Benign skin lesions are a common reason patients consult both primary care physicians and dermatologists. The impact of these consultations on caseloads in public medicine has not been studied in depth, but Macaya and coworkers1 did report that 25% of visits to a dermatologist were related to requests for aesthetic procedures for acrochordons, intradermal melanocytic nevi, seborrheic keratoses without inflammation, solar lentigines, ruby points, or wrinkles. We note that lesions of this type potentially generate a high level of demand for services: melanocytic nevi, for example, can be present in 100% of patient populations.

Minor outpatient surgery has been included in the portfolio of services provided at the primary care level during the last 10 years. At the same time, priority has been placed on oncologic processes at the level of hospital care, and as a result the organization and function of health care services have had to be redesigned. Clients’ access to diagnostic and therapeutic procedures for benign skin lesions has therefore come to vary greatly across the system, mainly because explicit, standardized criteria have not been established to guide the handling of these cases.2,3 In the absence of clinical criteria, some centers have applied Royal Decree 63/1995 on the organization of health care services in the Spanish National Health Service (NHS). Article 2.3c of that decree states that “attention, care, or services to improve aesthetic or cosmetic problems shall not be covered.”4,5 Later, Royal Decree 1030/2006 established a portfolio of common NHS services and the procedures for updating the list; among the exclusions from that portfolio were therapies “such as the use of waters, spas, or residential facilities or similar that are directed toward leisure activities, recreation, comfort, sports or aesthetic or cosmetic improvements.”6 In any case, from the clinical and organizational point of view, this normative framework should be reflected explicitly in the clinical pathway that patients follow and the decisions taken in specific situations at each care level (in primary care centers and clinical management units [CMUs] for dermatology).

In addition to the issue of variability of access to services, and the consequent risk of unequal care, there is also a clinical concern of particular importance: some types of benign lesions are especially difficult to diagnose, notably with respect to distinguishing benign melanocytic lesions from melanoma. This consideration should be reflected in any guidelines or recommendations intended to standardize the care of persons presenting with benign skin lesions.

In 2014, the Andalusian Regional Section of the Spanish Academy of Dermatology and Venereology (AEDV) created a working group to develop a portfolio of services for application by CMUs coordinating medical and surgical procedures in dermatology and sexually transmitted infections within the Andalusian NHS.7 The first step in the portfolio's development process consisted of defining functional units (nonmelanoma skin cancer, psoriasis, melanoma, sexually transmitted infections, etc.) and areas of care (general dermatology, dermatologic surgery, etc.). Next, relevant diseases were identified and grouped under the functional units, and the diagnostic and/or therapeutic procedures undertaken by dermatologists at each organizational level were specified. Finally, care processes were identified or developed for conditions that had priority or those for which no documentary support was in place (namely atopic dermatitis, urticaria, sexually transmitted infections, and benign cysts or tumors).

A document describing a care process, or clinical pathway, specifies the who-when-where-how governing a patient's receipt of care for a condition or a set of related ones. The document lists each intervention or other process required for care, situating them sequentially in time and throughout the pathway the patient follows during the various phases of a disease. It also identifies the professionals responsible for care at each point. The main reason for organizing and describing a care process is to ensure continuity of care at all times regardless of which primary- or tertiary-care professionals might be involved. Incorporated into the description will be aspects and dimensions of quality of care, such as clinical efficacy, safety, and the provision of information for patients or their caregivers. The main components of a documented care process are as follows: the patient's clinical pathway, quality-of-care criteria for interventions, critical safety points (CSPs), and indicators for monitoring quality.8

Persons with benign cysts or tumors are not homogeneous: they seek care through a variety of routes, have various motivations, and have seen different types of health care professionals about their problem. However, the present care process plan focuses on arriving at consensus in making decisions and treating patients in primary care centers and CMUs for dermatology, given the degree to which these 2 settings are currently at the opposite poles of care management.

Thus, the main purpose in planning this patient care process is to limit variability in how we attend persons with benign cysts or tumors, through the application of consensus-based recommendations endorsed by the Andalusian Regional Section of the AEDV. To meet that aim we applied the following precepts of the Fourth Andalusian Health Plan9:

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  Seek to have an effect on health, avoiding therapeutic interventions that have no benefits on individual or public health.

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  Pursue efficiency, giving priority to actions that have an effect on health and disregarding those with no intrinsic value.

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  Respond to the demands of clients in the immediate and surrounding communities whenever possible.

Finally, rather than serving to restrict access to services, care process planning for persons with benign cysts or tumors should aim to guarantee that patients receive all procedures required for a proper diagnosis and that treatment is recommended whenever it is indicated.

The stages in care for persons with benign lesions and the settings where care takes place are shown in Figure 1. More complete information about the clinical pathway these patients follow is presented in Tables 1 and 2, which describe steps to take in primary care centers and dermatology CMUs, respectively. The quality-of-care characteristics mentioned in the tables cover such actions as taking the patient's medical history and performing a physical examination. Also identified are the CSPs listed by the health service of the government of Andalusia (the Junta),10 along with aspects relevant to adequately informing patients or their caregivers.

Figure 1.

Clinical pathway showing how the patient with a benign cyst or tumor moves through the various care settings. Numerical references refer to Tables 1 or 2, which list quality-of-care characteristics to apply in primary care centers and dermatology CMUs, respectively. Patients treated in a minor outpatient surgery unit or in the dermatology CMU will be referred back to the family practitioner or dermatologist at the primary care center who first attended the patient so that the referring physician can see the results of pathologic examination. CMU refers to clinical management unit.

(0.76MB).

Table 3 describes decision-making recommendations to apply when a person consults a physician regarding a benign cyst or tumor in each of the care settings in the NHS. The recommendations can be summarized as follows:

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  Refer to a dermatologist any patient who has a lesion that has not been firmly diagnosed.

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  Offer surgical treatment for any lesion the dermatologist cannot diagnose firmly in order to rule out the possibility of malignancy.

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  Refer the case to the CMU for pathology for diagnostic confirmation whenever a lesion has been managed surgically (for diagnosis or with intention to treat) in any setting (primary care or a dermatology CMU).

This paper was drafted to reflect the consensus reached by dermatologists with clinical and management knowledge and experience who participated in a working group organized according to the Metaplan approach. This method forms groups to discuss available evidence or proposals introduced by a moderator, who poses questions and encourages participants to express opinions. The final consensus is reached by selecting ideas that have been repeated most often during the group's discussions. The participating dermatologists came from all the provinces and health centers in the autonomous community of Andalusia. Support in applying the method was given by professionals from the Spanish Society for Quality in Health Care (SECA).

Because of the lack of literature on the group's topic of focus, recommendations were drafted based on the framework of the Andalusian NHS; the purpose was to facilitate the system's ability to resolve many incidents involving care for the large group of patients with benign cysts and tumors.

The lack of available evidence supporting treatment of these lesions, a protocol for referring patients to specialists, or any other relevant criteria obliged us to base our recommendations on consensus among professionals with appropriate clinical and management experience. This situation is the main limitation affecting the recommendations (evidence level IV).

Over the last 10 years, the discussion of how to organize care for patients with benign cysts and tumors has focused on defining the settings (primary care or dermatology CMUs) where these lesions should be managed. However, the NHS must currently give priority to doing procedures that have a clear impact on health. The tendency is to recommend that the system set aside interventions unrelated to health. This new paradigm obliges us to redirect the priorities of dermatology CMUs toward integrated care processes that affect patients’ health without neglecting the use of all means necessary to correctly diagnose any type of lesion the patient seeks care for.