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Becevic M, Ge B, Braudis K, Cintrón C, Fleming D, Shyu CR, Edison K. Diagnostic and treatment concordance in primary care participants and dermatologists utilizing Extension for Community Health Outcomes (ECHO). J Telemed Telecare 2024; 30:1345-1352. [PMID: 36654477 PMCID: PMC11389051 DOI: 10.1177/1357633x221147074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Suboptimal access to dermatologic care is dependent on patient location and insurance type. Although there have been attempts to address access issues, barriers to providing excellent dermatologic care to all patients at the right time still exist. The objective of this study was to investigate the clinical impact of Dermatology Extension for Community Healthcare Outcomes (ECHO) project participation on primary care providers' diagnostic and treatment tendencies and accuracy. METHODS This was a retrospective cohort study constructed using Dermatology Extension for Community Healthcare Outcomes case and recommendation data from November 2015 to June 2021. The University of Missouri-based Dermatology Extension for Community Healthcare Outcomes specialty hub team offers regularly scheduled live interactive tele-mentoring sessions for primary care providers who practice in rural and underserved areas. 524 patient cases presented by 25 primary care providers were included in the analysis. Of those, 449 cases were included in diagnostic concordance, and 451 in treatment concordance analysis. RESULTS Less than 40% of all diagnoses were fully concordant with an expert panel. Over 33% of patients were misdiagnosed, and over 26% received partially correct diagnosis. Only 16% of all treatment recommendations were fully concordant with an expert panel. DISCUSSION Diagnostic and treatment accuracy of participants is low, and Dermatology Extension for Community Healthcare Outcomes platform ensured patients received correct diagnosis and treatment quickly. Although tele-dermatology models are effective, they continue to be underutilized. Dermatologists in practice and training should be encouraged to adopt innovative clinical educational models, like Dermatology ECHO, to expand access to dermatologic expertise for the most marginalized populations.
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Affiliation(s)
- Mirna Becevic
- Department of Dermatology, University of Missouri, Columbia, MO, USA
- Missouri Telehealth Network, University of Missouri, Columbia, MO, USA
- Institute for Data Science and Informatics, University of Missouri, Columbia, MO, USA
| | - Bin Ge
- Family and Community Medicine, University of Missouri, Columbia, MO, USA
| | - Kara Braudis
- Department of Dermatology, University of Missouri, Columbia, MO, USA
| | - Coralys Cintrón
- Calle San Antonio Rosales, Universidad del Sagrado Corazón, San Juan, Puerto Rico
| | - David Fleming
- Department of Medicine and Center for Health Ethics, University of Missouri, Columbia, MO, USA
| | - Chi-Ren Shyu
- Institute for Data Science and Informatics, University of Missouri, Columbia, MO, USA
- Department of Electrical Engineering and Computer Science, University of Missouri, Columbia, MO, USA
| | - Karen Edison
- Department of Dermatology, University of Missouri, Columbia, MO, USA
- Missouri Telehealth Network, University of Missouri, Columbia, MO, USA
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Hernandez AE, Benck KN, Huerta CT, Ogobuiro I, De La Cruz Ku G, Möller MG. Rural Melanoma Patients Have Less Surgery and Higher Melanoma-Specific Mortality. Am Surg 2024; 90:510-517. [PMID: 38061913 DOI: 10.1177/00031348231216485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND Melanoma causes most skin cancer-related deaths, and disparities in mortality persist. Rural communities, compared to urban, face higher levels of poverty and more barriers to care, leading to higher stage at presentation and shorter survival in melanoma. To further evaluate these disparities, we sought to assess the association between rurality and melanoma cause-specific mortality and receipt of recommended surgery in a national cohort. METHODS Patients with primary non-ocular, cutaneous melanoma from the SEER database, 2000-2017, were included. Outcomes included melanoma-specific survival and receipt of recommended surgery. Rurality was based on Rural-Urban Continuum Codes. Variables included age, sex, race, ethnicity, income, and stage. Multivariate regression models assessed the effect of rurality on survival and receipt of recommended surgery. RESULTS 103,606 patients diagnosed with non-ocular cutaneous primary melanoma met criteria during this period. 93.3% (n = 96620) were in urban areas and 6.7% (n = 6986) were in rural areas. On multivariate regression controlling for age, sex, race, ethnicity, and stage patients living in a rural area were less likely to receive recommended surgery (aOR .52, 95% CI: .29-.90, P = .02) and had increased hazard of melanoma-specific mortality (aHR 1.19, 95% CI: 1.02-1.40, P = .03) even after additionally controlling for surgery receipt. CONCLUSION Using a large national cohort, our study found that rural patients were less likely to receive recommended surgery and had shorter melanoma cause-specific survival. Our findings highlight the importance of access to cancer care in rural areas and how this ultimately effects survival for these patients.
