The role of accessibility policies and other determinants of health care provision in the initial prognosis of malignant melanoma: A cross-sectional study

doi:10.1016/j.jaad.2014.04.049

Journal of the American Academy of Dermatology

Volume 71, Issue 3, September 2014, Pages 507-515

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https://doi.org/10.1016/j.jaad.2014.04.049 Get rights and content

Background

The prognostic benefit of health care service provision and delivery policies for patients with malignant melanoma (MM) is not yet clear.

Objective

To analyze the role of health care provision determinants in the initial prognosis of MM.

Methods

A multicenter cross-sectional study was conducted at 14 public hospitals and recruited 3550 patients with MM between 2000 and 2009. The study variables were analyzed using univariate and multivariate models to identify their role in the variations observed.

Results

In a 10-year period, the number of patients with MM increased by 78.54%, with primary in situ MM (Tis) or MMs with a Breslow thickness <1 mm (T1) representing 51.72% of the total number of MMs in 2000, increasing to 62.23% by the end of the study period (P = .005). Among the variables that explained the variation in MM frequency the year of diagnosis after 2004 (univariate odds ratio [OR], 1.43 [P < .001]; multivariate OR, 1.36 [P = .005]) and diagnosis in centers with specific fast-track referral systems (univariate OR, 1.24 [P = .01]; multivariate OR, 1.59 [P = .025]) were shown to explain the increasing frequency of Tis-T1 MM.

Limitations

The primary potential limitation of this study is its retrospective nature.

Conclusion

Health care provision policies and interventions aimed at improving accessibility to specialized care appear to explain the increasing frequency of Tis-T1 MM.

Section snippets

Methods

TEDIMEL-A was a multicenter, cross-sectional study conducted at hospitals belonging to the Public Health System of Andalusia (PHSA), a region in southern Spain (Table I). Cases of primary in situ MM (Tis) or invasive cutaneous MM diagnosed between January 1, 2000, and December 31, 2009 were included in the study after verifying that the MMs failed to meet the following exclusion criteria: second primary MM, lack of Breslow thickness in the pathology report, and primary MM pathologically

Results

The dermatology and pathology units of 14 hospitals belonging to the PHSA and representative of the various hospital types, demographic features, and geographic features of the region participated in the study (Table I). The population covered by the participating centers numbered 5,422,660 inhabitants, which represents 64.18% of the total population of Andalusia (n = 8,449,265 in 2009; Table I).⁵ The number of cases of MM included by each of the participating centers during the 10-year study

Discussion

The TEDIMEL-A project has served to document the increasing frequency of MM diagnosis between 2000 and 2009 in Andalusia, the second largest region of Spain (87,590 km²). Considering the slight increase observed in T2-T4 tumors, the rising frequency of MMs might be primarily explained by the increase in the diagnosis of Tis-T1 tumors (Fig 2).⁵ This rising frequency in the diagnosis of melanoma, combined with the steady mortality of melanoma observed in recent decades, has prompted extensive

References (19)

G. Argenziano et al.
Dermoscopy of pigmented skin lesions: results of a consensus meeting via the Internet
J Am Acad Dermatol
(2003)
E. Linos et al.
Increasing burden of melanoma in the United States
J Invest Dermatol
(2009)
K.C. Lee et al.
Melanoma is up: are we up to this challenge?
J Invest Dermatol
(2009)
S. Martinez-Garcia et al.
Teledermatology. Review of 917 teleconsults
Actas Dermosifiliogr
(2007)
V.E. Cokkinides et al.
Sun exposure and sun-protection behaviors and attitudes among U.S. youth, 11 to 18 years of age
Prev Med
(2001)
G. Salerni et al.
Meta-analysis of digital dermoscopy follow-up of melanocytic skin lesions: a study on behalf of the International Dermoscopy Society
J Eur Acad Dermatol Venereol
(2013)
D. Moreno-Ramirez et al.
Store-and-forward teledermatology in skin cancer triage. Experience and evaluation of 2009 teleconsultations
Arch Dermatol
(2007)
C.M. Balch et al.
Final version of 2009 AJCC melanoma staging and classification
J Clin Oncol
(2009)
Spanish National Institute of Statistics web site. Demography and population. Current population 2002-2012. Available...

