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Original Article
DOI: 10.1016/j.adengl.2021.05.009
Open Access
Available online 22 May 2021
What Proportion of the Caseload at Dermatology Outpatient Clinics in Spain Do Skin Tumors Account for? Results from the DIADERM National Random Sampling Project
¿Cuánta carga asistencial supone la enfermedad tumoral cutánea en la actividad ambulatoria en la Dermatología española? Resultados del muestreo aleatorio nacional DIADERM
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A. Martin-Gorgojoa,b,
Corresponding author
alejandromartingorgojo@aedv.es

Corresponding author.
, M.Á. Descalzo-Gallegob, S. Arias-Santiagoc, A. Molina-Leyvac, Y. Gilaberted, P. Fernández-Crehuete, H. Husein-ElAhmedf, A. Viera-Ramírezg, P. Fernández-Peñash, R. Taberneri, A. Buendía-Eismanj, I. García-Dovalb
a Sección de Especialidades Médicas, Servicio de ITS/Dermatología, Ayuntamiento de Madrid, Madrid, Spain
b Unidad de Investigación, Fundación Piel Sana, Academia Española de Dermatología y Venereología, Madrid, Spain
c Servicio de Dermatología, Hospital Virgen de las Nieves, Granada, Spain
d Servicio de Dermatología, Hospital Universitario Miguel Servet, IIS Aragón, Zaragoza, Spain
e Servicio de Dermatología, Hospital Universitario Reina Sofía, Córdoba, Spain
f Servicio de Dermatología, Hospital General de Baza, Baza, Granada, Spain
g Servicio de Dermatología, Hospital Santa Catalina, Las Palmas de Gran Canaria, Canarias, Spain
h Department of Dermatology, Westmead Hospital, The University of Sydney, Westmead, New South Wales, Australia
i Departamento de Dermatología, Hospital de Son Llàtzer, Palma de Mallorca, Baleares, Spain
j Facultad de Medicina, Universidad de Granada, Granada, Spain
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Tables (3)
Table 1. Estimated Frequency of Diagnoses Made in Spain by Dermatologists in the Outpatient Clinic.
Table 2. Characteristics of Tumors Diagnosed in Spain.
Table 3. Description of Administrative Characteristics (Care Modality, Origin, and Destination) for Tumor-Associated Disease vs Non–Tumor-Associated Disease.a
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Abstract
Introduction and objective

A significant part of a dermatologist’s activity involves the diagnosis and management of tumors.The aim of this study was to analyze the caseload at public and private dermatology outpatient clinics in Spain to determine the proportion of tumor diagnoses.

Material and method

Observational cross-sectional study of diagnoses made in dermatology outpatient clinics during 2 data-collection periods in the DIADERM study, an anonymous survey of a random, representative sample of dermatologists across Spain. Diagnoses made during the 2 periods were coded according to the 10th revision of the International Classification of Diseases. There were 165 tumor-related codes, classified into 24 groups. For the purpose of this study, these groups were then reduced to benign melanocytic lesions, malignant melanocytic lesions, benign nonmelanocytic lesions, and malignant nonmelanocytic lesions.

Results

Tumors accounted for 46.2% of all diagnoses; 18.5% of the tumors were malignant (a category that included in situ forms of keratinocyte cancers). Four of the 10 most common diagnoses were of malignant tumors: in situ keratinocyte cancers, basal cell carcinoma, melanoma, and squamous cell carcinoma. Significant differences were observed between malignant and benign tumors according to type of practice (public vs. private) and geographic region.

Conclusion

Skin cancer accounts for a significant part of the dermatologist’s caseload in Spain. Differences can be observed depending on the public/private healthcare setting and other factors.

Keywords:
International Classification of Diseases 10th Revision
Hospital outpatient clinics
Ambulatory care
Dermatology
Prevalence
Skin neoplasms
Resumen
Introducción y objetivo

La patología tumoral conforma una parte esencial de la actividad dermatológica. El presente estudio pretende analizar la carga de la patología tumoral en la actividad dermatológica pública y privada del sistema de salud español.

Material y método

Estudio observacional de corte transversal de dos períodos de tiempo describiendo los diagnósticos realizados en consultas externas dermatológicas, obtenidos a través de la encuesta anónima DIADERM, realizada a una muestra aleatoria y representativa de dermatólogos. A partir de la codificación de diagnósticos CIE-10, se seleccionó toda la patología tumoral (165 diagnósticos codificados en los dos períodos), que se clasificaron en 24 grupos, posteriormente subclasificados en patología benigna y maligna, melanocítica y no melanocítica.