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Affiliation(s)
- Alexandra E Hernandez
- Department of Surgery, Division of Surgical Oncology,University of Miami Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kelley N Benck
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Carlos T Huerta
- Department of Surgery, Division of Surgical Oncology,University of Miami Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ifeanyichukwu Ogobuiro
- Department of Surgery, Division of Surgical Oncology,University of Miami Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Gabriel De La Cruz Ku
- University of Massachusetts School of Medicine, Worcester, MA, USA
- Universidad Cientifica del Sur, Lima, Peru
| | - Mecker G Möller
- University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Surgery, Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
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Zheng S, Yu H, Zheng X, Wu UT, Ming WK, Huang H, Song J, Zhang X, Lyu J, Deng L. Analysis and prediction of 5-year survival in patients with cutaneous melanoma: a model-based period analysis. Front Endocrinol (Lausanne) 2023; 14:1238086. [PMID: 38125787 PMCID: PMC10731280 DOI: 10.3389/fendo.2023.1238086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 10/30/2023] [Indexed: 12/23/2023] Open
Abstract
Background The survival and prognosis of patients are significantly threatened by cutaneous melanoma (CM), which is a highly aggressive disease. It is therefore crucial to determine the most recent survival rate of CM. This study used population-based cancer registry data to examine the 5-year relative survival rate of CM in the US. Methods Period analysis was used to assess the relative survival rate and trends of patients with CM in the Surveillance, Epidemiology, and End Results (SEER) database during 2004-2018. And based on the data stratified by age, gender, race and subtype in the SEER database, a generalized linear model was 12established to predict the 5-year relative survival rate of CM patients from 2019 to 2023. Results The 5-year relative survival increased to various degrees for both total CM and CM subtypes during the observation period. The improvement was greatest for amelanotic melanoma, increasing from 69.0% to 81.5%. The 5-year overall relative survival rates of CM were 92.9%, 93.5%, and 95.6% for 2004-2008, 2009-2013, and 2014-2018, respectively. Females had a marginally higher survival rate than males for almost all subtypes, older people had lower survival rates than younger people, white patients had higher survival rates than nonwhite ones, and urban locations had higher rates of survival from CM than rural locations did. The survival rate of CM was significantly lower for distant metastasis. Conclusion The survival rate of patients with CM gradually improved overall during 2004-2018. With the predicted survival rate of 96.7% for 2019-2023, this trend will still be present. Assessing the changes experienced by patients with CM over the previous 15 years can help in predicting the future course of CM. It also provides a scientific foundation that associated departments can use to develop efficient tumor prevention and control strategies.