There are more references available in the full text version of this article.

Cited by (20)

Teledermatology in the Health Center West Area of Granada: From primary to specialized care
2021, Semergen
La teledermatología (TD) es una herramienta sanitaria basada en la aplicación de tecnologías de la información y comunicación (TIC) para la atención de las enfermedades cutáneas a distancia, permitiendo una mejor conexión entre profesionales de atención primaria (AP) y de atención especializada. El objetivo de este estudio fue analizar las características de las teleconsultas realizadas a nuestro servicio en un periodo de 2 años (1 de enero de 2018 a 31 de diciembre de 2019).
Los datos fueron obtenidos de un sistema de TD con dermatoscopia que permite la realización de teleconsultas de manera asincrónica. Se analizaron los datos en un periodo de 24 meses. Las variables estudiadas fueron el centro de salud de origen, la sospecha diagnóstica del médico de AP, el tiempo y el tipo de respuesta y el juicio clínico emitido por el dermatólogo.
Entre el 1 de enero de 2018 y el 31 de diciembre de 2019 se recibieron un total de 3.294 teleconsultas. Fueron derivadas a la consulta de dermatología un 24,76%, mientras que el 25,63% requirieron un seguimiento posterior de forma telemática. La sospecha diagnóstica más frecuente por parte del médico de AP fue la de patología benigna (54,71%). El juicio clínico dermatológico más frecuente fue el de queratosis seborreica (20,19%), seguido por queratosis actínica (14,02%), nevus melanocítico común adquirido (13,24%) y carcinoma basocelular (8,98%).
El sistema de TD es una herramienta útil que permitió una rápida respuesta a un alto porcentaje de consultas, ayudando a evitar derivaciones innecesarias y una fácil comunicación entre AP y atención especializada. Además, permite priorizar los pacientes con patología tumoral maligna.
Teledermatology (TD) is a health tool based on the application of information and communication technologies (ICT) for the care of skin diseases at a distance, allowing a better connection between primary care professionals (PCP) and specialized care. The objective of this study was to analyze the characteristics of the teleconsultations made to our service in a period of 2 years (January 1, 2018 to December 31, 2019).
The data was obtained from a TD system with dermoscopy that allows teleconsultations to be carried out asynchronously. Data were analyzed over 24 months. The variables studied were the health centre of origin, the diagnostic suspicion of the PCP, the time and type of response, and the clinical judgment issued by the dermatologist.
Between January 1, 2018 and December 31, 2019, a total of 3,294 teleconsultations were received. 24.76% were referred to the dermatology consultation, while 25.63% required subsequent follow-up electronically. The most frequent diagnostic suspicion by the PCP was that of benign pathology (54.71%). The most frequent dermatological clinical judgment was that of seborrheic keratosis (20.19%), followed by actinic keratosis (14.02%), acquired common melanocytic nevi (13.24%) and basal cell carcinoma (8.98%).
The TD system is a useful tool that allowed a quick response to a high percentage of consultations, helping to avoid unnecessary referrals and easy communication between primary and specialized care. It also allows prioritizing those patients with malignant tumour pathology.
Direct-to-consumer, store-and-forward teledermatology with dermoscopy using the pharmacist as patient point-of-contact
2021, Journal of the American Pharmacists Association
Citation Excerpt :
Teledermatology with dermoscopy has been shown to improve the results of an Internet-based skin cancer screening system, as compared with screening systems based on the use of clinical images alone.4 Both the proximity and reliability of teledermatology with dermoscopy improve accessibility to specialized care, which can explain the increasing frequency with which thin melanomas (Tis-T1)5 are identified; this represents an early diagnosis, which is associated with a better prognosis. Since September 2017, we have been employing a “direct-to-consumer,” store-and-forward teledermatology with dermoscopy model in the private setting at the Viamed Santa Angela de la Cruz Hospital in Seville in collaboration with Bidafarma (Figure 1).
