Cost-minimization analysis of teledermatology versus conventional care in the Brazilian National Health System

Teledermatology has been constantly expanding in global health systems. The development of technological advances combined with the increased demand for dermatological care have led to the implementation and growth of this area. Teledermatology services have become a reliable and cost-effective access alternative for populations in need of dermatological care [1]. A literature review focusing on diagnosis and treatment of skin diseases through teledermatology confirmed the effectiveness of this alternative to improve accessibility to specialized care, as well as in diagnostic and therapeutic agreement, and in skin care provided by physicians, while reducing costs [2,3]. What makes it attractive is the optimization of care processes, resulting in more efficient use of resources, both financial and human [4]. The exchange of information about a patient between a nondermatologist and a dermatologist found good diagnostic efficiency and accuracy, with reduced costs and improved quality of life for patients [5]. On the other hand, a systematic review of economic evaluations focusing on telemedicine confirmed that it is cost–effective for applying in major medical fields, but in dermatology, studies could not confirm the positive capability of telemedicine. The authors pointed out that the evidence they analyzed was inconsistent, across a wide range of fields [6]. Nevertheless, the limited literature evaluating the economic consequences of teledermatology suggests that teledermatology may be cost–effective [7].

Brazil is a country of continental dimensions, and telehealth is a necessity and a solution for the integration of assistance networks, as well as for the coordination among the levels of care in the Brazilian National Health System (known by its acronym SUS). An integrated health system shows better results in terms of quality and efficiency [8]. The Telehealth Center of the State of Santa Catarina (TCSC) is one of the centers of the Brazilian Telehealth Program, an initiative of the Ministry of Health. Developed by the Federal University of Santa Catarina, in partnership with local government secretariat and municipalities, the TCSC telemedicine service aims to offer citizens better access to medical examinations, including dermatological, through a technological infrastructure that supports the performance of these examinations in the municipalities and their subsequent submission to the TCSC, meeting the needs of local professionals and strengthening primary care and the SUS [9]. A cost-minimization analysis (CMA) was conducted with 79,411 patients referred to the TCSC teledermatology service, in Santa Catarina State, Brazil, between January 1^st, 2016 and December 31^st, 2018. A decision tree model was performed to compare the cost of managing patients’ care in this teledermatology service versus the cost for the provision of conventional care. The economic analysis was carried out from the societal perspective.

During the period, 79,411 exams were performed at the teledermatology service; in that, 29.2% in 2016, 28.9% in 2017 and 42.0% in 2018. Most patients were female (63.7%), with a mean age of 50.4 (±20) years.

There was an increase of 43.8% in the examinations performed by the teledermatology service, from 2016 to 2018. In 2016, 9737 patients were classified in the categories white and blue, and this number increased to 13,179 in 2018. Between the years 2016 and 2018, 40.2% of exams were classified as a white or blue risk category, 40.0% as green and 19.8% as yellow. There were no significant differences in the distribution of categories between the years observed. Of the 15,693 exams classified as yellow and referred to tertiary care, 75.2% were suspected of having nonmelanoma skin cancer, 8.6% moderate-to-severe psoriasis, and 6.6% melanoma skin cancers.

In the 2013–2015 triennium, there were 7597 hospitalizations due to any of the selected dermatological diagnoses. In the 2016–2018 triennium, this figure rose to 10,751 hospitalizations. There was a decrease in the mean number of days spent at the hospital, which fell from 3.71 days in the first 3 years to 1.92 days in the second triennium (p < 0.001).

An important aspect to be emphasized in this evaluation refers to the innovation caused by teledermatology in the organization of health actions and services in the state of Santa Catarina. This organization proposal aimed to reduce unnecessary referrals and reduce the waiting time for consultation with specialists. In addition, it sought to provide support to the primary care professional in patient management [8,9,14].

A reduction of unnecessary referrals was observed in the 2016–2018 3-year period, and more patients could have been managed in primary care, avoiding commuting and expanding the access of more severe patients to the specialist. After the implementation of the teledermatology service in 2015, there was a significant drop in the number of patients on the waiting list, from 4080 to 98 patients, as well as in the average waiting time, from more than 1000 to 20 days, when comparing 2013 with 2017 [15]. Reductions in waiting list time after implementing teledermatology were also seen in Spain and the USA [16,17]. Moreover, it was found that teledermatology increased access to face-to-face dermatological care [17], and the mean rate of dermatological consultations avoided ranged from 45.5% to 57.0% when adopting the asynchronous system (store and forward), which reinforces its feasibility and importance, helping the general physicians to manage such conditions and optimizing medical hours and costs, especially in the public system [18,19]. A systematic review estimated the use of asynchronous teledermatology was associated with 43% of avoided trips [20]. These proportions reported in the literature are very close to those observed in the teledermatology service in Santa Catarina, which also adopts the asynchronous model.

The highest number of patients with their dermatological problems solved in primary care may be related to a higher qualification of care at this level. The educational benefit derived from the content of the teledermatology consultation is mentioned in the literature as a useful resource, with feedback many times faster than through traditional consultation processes [18], observing better knowledge of dermatology among primary care physicians who used this referral system [21,22].

