1
|
Spanos S, Singh N, Laginha BI, Arnolda G, Smith AL, Wilkinson D, Cust AE, Braithwaite J, Rapport F. Quality measures in primary care skin cancer management: a qualitative study of the views of key informants. BMJ Open 2024; 14:e080670. [PMID: 38991668 PMCID: PMC11243125 DOI: 10.1136/bmjopen-2023-080670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 06/17/2024] [Indexed: 07/13/2024] Open
Abstract
OBJECTIVES This study explored potential quality measures to improve skin cancer management in primary care settings, and the barriers and facilitators associated with their implementation. DESIGN Semistructured interviews and qualitative proforma surveys were conducted with skin cancer experts from a range of healthcare settings. Framework analysis was employed to identify key groups of quality measures within the domains of the Donabedian model of healthcare quality (structure, process, outcome). Interview and survey data were triangulated to identify common groups of quality measures, barriers and facilitators. PARTICIPANTS We purposively recruited skin cancer experts from Australia and internationally with knowledge and experience in skin cancer management. The final sample consisted of 15 participants who had clinical or academic backgrounds. RESULTS Participants unequivocally expressed the need for quality measures to guide skin cancer care. Ten groups of quality measures were identified: three groups related to the structural elements of care (eg, diagnostic tools), four related to the processes of care (eg, diagnostic process) and three related to outcomes of care (eg, treatment outcomes). Implementation barriers included clinician resistance, system inadequacies and external factors (eg, patient risk). Facilitators included incentives, education, agreed and feasible indicators and support and guidance. CONCLUSIONS To service a growing population of skin cancer patients in Australia, the role of primary care needs to be more clearly specified, and its care providers supported and more engaged in quality improvement processes. Structure, process and outcome quality measures, derived from detailed guidance for primary care settings, can be used to track practitioner performance and facilitate ongoing improvement.
Collapse
Affiliation(s)
- Samantha Spanos
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Nehal Singh
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Bela I Laginha
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Gaston Arnolda
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Andrea L Smith
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
| | - David Wilkinson
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
- National Skin Cancer Centres, South Brisbane, Queensland, Australia
| | - Anne E Cust
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Frances Rapport
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| |
Collapse
|
2
|
Lindsay D, Whiteman DC, Olsen CM, Gordon LG. Health care service use by people diagnosed with invasive melanoma in Queensland: a benefit incidence analysis. Med J Aust 2023; 219:417-422. [PMID: 37807891 DOI: 10.5694/mja2.52122] [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] [Received: 02/16/2023] [Accepted: 09/05/2023] [Indexed: 10/10/2023]
Abstract
OBJECTIVE To quantify differences, by residential remoteness and socio-economic status, in health care service use by people diagnosed with invasive melanoma in Queensland. DESIGN Benefit incidence analysis of CancerCostMod data, comprising Queensland Cancer Registry data linked with Queensland Hospital Admitted Patient Data Collection (QHAPDC), Medicare Benefits Schedule (MBS), and Pharmaceutical Benefits Scheme (PBS) data. SETTING, PARTICIPANTS Adults (18 years or older) newly diagnosed with invasive melanoma in Queensland during 1 July 2011 - 31 June 2015 and alive three years after diagnosis. MAIN OUTCOME MEASURES Concentration curves and indices quantifying differences by residential postcode-based remoteness (Australian Statistical Geography Standard - Remoteness Area) and socio-economic disadvantage (Index of Relative Socioeconomic Disadvantage) in hospital admissions (overall and by type) and use of MBS (overall and by type) and PBS services during the three years following diagnosis of invasive melanoma. RESULTS A total of 13 145 adults diagnosed with invasive melanoma during 2011-15 were alive three years after the diagnosis. Public hospital admissions were more frequent for people living in areas of greater socio-economic disadvantage (concentration index, -0.15; 95% confidence interval [CI], -0.19 to -0.12) or outside major cities (concentration index, -0.10; 95% CI, -0.13 to -0.06); private hospital admissions (concentration index, 0.11; 95% CI, 0.07-0.15) and specialist consultations (concentration index, 0.08; 95% CI, 0.07-0.10) were more frequent in areas of lesser disadvantage and in major cities (private hospital admissions: 0.10; 95% CI, 0.06-0.13; specialist services: 0.07; 95% CI, 0.06-0.09). Differences in other melanoma health care service use by residential remoteness and socio-economic disadvantage were not statistically significant. CONCLUSIONS Variation in health care service use by Queenslanders with primary diagnoses of invasive melanoma by residential socio-economic disadvantage and remoteness were generally minor. Our analysis suggests that access to health care for people with melanoma is fairly equitable in Queensland.