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Affiliation(s)
- Suzheng Zheng
- Department of Dermatology, The First Affiliated Hospital of Jinan University and Jinan University Institute of Dermatology, Guangzhou, China
| | - Hai Yu
- Department of Dermatology, The First Affiliated Hospital of Jinan University and Jinan University Institute of Dermatology, Guangzhou, China
| | - Xinkai Zheng
- Department of Dermatology, The First Affiliated Hospital of Jinan University and Jinan University Institute of Dermatology, Guangzhou, China
| | - U Tim Wu
- Meng Yi Centre Limited, Macao, Macao SAR, China
| | - Wai-kit Ming
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Hui Huang
- Department of Dermatology, The First Affiliated Hospital of Jinan University and Jinan University Institute of Dermatology, Guangzhou, China
| | - Jiaxin Song
- Department of Dermatology, The First Affiliated Hospital of Jinan University and Jinan University Institute of Dermatology, Guangzhou, China
| | - Xiaoxi Zhang
- Department of Dermatology, The First Affiliated Hospital of Jinan University and Jinan University Institute of Dermatology, Guangzhou, China
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Traditional Chinese Medicine Informatization, Guangzhou, China
| | - Liehua Deng
- Department of Dermatology, The First Affiliated Hospital of Jinan University and Jinan University Institute of Dermatology, Guangzhou, China
- Department of Dermatology, The Fifth Affiliated Hospital of Jinan University, Heyuan, China
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Patel RA, Torabi SJ, Kayastha D, Kuan EC, Manes RP. Medicare Utilization and Reimbursement Variation Between Rural and Urban Otolaryngologists. Otolaryngol Head Neck Surg 2023; 168:528-535. [PMID: 35852873 DOI: 10.1177/01945998221113550] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 06/24/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To compare billing practices, reimbursement rates, and patient populations of otolaryngology (ORL) physicians practicing in rural and urban settings. STUDY DESIGN Retrospective cross-sectional study. SETTING Medicare Provider Utilization and Payment Data: Physician and Other Supplier Data. METHODS Medicare-allowed payments, number of services, and number of patients were gathered along with patient population comorbidity statistics, including average hierarchical condition category risk scores. RESULTS In 2019, 92% of the overall total 8959 ORL physicians practiced in an urban setting. These 8243 urban ORL physicians, on average, billed for 51 (interquartile range [IQR], 31-67) unique Healthcare Common Procedure Coding System (HCPCS) codes, cared for 393 (IQR, 172-535) Medicare patients, performed 1761 (IQR, 502-2070) services, and collected $139,957 (IQR, $55,527-$178,479) per provider. In contrast, the 704 rural ORL physicians, on average, billed for a greater number of unique HCPCS codes (59; IQR, 37-77; P < .001), treated more Medicare patients (445; IQR, 242-614; P < .001), and performed more services (2330; IQR, 694-2748; P < .001) but collected about the same per provider ($141,035; IQR, $56,555-$172,864; P = .426). Older age was associated with rural practice (P = .027). Among both urban and rural ORL physicians, the variety and complexity of procedures and patient comorbidity profiles were comparable. CONCLUSION Most ORL physicians practice in large urban settings, a finding potentially related to financial sustainability and career opportunity. With an already small workforce, the aging rural ORL physician population is an identifiable weak point in the otolaryngology specialty that must be addressed with geo-specific recruitment campaigns, rural work incentivization, and the development of career advancement opportunities in rural areas.
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Affiliation(s)
- Rahul A Patel
- Frank H. Netter M.D. School of Medicine at Quinnipiac University, North Haven, Connecticut, USA
- Department of Surgery (Division of Otolaryngology), Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sina J Torabi
- Department of Surgery (Division of Otolaryngology), Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Darpan Kayastha
- Department of Surgery (Division of Otolaryngology), Yale University School of Medicine, New Haven, Connecticut, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - R Peter Manes
- Department of Surgery (Division of Otolaryngology), Yale University School of Medicine, New Haven, Connecticut, USA