Another aspect that deserves to be highlighted is the growth in the number of hospitalizations due to selected dermatological conditions, during the period 2016–2018, which occurred simultaneously with a significant decrease in the mean number of days spent at the hospital. A possible explanation for this, although not exhaustive, refers to the reduction of barriers to access to care. However, we have assumed that patients with the same diagnosis of hospitalization in different periods are matching cases, which is a limitation of this study. In addition, any change in the dermatological practice between the time periods could have contributed to differences seen in model parameters, although the teledermatology service team had not reported significant changes in this practice. A prospective study in university hospitals found teledermatology reduces the time required for a dermatologist to respond and the time required for a primary care team to receive an answer for a consultation to define the need for hospitalization. These findings suggest teledermatology as a tool to improve access to tertiary-level dermatological care [23]. In addition, teledermatology is a valuable mechanism for dermatologists to screen appointments and increase efficiency, thus expanding access to specialized care for hospitalized patients [24].

Teledermatology increases access to care without increasing cost [25]. A cost-minimization analysis was conducted to compare the organization-wide cost of managing referred dermatology patients within a teledermatology triage system versus a conventional dermatology care model at a general hospital. The study suggests that using teledermatology to triage and manage dermatology patients within a capitated healthcare system may be associated with significant cost savings [26]. Telemedicine usually avoids the overhead costs in the healthcare system that are associated with conventional in-person care. However, we also must consider societal costs [27].

The economic evaluation developed in this study adopted the societal perspective and included the use of direct medical resources in the production of procedures, in addition to commuting costs from the municipality of residence to the service, per diem and opportunity costs for the patient and companion, when applicable. In the scenario assessed here, teledermatology proved to be a cost-saving alternative to conventional care. The sensitivity analysis shows that incremental costs could vary according to the amounts spent on patients in secondary care. This finding reinforces the importance of teledermatology in reducing commuting costs and productivity loss for patients since it avoids unnecessary expenses [3,28]. In a country of continental dimensions such as Brazil, where distances separating rural and urban areas can be very large, the use of teledermatology has the potential to generate substantial savings in resources, as well as greater patients satisfaction.

Given that asynchronous teledermatology has the potential to reduce commuting and offers greater convenience to the patient, these gains can be addressed more holistically from a societal perspective [29,30].

The available current economic evidence is sparse, but suggested the asynchronous store-and-forward teledermatology may be cost-effective, especially when used as a screening mechanism to reduce the demand for face-to-face consultations and when considering the costs associated with productivity loss [7,29,31–33]. In this sense, our results are in line with the literature. However, because of country-specific variations in the health systems, it is problematic to generalize economic evaluations of telemedicine interventions from one country to another [6].

According to Landow et al. [32], by maximizing the time of a scarce resource, such as dermatologists, teledermatology provides improved access by increasing the number of patients evaluated and treated, and avoiding unnecessary and time-consuming face-to-face consultations. In this way, it fulfills three promises it makes about dermatological care: to be better, cheaper and faster. It is ‘better’ because, although it cannot offer the patient as much as a traditional visit, it extends the dermatologist’s reach to places and in ways that were previously not possible due to time and place limitations. It is ‘cheaper and faster’ for having the potential to reduce costs and increase the efficiency of patients and providers, by resulting in less time away from work and faster service. The results obtained by the present economic evaluation, focusing on the teledermatology service in Santa Catarina, are consonant with the fulfillment of these promises

A cost-minimization analysis was performed comparing the teledermatology service of the State of Santa Catarina, Brazil with the provision of conventional care. This economic evaluation adopted the societal perspective and included the use of direct medical resources in the production of procedures, in addition to commuting costs from the municipality of residence to the service, per diem and opportunity costs for the patient and companion, when applicable. In the scenario assessed here, teledermatology proved to be a cost-saving alternative to conventional care. This finding reinforces the importance of teledermatology in reducing commuting costs and productivity loss for patients since it avoids unnecessary expenses.

FA Acurcio, AA Guerra Junior and JA Teodoro designed the study, collected and analyzed the data and wrote the manuscript. MM Garcia and RG Pereira collected data, contributed with the discussion and reviewed the manuscript. M Akerman, LF Spinel, IC Borysow, RR Silva, PS Azevedo and PCIC Gomes contributed with the discussion and reviewed the manuscript. MCM Calvo and DH Nunes designed the study, contributed with the discussion and reviewed the manuscript. All authors approved the final version of the manuscript.

The authors are indebted to the team of the Telehealth Center of the State of Santa Catarina (TCSC) for their research support.

This study was supported by the Project ‘Diagnostic Evaluation of the Brazil Telehealth Program Networks,’ developed by the Hospital Alemão Oswaldo Cruz (HAOC), based on an agreement established with the Ministry of Health, under the Institutional Development Program of the Brazilian National Health System (PROADI-SUS). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Ethical aspects and confidentiality were strictly safeguarded, insofar as the data from a secondary source were not identified, access to them remained restricted to researchers, and results were presented exclusively in an aggregated manner. The principles outlined in the Declaration of Helsinki have been followed.