From screen to scalpel: safety, efficiency and diagnostic performance of a direct-to-surgery teledermatology pathway

Teledermatology is increasingly used to triage urgent suspected skin cancer referrals. A direct-to-surgery pathway allows selected patients to proceed directly to biopsy or excision without a preliminary face-to-face consultation. This study evaluated the safety, efficiency and diagnostic performance of a direct-to-surgery teledermatology pathway within a large National Health Service (NHS) skin cancer service.

A service evaluation was conducted at the University Hospitals of North Midlands. All teledermatology referrals received between February 2022 and July 2024 were reviewed. Demographics, pathway intervals, surgical outcomes, cancellations, histopathology and complications were extracted from electronic records. The primary outcome was compliance with the 28-day Faster Diagnosis Standard. Secondary outcomes included compliance with the 62-day referral-to-treatment target, surgical complications, cancellation rates and diagnostic concordance between teledermatology assessment and histopathology.

Of 18 587 teledermatology referrals, 5120 were triaged to the direct-to-surgery pathway. Following exclusion of 20 miscoded entries and 1 duplicate record, 5099 patients were included. A total of 4830 patients underwent surgery and 4825 had definitive histopathological diagnoses. The median time from referral to histology reporting was 46 days. Compliance with the 28-day Faster Diagnosis Standard was 99.86% (5092/5099), substantially exceeding the national target of 75%. Among patients diagnosed with melanoma or squamous cell carcinoma, 75.5% (440/583) commenced treatment within the 62-day referral-to-treatment target. Histopathology identified malignant pathology in 35.5% of lesions and premalignant pathology in a further 15.5%. Among lesions with both a recorded teledermatology diagnosis and definitive histology, overall concordance was 41.5% (1113/2679) with fair agreement (Cohen's κ=0.34). The overall complication rate was 1.3%.

This large single-centre evaluation demonstrates that a direct-to-surgery teledermatology pathway can safely support high-volume skin cancer surgery while achieving excellent compliance with the Faster Diagnosis Standard. Low complication rates and efficient progression through the diagnostic pathway support the use of teledermatology as an effective risk-stratification tool within contemporary skin cancer services.