Assessment of teledermatology effectiveness in rural skin cancer triage and follow-up care

Thesis Abstract

This study investigates the effectiveness of teledermatology in rural skin cancer triage and follow-up care, addressing barriers to timely assessment, diagnostic accuracy, and continuity of care in geographically dispersed populations. The problem centers on delayed referrals, limited access to dermatology specialists, and variable quality of in-person triage in rural settings, which may contribute to advanced-stage presentations and suboptimal follow-up. The aim is to evaluate whether asynchronous and synchronous teledermatology approaches improve triage accuracy, reduce time to definitive management, and enhance adherence to follow-up recommendations among rural patients. Specific objectives are (1) to compare diagnostic concordance between teledermatology assessments and in-person dermatology evaluations for suspected skin cancer lesions; (2) to quantify time intervals from primary presentation to definitive diagnosis and treatment under teledermatology pathways vs. usual care; (3) to assess patient satisfaction, access to care, and travel burden; (4) to evaluate follow-up adherence and recurrence surveillance after teledermatology-guided management; and (5) to identify organizational, technical, and patient-level determinants of teledermatology effectiveness. A mixed-methods design will be employed, combining a prospective cohort study with a qualitative process evaluation. The population includes adults residing in rural regions with skin lesions referred for dermatologic assessment over 24 months. A sample of 600 participants presenting with suspicious lesions will be recruited from 12 rural clinics, with 300 managed via teledermatology (intervention group) and 300 receiving standard in-person triage (control group). Data collection instruments will include standardized teledermatology triage protocols, chart abstractions for diagnostic and treatment timelines, validated patient-reported experience measures, and follow-up checklists. Diagnostic concordance will be analyzed using Cohen’s kappa and McNemar’s test. Time-to-event outcomes (time to biopsy, diagnosis, and treatment) will be examined through survival analysis (Kaplan–Meier curves and Cox proportional hazards models). Adherence to follow-up will be assessed via longitudinal remote monitoring data and clinic visit records. Qualitative data will be gathered through semi-structured interviews with patients, primary care providers, and teledermatology clinicians, and analyzed using thematic analysis informed by the Technology Acceptance Model and Normalization Process Theory to elucidate implementation facilitators and barriers. The study anticipates higher diagnostic concordance between teledermatology and in-person assessments for non-melanoma skin cancers, with diagnostic agreement for malignant melanoma approaching parity in a subset of cases where dermoscopic images are available. It is expected that teledermatology will shorten the interval from first presentation to definitive management by an average of 18–28 days (p < 0.05) compared with usual care, and will reduce patient-reported travel burden by approximately 60%, while maintaining or improving patient satisfaction scores. Follow-up adherence is projected to improve in the teledermatology group due to structured remote monitoring and prompt scheduling. The study will also identify clinic workflow characteristics, image quality, and internet connectivity as key determinants of effectiveness, with potential confounders including lesion complexity, rural broadband reliability, and patient health literacy. Contributions to knowledge include empirical evidence on the clinical effectiveness and timeliness of teledermatology in rural skin cancer care, a nuanced understanding of patient and provider experiences, and a framework for scalable integration of teledermatology into rural oncology pathways. The findings will inform guidelines for triage protocols, data-quality standards for teledermatology imaging, and policy recommendations to optimize reimbursement and infrastructure in rural health systems. The main conclusion will discuss the extent to which teledermatology can substitute or augment conventional triage without compromising diagnostic accuracy or follow-up outcomes. Recommendations will address strengthening image acquisition protocols, investing in broadband and IT support, developing standardized referral criteria, and enhancing patient engagement strategies to sustain follow-up across rural settings.