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Becevic M, Smith E, Golzy M, Bysani R, Rosenfeld A, Mutrux ER, Hoffman K, Wallach E, McElroy JA, Edison K. Melanoma Extension for Community Healthcare Outcomes: A Feasibility Study of Melanoma Screening Implementation in Primary Care Settings. Cureus 2021; 13:e15322. [PMID: 34221770 PMCID: PMC8240489 DOI: 10.7759/cureus.15322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Introduction Melanoma incidence rates are rising faster than the rates of any other malignancy. As a major global public health concern, melanoma can be identified by a visual exam not requiring expensive invasive procedures. However, non-dermatologists lack specialized training and skills to identify high-risk patients and implement melanoma skin screenings during regular exams. Most patients from rural and underserved areas have inadequate access to specialty dermatologic care, which can potentially lead to later-stage melanomas and poor patient outcomes. The objective of this study was to identify facilitators and barriers to the implementation of risk surveys and melanoma skin screenings in primary care settings through live interactive education and the telementoring project - Melanoma ECHO (Extension for Community Healthcare Outcomes). Methods This cross-sectional study was designed with theoretical concepts from dissemination and implementation research. Monthly Melanoma ECHO sessions were integrated into an ongoing Dermatology ECHO at the University of Missouri, Columbia, Missouri, USA, from April 2018 to February 2019. Ten primary care providers, medical doctors/doctors of osteopathic medicine (MDs/DOs), nurse practitioners (NPs), and physician assistants (PAs), from across Missouri participated. Eleven virtual monthly melanoma-related didactics and case-based discussions were provided to participants. Information regarding risk factors, risk surveys, and screening techniques was provided. Ongoing telementoring and guidance were also provided for de-identified real-life patient cases. The main outcomes and measures of the study were to identify the facilitators and barriers of risk survey and melanoma skin screenings in primary care settings and to quantify the number of high-risk patients identified by participating providers and the number of new melanomas detected by visual exams during the study period. Results The primary reason why six out of 10 providers reported participation in Melanoma ECHO was that implementing melanoma skin screenings in their practice was made easier as it increased their confidence. Nine providers reported increased knowledge, and eight cited professional networking as other facilitators. The main perceived barrier to melanoma skin screening was lack of administrative and nursing support, and six providers indicated that lack of time to incorporate skin exams was also a barrier. Combined, ten participants reported identifying 976 high-risk patients during the study period and detecting 36 new melanomas. Discussion and conclusion Our findings indicate that primary care providers may benefit from attending regularly scheduled and focused specialized telementoring sessions, such as Melanoma ECHO. Ongoing support from specialists may help providers practicing in rural and isolated areas with the successful integration of risk surveys and melanoma skin screenings in primary care settings. Further Melanoma ECHO sessions with a more diverse group of primary care providers are needed to better understand the generalizability of the results.
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Affiliation(s)
- Mirna Becevic
- Dermatology, University of Missouri School of Medicine, Columbia, USA
| | - Emily Smith
- Dermatology, University of Missouri School of Medicine, Columbia, USA
| | - Mojgan Golzy
- Health Management and Informatics, University of Missouri School of Medicine, Columbia, USA
| | | | - Adam Rosenfeld
- Dermatology, University of Missouri School of Medicine, Columbia, USA
| | - Ellen R Mutrux
- Missouri Telehealth Network, University of Missouri School of Medicine, Columbia, USA
| | - Kimberly Hoffman
- Family Medicine, University of Missouri School of Medicine, Columbia, USA
| | - Emmanuelle Wallach
- Missouri Telehealth Network, University of Missouri School of Medicine, Columbia, USA
| | - Jane A McElroy
- Family Medicine, University of Missouri School of Medicine, Columbia, USA
| | - Karen Edison
- Dermatology, University of Missouri School of Medicine, Columbia, USA
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Li J, Chen A, Parks M, Ghosh A, Casalino LP. County-Level Unemployment Rates and Service Intensity in Primary Care Physician Offices for Medicare Patients. Med Care Res Rev 2019; 78:218-228. [PMID: 31475618 DOI: 10.1177/1077558719872864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The macroeconomic environment has been shown to affect health-care service utilization. We examined the relationship between unemployment rate and service intensity among a nationally representative sample of primary care office visits from Medicare patients by merging data from the 2006-2012 National Ambulatory Medical Care Survey with unemployment data from the Bureau of Labor Statistics. Multispecialty practices demonstrated increases in the number of electrocardiogram tests prescribed and the number of return appointments scheduled. In contrast, single-specialty practices did not respond on those margins and instead increased the likelihood of administering diagnostic and screening examinations. We found no significant relationship between unemployment rates and the number of laboratory and imaging services, magnetic resonance imaging use, referrals, or medication prescribing. These results were robust to controlling for extensive visit characteristics and county-, year-, and month-fixed effects. Our results suggest that physicians responded to the Great Recession by changing their practice behavior.