To evaluate the frequency of nonmelanoma skin cancer (NMSC), NMSC precursors, and melanoma on a store-and-forward dermatology model featuring the pharmacist as the patient’s point-of-contact. The secondary objective was to define lesion changes and symptoms perceived by patients (clinical prediction rules by nonexpert observers) that can be predictive of malignity.
A cross-sectional study of teledermatology consultation was performed. All patients who underwent a teledermatology consultation between September 2018 and March 2020 were included. A patient could have more than 1 lesion per consultation. The object of the study was a defined dermatologic lesion. The differences between the variables were analyzed using a univariate model based on the chi-square test for independent qualitative variables and Fisher exact test in cases when the expected values in any of the cells of a contingency table were less than 5. Statistical significance was set at P < 0.05 (2-tailed).
A total of 225 lesions in 218 patients were considered for this study; 53.8% (n = 121) of the lesions were classified as benign, 16.4% (n = 37) as dubious, 23.1% (n = 52) as NMSC precursors, 5.8% (n = 13) as NMSC, and 0.9% (n = 2) as melanomas. Of the reported clinical lesion changes, spontaneous pain, pruritus, surface texture changes, color changes, or form changes had no statistically significant relationship with the diagnostic group, whereas the presence of spontaneous bleeding (P = 0.015) and size changes (P = 0.026) were more frequently observed in the “dubious lesion” and “of oncological relevance lesion” groups.
This “direct-to-consumer,” store-and-forward teledermatology with dermoscopy model featuring the pharmacist as the patient’s point-of-contact is useful for the diagnosis of melanoma, NMSC, and NMSC precursors when backed by a robust dermatology service.
Role of teledermatology in early diagnosis of melanoma
2020, Piel
Practice Models in Teledermatology in Spain: Longitudinal Study, 2009-2014
2018, Actas Dermo-Sifiliograficas
Citation Excerpt :
Store-and-forward TD has been shown to be effective in reducing the number of face-to-face consultations in hospitals.15 Face-to-face consultations and store-and-forward TD have shown similar results in terms of clinical improvement and time to intervention in patients with skin cancer.3,16 In recent years, there has been a considerable increase in the number of successful TD programs for managing skin cancer13 and for providing a rapid response in large urban areas.9
Teledermatology is the most advanced clinical specialty in telemedicine. The development of teledermatology in specific countries has not been studied in depth.
Our objective was to analyze teledermatology models in clinical practice in Spain. We paid special attention to organization, technical aspects, training, and the advantages/disadvantages as seen by teledermatologists. Two surveys were carried out (2009 and 2014).
Teledermatology was used at 25 centers in 2009 and at 70 in 2014. The extended survey was completed by 21 centers in 2009 and 41 in 2014. Store-and-forward teledermatology was the main technique (83%) in 2014. Only 12% of centers used the real-time method, and 5% used a hybrid modality. Patients lived less than 25 km away in 75% of cases (urban teledermatology). Most centers used mid-range bridge cameras; only 12% used mobile phones. Teledermoscopy and tertiary teledermatology were each used in 15% of centers. Teledermatology was restricted to skin cancer in 25% of cases, and 66% of centers used it to train primary care physicians. The main advantages, assessed on a scale of 1 to 10, were prioritization in cancer screening (8.3), rapid emergency care (7.8), training of and communication with primary care physicians (7.6), screening for trivial conditions (7.6), and reduction in the number of face-to-face visits (7.6). The main disadvantages were poor image quality (6.3), fear of error (5.7), difficulty in coordinating with primary care physicians (3.8), and time commitment (3.3). Between 2009 and 2014, the number of centers using teledermatology and the number of teledermatologists increased, as did use of the store-and-forward and urban models. The technology used also improved.