Collapse
Affiliation(s)
- Daniel Lindsay
- QIMR Berghofer Medical Research Institute, Brisbane, QLD
- The University of Queensland, Brisbane, QLD
| | - David C Whiteman
- QIMR Berghofer Medical Research Institute, Brisbane, QLD
- The University of Queensland, Brisbane, QLD
| | - Catherine M Olsen
- QIMR Berghofer Medical Research Institute, Brisbane, QLD
- The University of Queensland, Brisbane, QLD
| | - Louisa G Gordon
- QIMR Berghofer Medical Research Institute, Brisbane, QLD
- The University of Queensland, Brisbane, QLD
- Queensland University of Technology, Brisbane, QLD
| |
Collapse
|
3
|
Green AC, Pandeya N, Morton S, Simonidis J, Whiteman DC. Early detection of melanoma in specialised primary care practice in Australia. Cancer Epidemiol 2020; 70:101872. [PMID: 33360359 DOI: 10.1016/j.canep.2020.101872] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 11/17/2020] [Accepted: 11/20/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Primary care skin cancer clinics facilitate early treatment of melanoma in Australia. We investigated the clinical and histopathological features of melanomas diagnosed and treated in an established clinic in Brisbane. METHODS Retrospective audit of medical records of patients diagnosed with in situ or invasive primary cutaneous melanoma in a primary care clinic specializing in skin cancer, 2000-2017. Demographic and clinical data were standardly extracted by a medically-trained investigator. We used descriptive analyses to assess characteristics of patients and melanomas, and examine surgical management according to tumour thickness. RESULTS Of 380 patients (median age 57 years; 57 % male) newly diagnosed with 497 histologically-confirmed primary cutaneous melanomas, 369 were in situ and 128 invasive. Of the 369 in situ melanomas, 143 (39 %) were on the trunk and 87 (24 %) on the head and neck; 247 (67 %) were diagnosed by shave biopsy; and 141 (38 %) referred for wide local excision (WLE). Of the 128 invasive melanomas, only 21 (16 %) had thickness ≥ 0.8 mm and these occurred more often on head and neck than thin invasive melanomas (p = 0.02). The majority of invasive melanomas were diagnosed by excision biopsy, and WLE was carried out in a median of 3 days (melanomas ≥ 0.8 mm) and 2 days (<0.8 mm). The doctor detected the majority of in situ (83 %) and thin invasive (73 %) melanomas during surveillance, compared with 48 % of thicker invasive melanomas ≥ 0.8 mm (p < 0.001). CONCLUSION In Australia, specialised primary care practice plays a major role in detection and treatment of early primary melanoma.
Collapse
Affiliation(s)
- Adele C Green
- Population Health Department, QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, Queensland, 4006, Australia; CRUK Manchester and Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9PL, United Kingdom.
| | - Nirmala Pandeya
- Population Health Department, QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, Queensland, 4006, Australia.
| | - Sarah Morton
- Royal Brisbane and Women's Hospital, Brisbane, Herston, Queensland, 4006, Australia.
| | - John Simonidis
- The Melanoma Centre, Spring Hill, Brisbane 4000, Australia.
| | - David C Whiteman
- Population Health Department, QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, Queensland, 4006, Australia.