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Pearson J, Jacobson C, Ugochukwu N, Asare E, Kan K, Pace N, Han J, Wan N, Schonberger R, Andreae M. Geospatial analysis of patients' social determinants of health for health systems science and disparity research. Int Anesthesiol Clin 2023; 61:49-62. [PMID: 36480649 PMCID: PMC10107426 DOI: 10.1097/aia.0000000000000389] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Social context matters for health, healthcare processes/quality and patient outcomes. The social status and circumstances we are born into, grow up in and live under, are called social determinants of health; they drive our health, and how we access and experience care; they are the fundamental causes of disease outcomes. Such circumstances are influenced heavily by our location through neighborhood context, which relates to support networks. Geography can influence proximity to resources and is an important dimension of social determinants of health, which also encompass race/ethnicity, language, health literacy, gender identity, social capital, wealth and income. Beginning with an explanation of social determinants, we explore the use of Geospatial Analysis methods and geocoding, including the importance of collaborating with geography experts, the pitfalls of geocoding, and how geographic analysis can help us to understand patient populations within the context of Social Determinants of Health. We then explain mechanisms and methods of geospatial analysis with two examples: (1) Bayesian hierarchical regression with crossed random effects and (2) discontinuity regression i.e., change point analysis. We leveraged the local University of Utah and Yale cohorts of the Multicenter Perioperative Outcomes Group (MPOG.org ), a perioperative electronic health registry; we enriched the Utah cohort with US-census tract level social determinants of health after geocoding patient addresses and extracting social determinants of health from the National Neighborhood Database (NaNDA). We explain how to investigate the impact of US-census tract level community deprivation indices and racial/ethnic composition on (1) individual clinicians’ administration of risk-adjusted perioperative antiemetic prophylaxis, (2) patients’ decisions to defer cataract surgery at the cusp of Medicare eligibility and finally (3) methods to further characterize patient populations at risk through publicly available datasets in the context of public transit access. Our examples are not rigorous analyses, and our preliminary inferences should not be taken at face value, but rather seen as illustration of geospatial analysis processes and methods. Our worked examples show the potential utility of geospatial analysis, and in particular the power of geocoding patient addresses to extract US-census level social determinants of health from publicly available databases to enrich electronic health registries for healthcare disparity research and targeted health system level countermeasures.
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Affiliation(s)
- John Pearson
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Cameron Jacobson
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah
| | | | - Elliot Asare
- Section of Surgical Oncology, Division of General Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Kelvin Kan
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Nathan Pace
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jiuying Han
- Department of Geography, University of Utah, Salt Lake City, Utah
| | - Neng Wan
- Department of Geography, University of Utah, Salt Lake City, Utah
| | - Robert Schonberger
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
| | - Michael Andreae
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah
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Zakhem GA, Pulavarty AN, Lester JC, Stevenson ML. Skin Cancer in People of Color: A Systematic Review. Am J Clin Dermatol 2022; 23:137-151. [PMID: 34902111 DOI: 10.1007/s40257-021-00662-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND People of African, Asian, Hispanic or Latino, Pacific Islander, and Native Indian descent are considered people of color by the Skin of Color Society (SOCS). OBJECTIVES In this study, we assess incidence, risk factors, clinical characteristics, histopathology, treatment, and survival for skin malignancies in people of color as defined by the SOCS, by systematically reviewing the literature. METHODS An electronic literature search of the PubMed, EMBASE, and MEDLINE databases was performed. Articles published from 1 January 1990 through 12 December 2020 were included in the search. RESULTS We identified 2666 publications potentially meeting the study criteria. Titles and abstracts of these studies were reviewed and 2353 were excluded. The full text of 313 articles were evaluated and 251 were included in this review. CONCLUSION Differences in incidence, patterns, treatment, and survival exist among people of color for cutaneous malignancies. Further research and initiatives are needed to account for and mitigate these differences.
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Affiliation(s)
- George A Zakhem
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, 222 East 41st Street, 24th Floor, New York, NY, 10017, USA
| | - Akshay N Pulavarty
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, 222 East 41st Street, 24th Floor, New York, NY, 10017, USA
| | - Jenna C Lester
- University of California San Francisco, San Francisco, CA, USA
| | - Mary L Stevenson
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, 222 East 41st Street, 24th Floor, New York, NY, 10017, USA.