Teledermatology is an emerging technology that is becoming well established in Spain. More than 25% of dermatology centers in Spain have implemented a teledermatology model. Store-and-forward in an urban setting is the most widely used modality. Teledermatologists see this technology as an effective option with more advantages than disadvantages. General satisfaction is high, although there is room for significant improvement in some areas.
La teledermatología (TD) es la especialidad clínica más desarrollada de la telemedicina. El desarrollo de la TD en un país completo no se ha estudiado previamente en profundidad.
El objetivo fue analizar los modelos de TD en práctica real en España, centrándose en la organización, los aspectos técnicos, la docencia y las ventajas/desventajas percibidas por los teledermatólogos. Se realizaron 2 encuestas con teledermatólogos en 2009 y 2014.
Se identificaron 25 centros utilizando TD en 2009 y 70 en 2014. La encuesta ampliada fue completada por 21 centros en 2009 y 42 en 2014. Las características generales en 2014 fueron: TD almacenamiento (TDA) fue la técnica predominante (83%), solo el 12% TD en tiempo real y el 5% TD híbrida. El 75% de los pacientes vistos en TD viven a menos de 25 km (TD urbana). La mayoría de los centros utilizan cámaras bridge de gama media y solo el 12% utiliza los teléfonos móviles. El 15% practica teledermoscopia y el 15% TD terciaria. En el 25%, la TD se restringió a la oncología cutánea; el 66% utiliza la TD para formación de médicos de primaria. Las ventajas principales (puntuación 0-10) fueron priorización en oncología (8,3), asistencia rápida de urgencias (7,8), la formación y la comunicación con los médicos de primaria (7,6), el cribado de enfermedad banal (7,6) y la disminución de las visitas presenciales (7,6). Los principales inconvenientes fueron (puntuación 0-10): la baja calidad de imágenes (6,3), el miedo al error (5,7), difícil coordinación con los médicos de primaria (MP) (3,8) y consumo de tiempo (3,3). La evolución 2009-2014 mostró más centros con TD y más teledermatólogos, mejor tecnología y aumento de los modelos TDA y urbano.
La TD es una tecnología emergente que comienza su fase de consolidación en España. Más del 25% de los centros de dermatología en España han puesto en práctica un sistema de TD. El modelo predominante es TDA en un entorno urbano. Los dermatólogos perciben la TD como una opción efectiva con más ventajas que desventajas. La satisfacción general es alta, sin embargo, todavía hay áreas que necesitan mejoras significativas.
Lymph node dissection in the advanced age patient with melanoma
2018, Piel
Use of Lymph Node Ultrasound Prior to Sentinel Lymph Node Biopsy in 384 Patients with Melanoma: A Cost-Effectiveness Analysis
2017, Actas Dermo-Sifiliograficas
Citation Excerpt :
This cost represents a 0.96% increase in the cost of staging patients with melanoma and is an additional cost that can be considered acceptable for most health services, especially if we take into account the low-to-medium incidence of melanoma in Spain (8.76; 95% CI, 7.50-10.02).23 Thus, in the case of a hospital with a reference population of 500 000 inhabitants and an expected incidence of 40-50 cases/year and assuming that 50% of cases are diagnosed as melanoma in situ or T1, with no indication for SLNB, the inclusion of ultrasound during initial staging would represent an annual total extra cost of between €350 and €450, which most health services can afford.23,24 In addition, the cost of performing ultrasound on all of the patients (n = 384) and the lymph node biopsies performed to confirm ultrasound findings suspected of being malignant (n = 104) was partially compensated by the 23 SLNBs avoided (€42 560 vs €39 100).
Locoregional lymph node ultrasound is not typically included in guidelines as part of the staging process prior to sentinel lymph node biopsy (SLNB). The objective of the present study was to make a clinical and economic analysis of lymph node ultrasound prior to SLNB.
