in the long term or many patients do not keep their appointments, especially in private centers. Similarly, the official statistics show a higher percentage of check-ups in private clinics (41%).14 However, the study population in this case is different, since it includes only polyvalent centers with major outpatient surgery or imaging-based diagnostic techniques, thus probably ruling out many of the private centers included in DIADERM.

Our data on destination can be compared with those of Bertanha et al,2 who analyzed the destination of patients seen at a triage dermatology clinic for new patients in Brazil and reported a similar figure for discharges (33%). Curiously, we did not find significant differences in destination between public and private clinics. This is paradoxical, given that, depending on the origin, we did find a potentially greater ability to resolve cases in private clinics (see above). As for type of clinic, the tendency toward discharge is lower in specialist clinics than in general clinics, probably because fewer new patients are seen in the former and the most frequent diagnoses are chronic or oncologic diseases (Table 1), which require additional follow-up.

Around 1% of the consultations were via telemedicine. This represents a small percentage of the total number of consultations, although we know from a recent study that teledermatology has been implemented in more than 25% of dermatology services in Spain.12 This figure is higher than in the USA, where a recent survey showed that 11% of dermatologists used teledermatology,15 and lower than in the UK, where the percentage was 48%.16 Teledermatology was more frequently used in Galicia, Catalonia, and Andalucía. These differences may be explained by the uneven implementation of the electronic clinical history,17 the interest shown by autonomous communities and hospitals, and the presence of teams of dermatologists interested in the field. The results of recent studies indicate that teledermatology is well implemented in these 3 autonomous communities, although Madrid is the community with the highest number of services using it.12 The finding that most patients were from primary care is as expected, given that teledermatology is more frequently used for triage in order to avoid unnecessary referrals and reduce waiting times.7,11 The origin was direct in 17% of patients, probably because of access to teledermatology via smartphone apps, although this was not investigated in our survey. A survey carried out in 2014 only analyzed the use of teledermatology in public centers12; therefore, it would be interesting to perform new studies to investigate the implementation of direct access teledermatology via apps in Spain. Funding and patient age did not differ significantly from those of the face-to-face visits.

The limitations of the study are those of the survey itself, in which participation was not complete (response rate, 60%), although the sample size led us to envisage this problem, with the result that the sample was overestimated. Second, we recognize that there may well have been some ambiguity in destination between the options discharge and discharge with follow-up by primary care, especially in telemedicine, where, in the public system, the patient normally visits primary care to receive results, even if follow-up is not necessary; this may diminish the reliability of the results. Third, the low number of patients seen via teledermatology indicates that the corresponding results were not very accurate. Furthermore, the uneven distribution of the activity of teledermatology may lead to bias. Lastly, given that the study of the characteristics of teledermatology was not an initial objective of the survey, we were unable to study many potentially interesting variables that are specific to this discipline.

In conclusion, our results suggest that dermatology clinics in Spain have a considerable ability to resolve cases. Some of the differences observed between private and public centers are due to structural differences in the health system: the origin is more frequently direct in private centers, because in public centers, patients can only be referred to a dermatologist from another specialist or a primary care physician. The high percentage for direct origin in private centers points to a high demand for dermatology services in Spain. We can assume that a large number of these patients are being seen in primary care. It could be interesting to perform studies to compare the cost-effectiveness of management of patients in primary care with that of direct access to a dermatologist.

Teledermatology accounts for a small percentage of all dermatology consultations. It is most widely used in Galicia. Finally, access to teledermatology in Spain is direct in a significant number of cases, probably as a result of the use of smartphone apps. In summary, as far as we know, the data we present are the first to bring together the referral routes and the frequency and characteristics of teledermatology in Spain. We believe that performing similar studies in the future could be of interest, since they would show how these variables progress over time. Given the increasing use and interest in teledermatology, future studies could include other variables associated with teledermatology, such as the method used (real-time or prerecorded), the person who takes the photos, and the use of Smartphone apps.

The DIADERM study is sponsored by Fundación Piel Sana de la AEDV (Healthy Skin Foundation of the Spanish Academy of Dermatology and Venereology), which received funding from Novartis. The pharmaceutical company did not participate in data collection, data analysis, or interpretation of the results. Guillermo González-López received the Juan de Azúa grant from Fundación Piel Sana, part of which was used to fund the present study.

The authors declare that they have no conflicts of interest related to this article.