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Urban MJ, Shimomura A, Shah S, Losenegger T, Westrick J, Jagasia AA. Rural Otolaryngology Care Disparities: A Scoping Review. Otolaryngol Head Neck Surg 2022; 166:1219-1227. [PMID: 35015580 DOI: 10.1177/01945998211068822] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To broadly synthesize the literature regarding rural health disparities in otolaryngology, categorize findings, and identify research gaps to stimulate future work. STUDY DESIGN Scoping review. DATA SOURCES A comprehensive literature search was performed in the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Google Scholar, and CINAHL. REVIEW METHODS The methods were developed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. Peer-reviewed, English-language, US-based studies examining a rural disparity in otolaryngology-related disease incidence, prevalence, diagnosis, treatment, or outcome were included. Descriptive studies, commentaries, reviews, and letters to the editor were excluded. Studies published prior to 1980 were excluded. RESULTS The literature search resulted in 1536 unique abstracts and yielded 79 studies that met final criteria for inclusion. Seventy-five percent were published after 2010. The distribution of literature was as follows: otology (34.2%), head and neck cancer (20.3%), endocrine surgery (13.9%), rhinology and allergy (8.9%), trauma (5.1%), laryngology (3.8%), other pediatrics (2.5%), and adult sleep (1.3%). Studies on otolaryngology health care systems also accounted for 10.1%. The most common topics studied were practice patterns (41%) and epidemiology (27%), while the Southeast (47%) was the most common US region represented, and database study (42%) was the most common study design. CONCLUSION Overall, there was low-quality evidence with large gaps in the literature in all subspecialties, most notably facial plastic surgery, laryngology, adult sleep, and pediatrics. Importantly, there were few studies on intervention and zero studies on resident exposure to rural populations, which will be critical to making rural otolaryngology care more equitable in the future.
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Affiliation(s)
- Matthew J Urban
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Aoi Shimomura
- Loyola University of Chicago, Stritch School of Medicine, Maywood, Illinois, USA
| | - Swapnil Shah
- Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Tasher Losenegger
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Ashok A Jagasia
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Khushalani NI, Truong TG, Thompson JF. Current Challenges in Access to Melanoma Care: A Multidisciplinary Perspective. Am Soc Clin Oncol Educ Book 2021; 41:e295-e303. [PMID: 34061557 DOI: 10.1200/edbk_320301] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
A diagnosis of melanoma requires multidisciplinary specialized care across all stages of disease. Although many important advances have been made for the treatment of melanoma for local and advanced disease, barriers to optimal care remain for many patients who live in areas without ready access to the expertise of a specialized melanoma center. In this article, we review some of the recent advances in the treatment of melanoma and the persistent challenges around the world that prevent the delivery of the best standard of care to patients living in the community. With the therapeutic landscape continuing to evolve and newer more complex drug therapies soon to be approved, it is important to recognize the many challenges that patients face and attempt to identify tools and policies that will help to improve treatment outcomes for their melanoma.
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Affiliation(s)
| | - Thach-Giao Truong
- Melanoma Program, Kaiser Permanente Northern California, Vallejo, CA
| | - John F Thompson
- Melanoma Institute Australia, Sydney, Australia.,Department of Melanoma and Surgical Oncology, The University of Sydney, Sydney, Australia
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Rapport F, Smith AL, Cust AE, Mann GJ, Watts CG, Gyorki DE, Henderson M, Hong AM, Kelly JW, Long GV, Mar VJ, Morton RL, Saw RP, Scolyer RA, Spillane AJ, Thompson JF, Braithwaite J. Identifying challenges to implementation of clinical practice guidelines for sentinel lymph node biopsy in patients with melanoma in Australia: protocol paper for a mixed methods study. BMJ Open 2020; 10:e032636. [PMID: 32111612 PMCID: PMC7050375 DOI: 10.1136/bmjopen-2019-032636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 12/24/2019] [Accepted: 01/28/2020] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Sentinel lymph node biopsy (SLNB) is a diagnostic procedure developed in the 1990s. It is currently used to stage patients with primary cutaneous melanoma, provide prognostic information and guide management. The Australian Clinical Practice Guidelines state that SLNB should be considered for patients with cutaneous melanoma >1 mm in thickness (or >0.8 mm with high-risk pathology features). Until recently, sentinel lymph node (SLN) status was used to identify patients who might benefit from a completion lymph node dissection, a procedure that is no longer routinely recommended. SLN status is now also being used to identify patients who might benefit from systemic adjuvant therapies such as anti-programmed cell death 1 (PD1) checkpoint inhibitor immunotherapy or BRAF-directed molecular targeted therapy, treatments that have significantly improved relapse-free survival for patients with resected stage III melanoma and improved overall survival of patients with unresectable stage III and stage IV melanoma. Australian and international data indicate that approximately half of eligible patients receive an SLNB. METHODS AND ANALYSIS This mixed-methods study seeks to understand the structural, contextual and cultural factors affecting implementation of the SLNB guidelines. Data collection will include: (1) cross-sectional questionnaires and semistructured interviews with general practitioners and dermatologists; (2) semistructured interviews with other healthcare professionals involved in the diagnosis and early definitive care of melanoma patients and key stakeholders including researchers, representatives of professional colleges, training organisations and consumer melanoma groups; and (3) documentary analysis of documents from government, health services and non-government organisations. Descriptive analyses and multivariable regression models will be used to examine factors related to SLNB practices and attitudes. Qualitative data will be analysed using thematic analysis. ETHICS AND DISSEMINATION Ethics approval has been granted by the University of Sydney. Results will be disseminated through publications and presentations to clinicians, patients, policymakers and researchers and will inform the development of strategies for implementing SLNB guidelines in Australia.