| |
Collapse
|
4
|
GPs' involvement in diagnosing, treating, and referring patients with suspected or confirmed primary cutaneous melanoma: a qualitative study. BJGP Open 2020; 4:bjgpopen20X101028. [PMID: 32295791 PMCID: PMC7330208 DOI: 10.3399/bjgpopen20x101028] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 11/18/2019] [Indexed: 12/24/2022] Open
Abstract
Background In Australia, melanoma is managed in primary and secondary care settings. An individual concerned about a suspicious lesion typically presents first to their GP. Aim To identify factors influencing GPs’ decisions to diagnose, treat, or refer patients with suspected melanoma. Design & setting Semi-structured interviews were undertaken with 23 GPs working in general practice or skin cancer clinics in Australia. Method The semi-structured interviews were audio-recorded, de-identified, and professionally transcribed. Thematic analysis was used to analyse the data. Results Considerable variation existed in GPs’ self-reported confidence and involvement in melanoma management. Multiple factors were identified as influencing GPs’ decisions to diagnose, treat, or refer patients with suspected or confirmed melanoma. Health system level factors included the overlapping roles of GPs and specialists, and access to and/or availability of specialists. Practice level factors included opportunities for formal and informal training, and having a GP with a special interest in skin cancer within their practice. GP and patient level factors included the GP’s clinical interests, the clinical features (for example, site and size) and histopathology of the suspected melanoma, eligibility for possible sentinel lymph node biopsy, and patient preferences. For some GPs, concerns over misdiagnosis and the option of referring patients at any stage in the melanoma management continuum appeared to affect their interest and confidence in melanoma management. Conclusion GP involvement in melanoma patient care can extend well beyond cancer screening, prevention and supportive care roles to include provision of definitive melanoma patient management. GPs with an interest in being involved in melanoma management should be encouraged and supported to develop the skills needed to manage these patients, and to refer when appropriate.
Collapse
|
5
|
Pereira da Veiga CR, Pereira da Veiga C, Drummond-Lage AP, Alves Wainstein AJ, Cristina de Melo A. Journey of the Patient With Melanoma: Understanding Resource Use and Bridging the Gap Between Dermatologist, Surgeon, and Oncologist in Different Health Care Systems. J Glob Oncol 2020; 5:1-8. [PMID: 31283414 PMCID: PMC6690632 DOI: 10.1200/jgo.19.00022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE New scientific evidence has led to modifications in the clinical practice of handling melanoma. In health care systems, there is currently a wide variety of clinical procedures to treat cancer, and the various routes have different effects on the survival of patients with cancer. Thus, this article aimed to evaluate the journey of patients with melanoma in the public and private health care systems in Brazil from the viewpoint of different medical professionals involved in the diagnosis and treatment of the disease. The study also considers the resources used for the complete delivery cycle of health care at different stages of the evolution of melanoma. METHODS We conducted a behavioral study by applying a questionnaire to a group of medical professionals. A nonprobabilistic sampling method for convenience was used, justified by the heterogeneous national incidence and the limited availability of medical professionals who diagnose and treat melanoma. RESULTS The questionnaire was answered by 138 doctors, including doctors from the Brazilian states with the highest concentration of medical specialists and regions with a higher melanoma incidence. The results of this study have the potential to enrich our understanding of the reality of Brazilian health care systems and, at the same time, allow us to discuss the multiple ways in which professionals from diverse specialist fields understand and explain decision making in health care. CONCLUSION Health care decision making is complex and, among other factors, depends on the diversity of available health resources and the knowledge of which treatments provide the greatest benefit to patients and greatest value to the system as a whole. This work can inform debates and reflection that are applicable not only in Brazil, but also in various other countries with similar realities.
Collapse
Affiliation(s)
| | | | | | | | - Andreia Cristina de Melo
- Brazilian National Cancer Institute, Hospital do Câncer II, Rio de Janeiro, Rio de Janeiro, Brazil
| |
Collapse
|
6
|
Newman-Toker DE, Wang Z, Zhu Y, Nassery N, Saber Tehrani AS, Schaffer AC, Yu-Moe CW, Clemens GD, Fanai M, Siegal D. Rate of diagnostic errors and serious misdiagnosis-related harms for major vascular events, infections, and cancers: toward a national incidence estimate using the “Big Three”. Diagnosis (Berl) 2020; 8:67-84. [DOI: 10.1515/dx-2019-0104] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 02/12/2020] [Indexed: 02/06/2023]
Abstract
Abstract
Background
Missed vascular events, infections, and cancers account for ~75% of serious harms from diagnostic errors. Just 15 diseases from these “Big Three” categories account for nearly half of all serious misdiagnosis-related harms in malpractice claims. As part of a larger project estimating total US burden of serious misdiagnosis-related harms, we performed a focused literature review to measure diagnostic error and harm rates for these 15 conditions.