Resultados

El 46,2% de los diagnósticos fueron de patología tumoral. El 18,5% de los diagnósticos globales se debió a patología tumoral maligna (incluyendo entre estos diagnósticos los tumores queratinocíticos in situ). De los primeros 10 diagnósticos de patología tumoral en frecuencia, 4 eran malignos: tumores queratinocíticos in situ, carcinoma basocelular, melanoma y carcinoma espinocelular. Se encontraron algunas diferencias significativas entre patología tumoral maligna y benigna atendiendo al ámbito de su asistencia (público/privado), así como a factores geográficos.

Conclusión

El cáncer cutáneo tiene un peso importante en la asistencia dermatológica en España. Se pueden observar algunas diferencias en función del ámbito de atención público/privado y de otros factores.

Palabras clave:
Clasificación Internacional de Enfermedades 10.a revisión
Consulta externa hospitalaria
Actividad ambulatoria
Dermatología
Prevalencia
Neoplasias cutáneas
Full Text
Introduction

The objective of the DIADERM study was to analyze diagnoses made in the dermatology clinics of members of the Spanish Academy of Dermatology and Venereology (Academia Española de Dermatología y Venerología [AEDV]).1 The study showed that the most common diagnoses made by dermatologists belonged to the following categories of the International Statistical Classification of Diseases, Tenth Edition (ICD-10): L57 (skin abnormalities, such as actinic keratosis), C44 (nonmelanoma skin cancer, such as basal cell carcinoma), and D22 (melanocytic nevi). This finding highlighted the importance of skin cancer in the daily practice of dermatologists.

The caseload generated by dermatologic conditions in primary care is substantial,2 and a considerable percentage of patients are referred from this level to dermatology clinics. Similarly, the dermatologist plays an active role on hospital wards3,4 and in emergency departments.5 Dermatologists show better diagnostic performance with respect to skin tumors (agreement between the presumptive diagnosis of primary care specialists and dermatologists is weaker in skin tumors6). The same is true for therapeutic performance. In addition to being the main parties involved in the surgical treatment of skin cancer,7 dermatologists are more effective and efficient with respect to this condition, according to data from Spain.8 They also achieve a lower percentage of positive margins in keratinocyte carcinoma than other surgical specialties,9 as well as better outcomes in the treatment of patients with melanoma.10

We estimated the prevalence of coded diagnoses in dermatology clinics to measure the demand for outpatient care of tumors by dermatologists in Spain. We also analyzed some of the differences between these diagnoses according to factors such as geographic area, origin of the consultation, and destination of the referral, taking into accout both public and private health care settings.

Methods

We performed a cross-sectional observational study based on estimated data on the prevalence of skin diseases collected over 2 periods (January 19 to 21 and May 18 to 20, 2016). The data were obtained via the anonymous DIADERM survey, which was carried out in a random and representative sample of dermatologists in Spain. The methodology and characteristics of the survey (including the data collected and the method for coding the diagnoses) are addressed in detail in the first manuscript of the project.1

The specific analysis of tumors was made by reviewing the complete list of coded diagnoses, from which a total of 165 diseases were selected. Based on the list of selected diagnoses, we formed 24 diagnostic groups, which, in some cases, included more than 1 category from the ICD-10. In order to perform the statistical analyses, the classification was reduced to 4 groups (benign melanocytic, malignant melanocytic, benign nonmelanocytic, and malignant nonmelanocytic) and 2 groups (benign and malignant vs non–tumor-associated disease). In situ keratinocyte cancers (including actinic keratosis, Bowen disease, and leukoplasia) were classified as malignant. Keratoacanthomas were also included as malignant tumors: while these are traditionally categorized as benign, they are now considered a well-differentiated form of squamous cell carcinoma.11 Similarly, cutaneous horns were classified as malignant, since, in a significant percentage of cases, this clinical diagnosis is associated with premalignant or malignant lesions.12

We included variables that had previously been collected in the study, as well as the type of climate (subtropical, Mediterranean, continental-Mediterranean, and oceanic; this variable was created in ecological terms by taking into account the geographic areas of each of the sections and its predominant climate).

The statistical analysis was performed using the survey module of Stata and taking into consideration the design used to collect the sample.13 The module includes standard errors for correlated data. Furthermore, given the real number of dermatologists for each section of the AEDV, which was close to unity, it was not necessary to apply a correction for finite populations.