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Affiliation(s)
- Jing Li
- Cornell University, New York, NY, USA
| | - Alice Chen
- University of Southern California, Los Angeles, CA, USA
| | - Moon Parks
- U.S. Government Accountability Office, Washington, DC, USA
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Xie Q, Faust K, Van Ommeren R, Sheikh A, Djuric U, Diamandis P. Deep learning for image analysis: Personalizing medicine closer to the point of care. Crit Rev Clin Lab Sci 2019; 56:61-73. [PMID: 30628494 DOI: 10.1080/10408363.2018.1536111] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The precision-based revolution in medicine continues to demand stratification of patients into smaller and more personalized subgroups. While genomic technologies have largely led this movement, diagnostic results can take days to weeks to generate. Management at, or closer to, the point of care still heavily relies on the subjective qualitative interpretation of clinical and diagnostic imaging findings. New and emerging technological advances in artificial intelligence (AI) now appear poised to help bring objectivity and precision to these traditionally qualitative analytic tools. In particular, one specific form of AI, known as deep learning, is achieving expert-level disease classifications in many areas of diagnostic medicine dependent on visual and image-based findings. Here, we briefly review concepts of deep learning, and more specifically recent developments in convolutional neural networks (CNNs), to highlight their transformative potential in personalized medicine and, in particular, diagnostic histopathology. Understanding the opportunities and challenges of these quantitative machine-based decision support tools is critical to their widespread introduction into routine diagnostics.
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Affiliation(s)
- Quin Xie
- a Department of Laboratory Medicine and Pathobiology , University of Toronto , Toronto , Canada.,b MacFeeters-Hamilton Brain Tumour Centre , Princess Margaret Cancer Centre , Toronto , Canada
| | - Kevin Faust
- b MacFeeters-Hamilton Brain Tumour Centre , Princess Margaret Cancer Centre , Toronto , Canada.,c Department of Computer Science , University of Toronto , Toronto , Canada
| | - Randy Van Ommeren
- a Department of Laboratory Medicine and Pathobiology , University of Toronto , Toronto , Canada.,b MacFeeters-Hamilton Brain Tumour Centre , Princess Margaret Cancer Centre , Toronto , Canada
| | - Adeel Sheikh
- b MacFeeters-Hamilton Brain Tumour Centre , Princess Margaret Cancer Centre , Toronto , Canada
| | - Ugljesa Djuric
- b MacFeeters-Hamilton Brain Tumour Centre , Princess Margaret Cancer Centre , Toronto , Canada
| | - Phedias Diamandis
- a Department of Laboratory Medicine and Pathobiology , University of Toronto , Toronto , Canada.,b MacFeeters-Hamilton Brain Tumour Centre , Princess Margaret Cancer Centre , Toronto , Canada.,d Laboratory Medicine Program , University Health Network , Toronto , Canada
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Robinson JK, Jain N, Marghoob AA, McGaghie W, MacLean M, Gerami P, Hultgren B, Turrisi R, Mallett K, Martin GJ. A Randomized Trial on the Efficacy of Mastery Learning for Primary Care Provider Melanoma Opportunistic Screening Skills and Practice. J Gen Intern Med 2018; 33:855-862. [PMID: 29404948 PMCID: PMC5975143 DOI: 10.1007/s11606-018-4311-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 12/19/2017] [Accepted: 01/04/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Early detection of melanoma represents an opportunity to reduce the burden of disease among people at increased risk for melanoma. OBJECTIVE To develop and demonstrate the efficacy of online training. DESIGN Randomized educational trial. PARTICIPANTS Primary care providers (PCPs). INTERVENTION Mastery learning course with visual and dermoscopic assessment, diagnosis and management, and deliberate practice with feedback to reach a minimum passing standard. MAIN MEASURES Pre-test/post-test diagnostic accuracy. Referral of concerning lesions for 3 months before and after the educational intervention. KEY RESULTS Among the 89 PCPs, 89.8% were internal medicine physicians, and the remainder were physician assistants embedded in internists' practices. There were no differences between control and intervention groups regarding gender, age, race, or percentage of full-time PCPs. The control group had more PCPs who reported less than 5 years of practice (n = 18) than the intervention group (n = 6) (χ2 [6, n = 89] = 14.34, p = 0.03). PCPs in the intervention group answered more melanoma detection questions correctly on the post-test (M = 10.05, SE = 1.24) compared to control group PCPs (M = 7.11, SE = 0.24), and had fewer false-positive and no false-negative melanoma diagnoses (intervention, M = 1.09, SE = 0. 20; control, M = 3.1, SE = 0.23; ANCOVA, F[1,378] =27.86, p < 0.001; ηp2 = 0.26). PCPs who underwent training referred fewer benign lesions, including nevi, seborrheic keratoses, and dermatofibromas, than control PCPs (F[1,79] = 72.89, p < 0.001; ηp2 = 0.489; F[1,79] = 25.82, p < 0.001; ηp2 = 0.246; F[1,79] = 34.25, p < 0.001; ηp2 = 0.302; respectively). Those receiving training referred significantly more melanomas than controls (F[1,79] = 24.38, p < 0.001; ηp2 = 0.236). Referred melanomas (0.8 ± 0.07 per month for intervention, 0.17 ± 0.06 for control) were mostly located on the head and neck. CONCLUSIONS Mastery learning improved PCPs' ability to detect melanoma on a standardized post-test and may improve referral of patients with suspected melanoma. Further studies are needed to confirm this finding. ClinicalTrials.gov NCT02385253.