Methods
We searched PubMed, Google, and cited references. For errors, we selected high-quality, modern, US-based studies, if available, and best available evidence otherwise. For harms, we used literature-based estimates of the generic (disease-agnostic) rate of serious harms (morbidity/mortality) per diagnostic error and applied claims-based severity weights to construct disease-specific rates. Results were validated via expert review and comparison to prior literature that used different methods. We used Monte Carlo analysis to construct probabilistic plausible ranges (PPRs) around estimates.
Results
Rates for the 15 diseases were drawn from 28 published studies representing 91,755 patients. Diagnostic error (false negative) rates ranged from 2.2% (myocardial infarction) to 62.1% (spinal abscess), with a median of 13.6% [interquartile range (IQR) 9.2–24.7] and an aggregate mean of 9.7% (PPR 8.2–12.3). Serious misdiagnosis-related harm rates per incident disease case ranged from 1.2% (myocardial infarction) to 35.6% (spinal abscess), with a median of 5.5% (IQR 4.6–13.6) and an aggregate mean of 5.2% (PPR 4.5–6.7). Rates were considered face valid by domain experts and consistent with prior literature reports.
Conclusions
Diagnostic improvement initiatives should focus on dangerous conditions with higher diagnostic error and misdiagnosis-related harm rates.
Collapse
Affiliation(s)
- David E. Newman-Toker
- Department of Neurology , The Johns Hopkins University School of Medicine , Baltimore, MD , USA
- Director, Armstrong Institute Center for Diagnostic Excellence , The Johns Hopkins University School of Medicine , Baltimore, MD , USA
- Professor, Department of Epidemiology , The Johns Hopkins Bloomberg School of Public Health , Baltimore, MD , USA
| | - Zheyu Wang
- Department of Oncology , The Johns Hopkins University School of Medicine , Baltimore, MD , USA
- Department of Biostatistics, The Johns Hopkins Bloomberg School of Public Health , Baltimore, MD , USA
| | - Yuxin Zhu
- Department of Oncology , The Johns Hopkins University School of Medicine , Baltimore, MD , USA
- Department of Biostatistics, The Johns Hopkins Bloomberg School of Public Health , Baltimore, MD , USA
| | - Najlla Nassery
- Department of Medicine , The Johns Hopkins University School of Medicine , Baltimore, MD , USA
| | - Ali S. Saber Tehrani
- Department of Neurology , The Johns Hopkins University School of Medicine , Baltimore, MD , USA
| | - Adam C. Schaffer
- Department of Patient Safety, CRICO , Boston, MA , USA
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School , Boston, MA , USA
| | | | - Gwendolyn D. Clemens
- Department of Biostatistics, The Johns Hopkins Bloomberg School of Public Health , Baltimore, MD , USA
| | - Mehdi Fanai
- Department of Neurology , The Johns Hopkins University School of Medicine , Baltimore, MD , USA
| | - Dana Siegal
- Director of Patient Safety, CRICO Strategies , Boston, MA , USA
| |
Collapse
|
7
|
Janda M, Horsham C, Vagenas D, Loescher LJ, Gillespie N, Koh U, Curiel-Lewandrowski C, Hofmann-Wellenhof R, Halpern A, Whiteman DC, Whitty JA, Smithers BM, Soyer HP. Accuracy of mobile digital teledermoscopy for skin self-examinations in adults at high risk of skin cancer: an open-label, randomised controlled trial. LANCET DIGITAL HEALTH 2020; 2:e129-e137. [PMID: 33334577 DOI: 10.1016/s2589-7500(20)30001-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/16/2019] [Accepted: 01/08/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Skin self-examinations supplemented with mobile teledermoscopy might improve early detection of skin cancers compared with naked-eye skin self-examinations. We aimed to assess whether mobile teledermoscopy-enhanced skin self-examination can improve sensitivity and specificity of self-detection of skin cancers when compared with naked-eye skin self-examination. METHODS This randomised, controlled trial was done in Brisbane (QLD, Australia). Eligible participants (aged ≥18 years) had at least two skin cancer risk factors as self-reported in the eligibility survey and had to own or have access to an iPhone compatible with a dermatoscope attachment (iPhone versions 5-8). Participants were randomly assigned (1:1), via a computer-generated randomisation procedure, to the intervention group (mobile dermoscopy-enhanced self-skin examination) or the control group (naked-eye skin self-examination). Control group and intervention group participants received web-based instructions on how to complete a whole body skin self-examination. All