The study was classified as a non–postauthorization study by the Spanish Agency of Medicines and Medical Devices and approved by the Clinical Research Ethics Committee of the Province of Granada, Spain (October 8, 2014).

Results

Tumors accounted for 46.2% of the diagnoses; 18.5% of all diseases seen at the clinic were malignant. Table 1 shows the population-based diagnoses by group in order of frequency. Of the 10 most common diagnostic groups, in situ keratinocyte tumors were second in frequency, basal cell carcinoma fourth, malignant melanocytic tumors eighth, and squamous cell carcinoma ninth.

Table 1.

Estimated Frequency of Diagnoses Made in Spain by Dermatologists in the Outpatient Clinic.

Grouped Diagnosis  Estimated Frequency in 5 Days (1 Working Week)  Percentage of Tumor Group  Percentage of Total Diagnoses 
Benign melanocytic tumors  16 677  20.4  9.4 
In situ keratinocyte tumors  14 858  18.2  8.4 
Seborrheic keratosis and associated conditions  12 687  15.5  7.2 
Basal cell carcinoma  10 934  13.4  6.2 
Benign fibrous tumors  5653  6.9  3.2 
Benign adnexal tumors  4597  5.6  2.6 
Potentially UV-induced benign tumors  4546  5.6  2.6 
Malignant melanocytic tumors  2865  3.5  1.6 
Squamous cell carcinoma  2662  3.3  1.5 
Benign vascular tumors  2302  2.8  1.3 
Other benign lesions  1246  1.5  0.7 
Cancer-related syndromes (and associated benign lesions)  740  0.9  0.4 
Cutaneous horn and keratoacanthoma  636  0.8  0.4 
Lymphomas  366  0.4  0.2 
Hamartomas and associated conditions  302  0.4  0.2 
Malignant tumor NOS  208  0.3  0.1 
Metastasis and associated conditions  191  0.2  0.1 
Nonclassified tumors  96  0.1  0.1 
Malignant vascular tumors  77  0.1  0.0 
Melanocytosis  64  0.1  0.0 
Basosquamous cell carcinoma  32  0.0  0.0 
Merkel carcinoma  32  0.0  0.0 
Malignant adnexal tumors  31  0.0  0.0 
Fibroepithelioma of Pinkus  16  0.0  0.0 
Subtotal for tumor diagnoses  81 820  100  46.2 
Subtotal for non–tumor diagnoses  95 152    53.8 
Total  176 972    100 

Abbreviation: NOS, not otherwise specified.

Table 2 shows the differences between the variables, taking into account the 4 tumor groups. Malignant tumors were more likely to be the main presenting complaint and the reason for follow-up visits. They were also more likely to be managed in the public health system and less likely to be the definitive diagnosis. The differences were statistically significant.

Table 2.

Characteristics of Tumors Diagnosed in Spain.

Characteristic  Benign Melanocytic (n = 16 741; 21%)  Malignant Melanocytic (n = 2865; 3%)  Benign Nonmelanocytic (n = 32 074; 39%)  Malignant Nonmelanocytic (n = 29 835; 37%)  Total (N = 81 515)  P 
  n (% of Column Total)  n (% of Column Total)  n (% of Column Total)  n (% of Column Total)  n (% of Column Total)   
Presenting complaint            .000 
Primary (presenting complaint and diagnosis are the same)  13 418 (83)  2596 (92)  23 504 (75)  24 020 (83)  63 539 (80)   
Secondary  2788 (17)  238 (8)  7664 (25)  4879 (17)  15 568 (20)   
Diagnostic confirmation            .007 
Probable  1224 (7)  328 (11)  3032 (10)  4048 (14)  8631 (11)   
Definitive  15 150 (93)  2522 (89)  28 556 (90)  25 297 (86)  71 524 (89)   
Checkups            .000 
Diagnosis during follow-up visit  8070 (48)  2513 (88)  12 827 (40)  19 968 (67)  43 376 (53)   
New patient  8671 (52)  353 (12)  19 248 (60)  9868 (33)  38 139 (47)   
System            .000 
Private  5538 (35)  285 (10)  13 138 (42)  5092 (18)  24 053 (31)   
Public  10 339 (65)  2566 (90)  17 915 (58)  23 852 (82)  54 671 (69)   
Survey phase            .150 
January (cold season)  8709 (52)  1677 (59)  18 226 (57)  17 202 (58)  45 813 (56)   
May (warm season)  8032 (48)  1188 (41)  13 848 (43)  12 634 (42)  35 703 (44)   
Type of climatea            .005 
Subtropical  1011 (6)  347 (12)  2153 (7)  1763 (6)  5273 (6)   
Mediterranean climate  7193 (43)  1160 (40)  16 501 (51)  14 568 (49)  39 422 (48)   
Continental-Mediterranean  7053 (42)  771 (27)  10 306 (32)  10 259 (34)  28 389 (35)   
Oceanic  1484 (9)  588 (21)  3115 (10)  3246 (11)  8432 (10)   
Geographic area            NA 
Asturias, Cantabria, and Castile-Leon (ACCL)  1523 (9)  76 (3)  2756 (9)  1599 (5)  5954 (7)   
Andalusia  2033 (12)  320 (11)  5219 (16)  4290 (14)  11 863 (15)   
Balearic Islands  338 (2)  33 (1)  532 (2)  693 (2)  1595 (2)   
Canary Islands  1011 (6)  347 (12)  2153 (7)  1763 (6)  5273 (6)   
Catalonia  1853 (11)  472 (16)  4665 (15)  3676 (12)  10 666 (13)   
Central Spain  2816 (17)  354 (12)  3991 (12)  5021 (17)  12 182 (15)   
Galicia  1484 (9)  588 (21)  3115 (10)  3246 (11)  8432 (10)   
Murcia  156 (1)  57 (2)  213 (1)  425 (1)  850 (1)   
Basque Country, Navarre, Aragon, and La Rioja (VNAR)  2714 (16)  342 (12)  3559 (11)  3640 (12)  10 253 (13)   
Valencia  2812 (17)  280 (10)  5873 (18)  5484 (18)  14 448 (18)   