We performed a retrospective study of 384 patients with clinical stage I-II primary melanoma who underwent locorregional lymph node ultrasound (with or without ultrasound-guided biopsy) prior to SLNB between 2004 and 2015. We evaluated the reliability and cost-effectiveness of the strategy.
Use of locorregional lymph node ultrasound avoided SLNB in 23 patients (6%). Ultrasound had a sensitivity of 46% and specificity of 76% for the detection of metastatic lymph nodes that were not clinically palpable. False negatives were significantly more common in patients aged over 60 years and in tumors with a thickness of less than 2 mm. The staging process using SLNB and ultrasound with ultrasound-guided biopsy produced an increase of €16.30 in the unit price. Our cost-effectiveness analysis identified the staging protocol with ultrasound and SLNB as the dominant strategy, with a lower cost-effectiveness ratio than the alternative, consisting of SLNB alone (8,095.24 vs €28,605.00).
Ultrasound with ultrasound-guided biopsy for the diagnostic staging of melanoma prior to SLNB is a useful and cost-effective tool. This procedure does not substitute SLNB, though it does allow to avoid SLNB in a not insignificant proportion of patients.
La ecografía ganglionar locorregional como parte de la estadificación previa a la biopsia del ganglio centinela (BSGC) en pacientes con melanoma no se incluye habitualmente en las guías de manejo. El objetivo de este estudio es evaluarla desde la perspectiva clínica y económica.
Estudio retrospectivo de 384 pacientes con melanoma primario de estadios clínicos I-II, en el periodo 2004-2015, a los que se les realizó una ecografía ganglionar locorregional (±biopsia ecodirigida) previa a la BSGC. Se evaluó la fiabilidad de la técnica y se realizó un análisis de su coste efectividad.
En 23 pacientes (6%) se pudo evitar la realización de la BSGC mediante la técnica. La ecografía mostró una sensibilidad del 46% y una especificidad del 76% para la detección de ganglios metastásicos clínicamente no palpables. Los falsos negativos fueron significativamente más frecuentes en pacientes mayores de 60 años y con tumores < 2 mm. El coste unitario del proceso de estadificación mediante BSGC con ecografía-biopsia ecodirigida generó un sobrecoste de 16,30 €. El análisis coste-efectividad identificó como estrategia dominante desde ese punto de vista el protocolo de estadificación con ecografía y BSGC, con una ratio coste-efectividad inferior a la de la alternativa consistente en BSGC (8.095,24 vs 28.605,00 €)
La ecografía con biopsia ecodirigida como método diagnóstico de estadificación previo a la BSGC es una herramienta útil y coste-efectiva, que no sustituye a la BSGC, pero que permite en un porcentaje no desdeñable de casos evitar su realización.

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: The Trends in Melanoma Diagnosis in Andalusia (TEDIMEL-A) Project Study Group is funded by a competitive public grant of the Health Institute Carlos III of the Spanish Health Ministry (IP 10-1929 2010-2013).

: Conflicts of interest: None declared.

: Reprints not available from the authors.

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Original articleThe role of accessibility policies and other determinants of health care provision in the initial prognosis of malignant melanoma: A cross-sectional study

Background

Objective

Methods

Results

Limitations

Conclusion

Section snippets

Methods

Results

Discussion

J Am Acad Dermatol

J Invest Dermatol

J Invest Dermatol

Actas Dermosifiliogr

Prev Med

Meta-analysis of digital dermoscopy follow-up of melanocytic skin lesions: a study on behalf of the International Dermoscopy Society

J Eur Acad Dermatol Venereol

Store-and-forward teledermatology in skin cancer triage. Experience and evaluation of 2009 teleconsultations

Arch Dermatol

Final version of 2009 AJCC melanoma staging and classification

J Clin Oncol

Original article
The role of accessibility policies and other determinants of health care provision in the initial prognosis of malignant melanoma: A cross-sectional study