Cost and Utility Analysis of a Store-and-Forward Teledermatology Referral System: A Randomized Clinical Trial
Abstract
IMPORTANCE: The costs and utility of teledermatology are important features of implementation. Such an analysis requires a description of the perspective of the entity that will bear the cost. OBJECTIVE: To assess the costs and utility of a store-and-forward teledermatology referral process compared with a conventional referral process from the perspectives of the Department of Veterans Affairs (VA) and society. DESIGN, SETTING, AND PARTICIPANTS: Three hundred ninety-one randomized participants were referred from remote sites of primary care to the dermatology services of 2 VA medical facilities for ambulatory skin conditions from December 2008 through June 2010, and follow-up was completed in March 2011. The time trade-off utility measures and costs were collected during a 9-month period among participants in a 2-site parallel group randomized clinical trial. The perspectives of the VA and society were evaluated. The multiple imputation procedure or weighted means were used for missing data elements. Data were analyzed from January to July 2014. INTERVENTIONS: Referrals were managed using store-and-forward teledermatology or a conventional text-based referral process. MAIN OUTCOMES AND MEASURES: Total costs from the perspectives of the VA and society incurred during the 9-month follow-up were used to derive per-participant costs. Utility, using the time trade-off method, was the measure of effectiveness. RESULTS: From the VA perspective, the total cost for conventional referrals was $66 145 (minimum, $58 697; maximum, $71 635), or $338 (SD, $291) per participant (196 participants); the total cost for teledermatology referrals was $59 917 (mimimum, $51 794; maximum, $70 398), or $308 (SD, $298) per participant (195 participants). The $30 difference in per-participant cost was not statistically significant (95% CI, -$79 to $20). From the societal perspective, the total cost for conventional referrals was $106 194 (minimum, $98 746; maximum, $111 684), or $542 (SD, $403) per participant (196 participants); the total cost for teledermatology referrals was $89 523 (minimum, $81 400; maximum, $100 400) or $460 (SD, $428) per participant. This $82 difference in per-participant cost was statistically significant (95% CI, -$12 to -$152). From baseline to the 9-month follow-up, the time trade-off utility value improved by 0.02 in the conventional referral group and 0.03 in the teledermatology group. This difference was not statistically significant (P = .50). CONCLUSIONS AND RELEVANCE: Compared with conventional referrals, store-and-forward teledermatology referrals were performed at a comparable cost (VA perspective) or at a lower cost (societal perspective) with no evidence of a difference in utility as measured by the time trade-off method. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00488293.
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Several services, including those at the VHA, VA, UCSF, and Mayo Clinic, use private networks where the eConsult service is embedded into an electronic health record shared by referring providers and specialists, enabling the specialist to directly access patient information.
“Several services, including those at the VHA, 11,12 Veteran's Affairs (VA), [13][14][15] UCSF, 16,17 and the Mayo Clinic, 10,18,19 use private networks, where the eConsult service is embedded into an electronic health record shared by referring providers and specialists, enabling the specialist to directly access patient information.”
From A Systematic Review of Asynchronous, Provider-to-Provider, Electronic Consultation Services to Improve Access to Specialty Care Available Worldwide (2019) · cites this paper as [14]
Studies comparing costs of eConsults with in-person specialist visits report eConsult costs ranging from $5 per eConsult (compared with $56 for face-to-face) to $298 per person using eConsult (compared with $338 for face-to-face).
“Studies comparing costs (i.e., those conducting a cost-minimization analysis) of eConsults with in-person specialist visits report eConsult costs (viewed through impact on health services) ranging from $5 per eConsult (compared with $56 for face-to-face) 33 ; to $298 per person using eConsult (compared with $338 for face-to-face). 14”
From A Systematic Review of Asynchronous, Provider-to-Provider, Electronic Consultation Services to Improve Access to Specialty Care Available Worldwide (2019) · cites this paper as [14]
From a societal perspective, another study found that costs of eConsult averaged at $460 per patient, compared with face-to-face costs of $542 per patient.