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Affiliation(s)
- June K Robinson
- Department of Dermatology , Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Namita Jain
- Department of Dermatology , Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ashfaq A Marghoob
- Department of Dermatology, Memorial Sloan-Kettering Cancer Center, Hauppauge, NY, USA
| | - William McGaghie
- Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael MacLean
- Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Pedram Gerami
- Department of Dermatology , Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Brittney Hultgren
- Biobehavioral Health and Prevention Research Center, The Pennsylvania State University, University Park, PA, USA
| | - Rob Turrisi
- Biobehavioral Health and Prevention Research Center, The Pennsylvania State University, University Park, PA, USA
| | - Kimberly Mallett
- Biobehavioral Health and Prevention Research Center, The Pennsylvania State University, University Park, PA, USA
| | - Gary J Martin
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Goulart JM, Quigley EA, Dusza S, Jewell ST, Alexander G, Asgari MM, Eide MJ, Fletcher SW, Geller AC, Marghoob AA, Weinstock MA, Halpern AC. Skin cancer education for primary care physicians: a systematic review of published evaluated interventions. J Gen Intern Med 2011; 26:1027-35. [PMID: 21472502 PMCID: PMC3157536 DOI: 10.1007/s11606-011-1692-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2010] [Revised: 02/14/2011] [Accepted: 03/02/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Early detection of melanoma may provide an opportunity to positively impact melanoma mortality. Numerous skin cancer educational interventions have been developed for primary care physicians (PCPs) to improve diagnostic accuracy. Standardized training is also a prerequisite for formal testing of melanoma screening in the primary care setting. OBJECTIVE We conducted a systematic review to determine the extent of evaluated interventions designed to educate PCPs about skin cancer, including melanoma. DESIGN Relevant studies in the English language were identified through systemic searches performed in MEDLINE, EMBASE, BIOSIS, and Cochrane through December 2010. Supplementary information was obtained from corresponding authors of the included studies when necessary. APPROACH Studies eligible for inclusion formally evaluated skin cancer education interventions and were designed primarily for PCPs. Excluded studies lacked a specified training intervention, used decision-making software, focused solely on risk factor identification, or did not directly educate or assess participants. Twenty studies met the selection criteria. Data were extracted according to intervention content and delivery format, and study outcomes. KEY RESULTS All interventions included instructions about skin cancer diagnosis, but otherwise varied in content. Curricula utilized six distinct educational techniques, usually incorporating more than one. Intervention duration varied from 12 min to over 6 h. Eight of the 20 studies were randomized trials. Most studies (18/20, 90%) found a significant improvement in at least one of the following five outcome categories: knowledge, competence, confidence, diagnostic performance, or systems outcomes. Competence was most commonly measured; no study evaluated all categories. Variability in study design, interventions, and outcome measures prevented correlation of outcomes with intervention characteristics. CONCLUSIONS Despite the development of many isolated educational interventions, few have been tested rigorously or evaluated under sufficient standardized conditions to allow for quantitative comparison. Improved and rigorously tested skin cancer educational interventions for PCPs with outcome measures focusing on changes in performance are needed.
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Affiliation(s)
- Jacqueline M Goulart
- Dermatology Service, Memorial Sloan-Kettering Cancer Center, New York, NY 07920, USA
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