The frequencies correspond to the estimated number of lesions seen in the dermatology outpatient clinic during 5 working days throughout Spain.

a

Predominantly subtropical climate: Canary Islands. Predominantly oceanic climate: Galicia. Predominantly continental climate: ACCL, central Spain, VNAR. Predominantly Mediterranean climate: other areas.

As for the ecological analysis of the type of climate according to geographic area, we recorded a larger percentage of benign melanocytic tumors in areas with a mainly continental-Mediterranean climate, malignant melanocytic tumors in areas with a mainly oceanic and subtropical climate, and benign nonmelanocytic tumors in areas with a mainly subtropical and Mediterranean climate.

Table 3 shows the results of an analysis of specific variables by comparing non–tumor-associated disease with benign and malignant tumors. Statistically significant differences were observed between the groups with respect to the origin and destination of the referrals. In private clinics, consultations for malignant tumors were proportionally more likely to come from another dermatologist. As for destination, patients with benign tumors were more frequently discharged, whereas those with malignant tumors were usually referred for additional dermatologic care. In the public health setting, malignant tumors were also more likely to be referred from another dermatologist. In more than half of cases, benign tumors came from primary care physicians. Patients with benign tumors were somewhat more likely to be discharged (and less likely to receive additional dermatologic care) in the public setting than in the private setting. As in the private setting, patients with malignant tumors were normally referred for additional dermatologic care. Follow-up was more likely to be with the primary care physician for all diseases, including malignant tumors, in the public setting than in the private setting.

Table 3.

Description of Administrative Characteristics (Care Modality, Origin, and Destination) for Tumor-Associated Disease vs Non–Tumor-Associated Disease.a

Characteristics  Nontumor (n = 95 152; 54%)  Benign Tumor (n = 48 814; 28%)  Malignant Tumor (n = 32 701; 18%)  Total (N = 176 667)  P Value 
  n (% of Column Total)  n (% of Column Total)  n (% of Column Total)  n (% of Column Total)   
Teledermatology          .568 
No  93 074 (99)  48 400 (99)  32 237 (99)  173 711 (99)   
Yes  934 (1)  414 (1)  464 (1)  1813 (1)   
Origin: private health system          .002 
Direct  22 197 (75)  14 355 (78)  3203 (60)  39 755 (75)   
PCP  2283 (8)  838 (5)  430 (8)  3550 (7)   
Specialist  946 (3)  350 (2)  257 (5)  1553 (3)   
Dermatologist  4068 (14)  2865 (16)  1440 (27)  8374 (16)   
Destination: private health system          .000 
Discharge  6914 (23)  7826 (43)  468 (9)  15 208 (29)   
PCP  468 (2)  129 (1)  65 (1)  663 (1)   
Specialist  411 (1)  273 (1)  192 (4)  875 (2)   
Dermatologist  21 778 (74)  10 167 (55)  4638 (86)  36 583 (69)   
Origin: public health system          .000 
Direct  6789 (11)  3514 (13)  1490 (6)  11 793 (10)   
PCP  24 776 (41)  15 937 (57)  7907 (30)  48 618 (42)   
Specialist  4413 (7)  884 (3)  994 (4)  6290 (5)   
Dermatologist  24 958 (41)  7647 (27)  15 678 (60)  48 283 (42)   
Destination: public health system          .000 
Discharge  14 875 (24)  13 487 (48)  2636 (10)  30 998 (27)   
PCP  4936 (8)  1457 (5)  992 (4)  7384 (6)   
Specialist  1289 (2)  478 (2)  753 (3)  2519 (2)   
Dermatologist  39 383 (65)  12 438 (45)  21 680 (83)  73 501 (64)   