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Affiliation(s)
- Frances Rapport
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Andrea L Smith
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Anne E Cust
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Melanoma Institute Australia, Sydney, New South Wales, Australia
| | - Graham J Mann
- Melanoma Institute Australia, Sydney, New South Wales, Australia
- The John Curtin School of Medical Research, Australian National Univeristy, Canberra, Australian Capital Territory, Australia
| | - Caroline G Watts
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - David E Gyorki
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | | | - Angela M Hong
- Melanoma Institute Australia, Sydney, New South Wales, Australia
- Sydney School of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - John W Kelly
- Victorian Melanoma Service, The Alfred Hosptial, Melbourne, Victoria, Australia
| | - Georgina V Long
- Melanoma Institute Australia, Sydney, New South Wales, Australia
- Sydney School of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Victoria J Mar
- Victorian Melanoma Service, The Alfred Hosptial, Melbourne, Victoria, Australia
| | - Rachael L Morton
- Melanoma Institute Australia, Sydney, New South Wales, Australia
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Robyn Pm Saw
- Melanoma Institute Australia, Sydney, New South Wales, Australia
- Sydney School of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Richard A Scolyer
- Melanoma Institute Australia, Sydney, New South Wales, Australia
- Sydney School of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Andrew J Spillane
- Melanoma Institute Australia, Sydney, New South Wales, Australia
- Sydney School of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - John F Thompson
- Melanoma Institute Australia, Sydney, New South Wales, Australia
- Sydney School of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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10
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Berger ER, Bilimoria KY, Kinnier CV, Minami CA, Bethke KP, Hansen NM, Merkow RP, Winchester DP, Yang AD. Assessment of hospital-level adjusted breast cancer sentinel lymph node positivity rates. J Surg Oncol 2018; 119:101-108. [PMID: 30481371 DOI: 10.1002/jso.25294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 10/22/2018] [Indexed: 11/12/2022]
Abstract
BACKGROUND/OBJECTIVES Proficiency of performing sentinel lymph node biopsy (SLNB) for breast cancer varies among hospitals and may be reflected in the hospital's SLNB positivity rate. Our objectives were to examine whether hospital characteristics are associated with variation in SLNB positivity rates and whether hospitals with lower-than-expected SLNB positivity rates have worse patient survival. METHODS Using the National Cancer Data Base, stage I to III breast cancer patients were identified (2004-2012). Hospital-level SLNB positivity rates were adjusted for tumor and patient factors. Hospitals were divided into terciles of SLNB positivity rates (lower-, higher-, as-expected). Hospital characteristics and survival were examined across terciles. RESULTS Of 438 610 SLNB patients (from 1357 hospitals), 78 104 had one or more positive SLN (21.3%). Hospitals in the low and high terciles were more likely to be low volume (low: RRR, 4.40; 95% CI, 2.89-6.57; P < 0.001; and high: RRR, 1.79; 95% CI, 1.21-2.64; P < 0.001) compared to hospitals with as-expected (middle tercile) SLNB positivity rates. Stage I patients at low- and high-tercile hospitals had statistically worse survival. CONCLUSIONS There is a wide variation in hospital SLNB positivity rates. Hospitals with lower- or higher-than-expected SLNB positivity rates were associated with survival differences. Hospital SLNB positivity rates may be a novel 'process measure' to report to hospitals for internal quality assessment.