“From a societal perspective, another study found (through a cost minimization analysis) that costs of eConsult averaged at $460 per patient, compared with face-to-face costs of $542 per patient.14”
From A Systematic Review of Asynchronous, Provider-to-Provider, Electronic Consultation Services to Improve Access to Specialty Care Available Worldwide (2019) · cites this paper as [14]
A 9-month randomized clinical trial with 391 patients found that from a societal perspective, a tele-dermatology appointment was US$82 less expensive per patient than a conventional referral.
“This 9-month randomized clinical trial with 391 patients found that from a societal perspective, a tele-dermatology appointment was US$82 less expensive per patient than a conventional referral (Datta et al., 2015).”
From Patient and practitioner satisfaction with tele-dermatology including Australia’s indigenous population: A systematic review of the literature (2016) · cites this paper as Datta et al., 2015
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Teledermatology: Economics and Cost-Effectiveness
Zakaria, A., & Amerson, E. H. (2023) · Updates in clinical dermatology · doi:10.1007/978-3-031-27276-9_6
Heselmans, A., Aertgeerts, B., Roegies, K., Beele, H., Verhaeghe, E., Sutter, A. D., & Delvaux, N. (2025) · International Journal of Clinical Practice · doi:10.1155/ijcp/2314602
Kristensson, H., Nätterdahl, C., Persson, B., Saleh, K., Kappelin, J., Helkkula, T., Johansson, F. N. J., Palmgren, J., Lapins, J., Rados, N., et al. (2026) · Archives of Dermatological Research · doi:10.1007/s00403-025-04482-7
Effectiveness of Teledermatology in Clinical, Patient, and Operational Outcomes: A Systematic Review
Ijaz, M., Mizori, R., & Omran, Y. A. (2026) · Dermatology Practical & Conceptual · doi:10.5826/dpc.1601a6055
Socioeconomic Evaluation of Pediatric Teledermatology in a Tertiary Hospital
Palazón‐Cabanes, J. C., Juan‐Carpena, G., Cabanes, B. P., de Gracia, L. B., Martínez-Miravete, M. T., & Betlloch, I. (2026) · Telemedicine Journal and e-Health · doi:10.1177/15305627261432980
Björkman, K. O., Rejler, M., Masterson, D., Arvidsson, E., & Fristedt, S. (2026) · BMJ Open · doi:10.1136/bmjopen-2025-105430
- Authors
- Datta, S. K., Warshaw, E. M., Edison, K. E., Kapur, K., Thottapurathu, L., Moritz, T. E., Reda, D. J., & Whited, J. D.
- Affiliations
- Duke Medical Center (US)
- University of Minnesota (US)
- University of Missouri (US)
- Boston Children's Hospital (US)
- Edward Hines, Jr. VA Hospital (US)
- Venue
- JAMA Dermatology
- Publisher
- American Medical Association (AMA)
- Published
- 2015-12-01
- Volume
- 151
- Issue
- 12
- Pages
- 1323
- ISSN
- 2168-6068 (ISSN-L)
- OpenAlex
- W2123692745
- Cited by
- 72
- References
- 13
- Citations by year
- 2026: 4 · 2025: 1 · 2024: 5 · 2023: 5 · 2022: 10 · 2021: 8 · 2020: 12 · 2019: 5 · 2018: 6 · 2017: 7 · 2016: 8 · 2015: 1
- FWCI
- 7.85
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- JAMA Dermatology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Health Systems, Economic Evaluations, Quality of Life
- Social Sciences › Business, Management and Accounting › Organizational Behavior and Human Resource Management › Healthcare Systems and Technology
- Keywords
- store-and-forward teledermatology, dermatology referral, cost analysis, health utility, time trade-off, veterans, primary care referral, cost-effectiveness, societal perspective, Department of Veterans Affairs, telehealth implementation, cost per participant, cost per quality-adjusted life year
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