Abbreviation: PCP, primary care physician.

a

The frequencies correspond to the estimated number of lesions seen at the dermatology outpatient clinic over 5 working days throughout Spain.

Discussion

In the present study, we observed that tumors accounted for almost half of the diagnoses made in dermatology outpatient clinics (46.2%) in Spain. Overall, 18.5% of the caseload of specialists in medical-surgical dermatology and venereology in Spain corresponds to malignant tumors (including in situ keratinocyte tumors). If we exclude in situ keratinocyte cancers, this percentage falls to 10.1%. Patients with malignant tumors as the main reason for seeking care tend to be seen more frequently in the public health setting and generate more follow-up visits. Differences were also observed with respect to the origin and destination of the consultations, depending on whether they were managed in the private or public setting, although this could be affected a priori by organizational factors.

The method followed to classify patients was similar to that used in other studies in Europe, insofar as tumors were classed as benign and malignant.14,15 This approach attempted to be more inclusive than in other studies, where the only cancers taken into consideration were basal cell carcinoma,16 squamous cell and basal cell carcinoma,17 and nonmelanoma skin cancer.13 Given that keratoacanthoma was traditionally considered benign and cutaneous horns as benign or malignant, we also performed a sensitivity analysis including both diagnoses as benign tumors and found no significant variations in our findings (data not shown).

Although differences in diagnoses were analyzed according to geographic region, this was not specifically by comparing rural and urban areas, as in a study performed in Australia.18 In any case, we believe that the manner in which the data were analyzed provides a more complete idea of the real caseload of skin tumor diagnoses in Spain than other approaches, since not all tumors require surgery8 or are managed via interdepartmental consultations (with the percentage of activity above the 5.7% that interdepartmental consultations for skin cancers were thought to represent19).

Dermatologists’ caseload has grown in recent decades, with a clear increase in tumor diagnoses.6,13–15 The economic impact of skin cancer on health systems is growing and clear, and according to a recent study based on data from public hospitals in Portugal, it is 4-fold greater when the overall number of nonmelanoma cases is compared with the number of melanoma cases.20 Some groups have proposed new forms of multidisciplinary and integrated management of patients with skin tumors.21 The specialist in medical-surgical dermatology and venereology clearly plays a key role in the care of these patients.

Our study has a series of strengths, such as the methodology used (representative of the demand for dermatologic care) and its sample size, which enabled us to report accurate results. Its limitations include potential error in measuring the ecological variable climate (which was generated based on the predominant one and only for purposes of generating a hypothesis).

Conclusion

Almost one-fifth of the caseload of specialists in medical-surgical dermatology and venereology in Spain corresponds to malignant cutaneous tumors. Differences are observed between diagnoses based on factors such as the care setting (public vs. private), the geographic area, and the origin of the consultation and destination at discharge. Additional studies are warranted to analyze these factors and determine whether they are due to geographic, cultural, or organizational aspects or to variability in clinical practice.

Funding

The DIADERM study was promoted by the Healthy Skin Foundation of the Spanish Academy of Dermatology and Venereology (Fundación Piel Sana de la Academia Española de Dermatología y Venereología), which received funding from Novartis. The pharmaceutical company did not participate in data collection, data analysis, or interpretation of the results.

Conflicts of interest

The authors declare that they have no conflicts of interest.

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Please cite this article as: Martin-Gorgojo A, Descalzo-Gallego MÁ, Arias-Santiago S, Molina-Leyva A, Gilaberte Y, Fernández-Crehuet P, et al., ¿Cuánta carga asistencial supone la enfermedad tumoral cutánea en la actividad ambulatoria en la Dermatología española? Resultados del muestreo aleatorio nacional DIADERM, ACTAS Dermo-Sifiliográficas, 2021, https://doi.org/10.1016/j.ad.2021.02.004

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