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Affiliation(s)
- Elizabeth R Berger
- The Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois.,Department of Surgery, Loyola University Health System, Maywood, Illinois
| | - Karl Y Bilimoria
- Northwestern Institute for Comparatives Effectiveness Research (NICER) in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University and Northwestern Memorial Hospital, Chicago, Illinois.,Department of Surgery and Center for Healthcare Studies, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine and Northwestern Medicine, Northwestern University, Chicago, Illinois.,Department of Surgery, Division of Breast Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Christine V Kinnier
- Department of Surgery and Center for Healthcare Studies, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine and Northwestern Medicine, Northwestern University, Chicago, Illinois.,Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Christina A Minami
- Department of Surgery and Center for Healthcare Studies, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine and Northwestern Medicine, Northwestern University, Chicago, Illinois.,Department of Surgery, Division of Breast Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Kevin P Bethke
- Department of Surgery, Division of Breast Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Nora M Hansen
- Department of Surgery, Division of Breast Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Ryan P Merkow
- Department of Surgery and Center for Healthcare Studies, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine and Northwestern Medicine, Northwestern University, Chicago, Illinois.,Department of Surgery, Division of Breast Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Anthony D Yang
- Northwestern Institute for Comparatives Effectiveness Research (NICER) in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University and Northwestern Memorial Hospital, Chicago, Illinois.,Department of Surgery and Center for Healthcare Studies, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine and Northwestern Medicine, Northwestern University, Chicago, Illinois.,Department of Surgery, Division of Breast Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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11
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Look Hong NJ, Cheng SY, Baxter NN, Wright FC. Melanoma patterns of care in Ontario: A call for a strategic alignment of multidisciplinary care. J Surg Oncol 2018; 117:597-617. [PMID: 29228470 DOI: 10.1002/jso.24936] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 11/02/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Variability in melanoma management has prompted concerns about equitable and timely treatment. We investigated patterns of melanoma diagnosis and treatment using population-level data. METHODS Patients with invasive cutaneous melanoma were identified retrospectively from the Ontario Cancer Registry (2003-2012) and deterministically linked with administrative databases to identify incidence, disease characteristics, geographic origin, and multimodal treatment within a year of diagnosis. Melanoma treatment was categorized as inadequate or adequate based on multidisciplinary clinical algorithms. Multivariable logistic regression was used to model factors associated with treatment adequacy. RESULTS From 2003 to 2012, 22 918 patients with invasive melanoma were identified with annual age/sex standardized incidence rates of 11.7-14.3/100 000 for females and 13.4-15.9/100 000 for males. Melanoma occurred at median age of 62 and primarily on extremities (43.9%). Within 1 year after diagnosis, 86.7% of patients received surgery as primary therapy. A total of 2312 (10.6%) patients received inadequate or no treatment after diagnosis. Receiving adequate treatment was associated with consultation with dermatology (OR 1.92, CI 1.71-2.14), plastic surgery (OR 4.80, CI 4.32-5.34), or general surgery (OR 2.15, CI 1.94-2.38). CONCLUSIONS Significant variation exists in melanoma management and nearly one in nine patients is inadequately treated. Referral to sub-specialized providers is critical for ensuring appropriate care.
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Affiliation(s)
- Nicole J Look Hong
- Department of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontorio, Canada
| | - Stephanie Y Cheng
- Institute for Clinical Evaluative Sciences, Toronto, Ontorio, Canada
| | - Nancy N Baxter
- Institute for Clinical Evaluative Sciences, Toronto, Ontorio, Canada
- St. Michael's Hospital, Department of Surgery and Keenan Research Centre, Toronto, Ontorio, Canada
| | - Frances C Wright
- Department of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontorio, Canada
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12
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Epidemiology of malignant cutaneous granular cell tumors: A US population-based cohort analysis using the Surveillance, Epidemiology, and End Results (SEER) database. J Am Acad Dermatol 2017; 78:490-497.e1. [PMID: 28989104 DOI: 10.1016/j.jaad.2017.09.062] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 09/19/2017] [Accepted: 09/24/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Malignant cutaneous granular cell tumors (mcGCTs) are rare and associated with substantial morbidity and mortality. The literature includes single-institution studies. OBJECTIVE To examine the incidence, secondary malignancies, treatment, overall survival, and disease-specific survival (DSS) of patients with mcGCT. METHODS A population-based cohort analysis was conducted in the Surveillance, Epidemiology, and End Results database from 1973 to 2013 for patients with a diagnosis of mcGCT. Risk-adjusted associations between overall survival/DSS and patient characteristics and treatment modalities were assessed by Cox proportional hazard regression. Quantile regression was used to determine median survival times. RESULTS The 5-year DSS rate was 62.8%. Patients demonstrated an increased risk for renal and pancreatic cancers. In risk-adjusted models, male sex (hazard ratio [HR], 0.21; 95% confidence interval [CI], 0.06-0.82; P = .02), advanced cancer stage (HR, 2.29; 95% CI, 1.40-3.72; P < .01), and surgical resection (HR, 0.06; 95% CI, 0.01-0.59; P = .02) predicted DSS. Median survival time in years increased for males (1.39), earlier stage (0.60), and surgical intervention (5.34). LIMITATIONS Absent or incorrect reporting in retrospective Surveillance, Epidemiology, and End Results data is possible. The database is more likely to include academic centers. Some subanalyses may be underpowered because of the limited sample size for a rare cancer. CONCLUSIONS Our study presents an in-depth assessment of factors that identify high-risk patients. Residency in a nonmetro area, black race, female sex, and no surgical resection were each associated with poorer DSS.
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13
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Adjusted Hospital Sentinel Lymph Node Positivity Rates in Melanoma: A Novel Potential Measure of Quality. Ann Surg 2016; 263:392-8. [PMID: 26488806 DOI: 10.1097/sla.0000000000001052] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Our objectives were to examine whether hospital characteristics are associated with lower- and higher-than-expected sentinel lymph node biopsy (SLNB) positivity rates and whether hospitals with lower- or higher-than-expected SLNB positivity rates have worse patient outcomes. BACKGROUND Surgeon and pathologist SLNB technical errors may lead to incorrect melanoma staging. A hospital's SLNB positivity rate may reflect its SLNB proficiency for melanoma, but this has never been investigated. METHODS Stage IA-III melanoma patients undergoing SLNB were identified from the National Cancer Data Base (2004-2010). Hospital-level SLNB positivity rates were adjusted for patient- and tumor factors. Hospitals were divided into terciles of adjusted SLNB positivity rates. Hospital characteristics (using multinomial logistic regression) and survival (using Cox modeling) were examined across terciles. RESULTS Of 33,639 SLNB patients (from 646 hospitals), 2916 (8.7%) had at least 1 positive lymph node. Hospitals with lower- (low tercile) and higher-than-expected (high tercile) SLNB positivity rates were more likely to be low-volume hospitals (low tercile: relative risk ratio (RRR) = 2.57, P = 0.002; high tercile: RRR = 2.3, P = 0.004) compared to hospitals with expected rates (middle tercile). Stage I patients treated at lower-than-expected SLNB positivity rate hospitals had worse 5-year survival than those treated at expected SLNB positivity rate hospitals (90.0% vs 91.9%, P = 0.014; hazard ratio = 1.28, 95% CI: 1.05-1.57); survival differences were not observed by SLNB positivity rates for stage II/III. CONCLUSIONS Adjusted hospital SLNB positivity rates varied widely. Surgery at hospitals with lower-than-expected SLNB positivity rates was associated with decreased survival. Hospital SLNB positivity rates may be a novel measure to confidentially report to hospitals for internal quality assessment.
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