participants completed skin examinations at baseline, 1 month, and 2 months; intervention group participants submitted photographs of suspicious lesions to a dermatologist for telediagnosis after each skin examination and control group participants noted lesions on a body chart that was sent to the research team after each skin examination. All participants had an in-person whole-body clinical skin examination within 3 months of their last skin self-examination. Primary outcomes were sensitivity and specificity of skin self-examination, patient selection of clinically atypical lesions suspicious for melanoma or keratinocyte skin cancers (body sites examined, number of lesions photographed, types of lesions, and lesions missed), and diagnostic concordance of telediagnosis versus in-person whole-body clinical skin examination diagnosis. All primary outcomes were analysed in the modified intention-to-treat population, which included all patients who had a clinical skin examination within 3 months of their last skin self-examination. This trial was registered with the Australian and New Zealand Clinical Trials Registry, ACTRN12616000989448. FINDINGS Between March 6, 2017, and June 7, 2018, 234 participants consented to enrol in the study, of whom 116 (50%) were assigned to the intervention group and 118 (50%) were assigned to the control group. 199 participants (98 participants in the intervention group and 101 participants in the control group) attended the clinical skin examination and thus were eligible for analyses. Participants in the intervention group submitted 615 lesions (median 6·0 per person; range 1-24) for telediagnosis and participants in the control group identified and recorded 673 lesions (median 6·0 per person; range 1-16). At the lesion level, sensitivity for lesions clinically suspicious for skin cancer was 75% (95% CI 63-84) in the intervention group and 88% (95% CI 80-91) in the control group (p=0·04). Specificity was 87% (95% CI 85-90) in the intervention group and 89% (95% CI 87-91) in the control group (p=0·42). At the individual level, the intervention group had a sensitivity of 87% (95% CI 76-99) compared with 97% (95% CI 91-100) in the control group (p=0·26), and a specificity of 95% (95% CI 90-100) compared with 96% (95% CI 91-100) in the control group. The overall diagnostic concordance between the telediagnosis and in-person clinical skin examination was 88%. INTERPRETATION The use of mobile teledermoscopy did not increase sensitivity for the detection of skin cancers compared with naked-eye skin self-examination; thus, further evidence is necessary for inclusion of skin self-examination technology for public health benefit. FUNDING National Health and Medical Research Council (Australia).
Collapse
Affiliation(s)
- Monika Janda
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia; School of Public Health and Social Work, Institute for Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia.
| | - Caitlin Horsham
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia; School of Public Health and Social Work, Institute for Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Dimitrios Vagenas
- School of Public Health and Social Work, Institute for Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Lois J Loescher
- Mel and Enid Zuckerman College of Public Health, Colleges of Nursing and Public Health, The University of Arizona, Tucson, AZ, USA; University of Arizona Cancer Center, The University of Arizona, Tucson, AZ, USA
| | - Nicole Gillespie
- UQ Business School, The University of Queensland, Brisbane, QLD, Australia
| | - Uyen Koh
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | | | | | - Allan Halpern
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David C Whiteman
- QIMR Berghofer Institute of Medical Research, Brisbane, QLD, Australia
| | - Jennifer A Whitty
- Department of Population Health, University of East Anglia, Norwich, UK; National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) East of England, Cambridge, UK
| | - B Mark Smithers
- Queensland Melanoma Project, The University of Queensland, Brisbane, QLD, Australia
| | - H Peter Soyer
- The Diamantina Institute, The University of Queensland, Brisbane, QLD, Australia; Dermatology Department, Princess Alexandra Hospital, Brisbane, QLD, Australia
| |
Collapse
|
8
|
Pinaire J, Azé J, Bringay S, Landais P. Patient healthcare trajectory. An essential monitoring tool: a systematic review. Health Inf Sci Syst 2017; 5:1. [PMID: 28413630 PMCID: PMC5390363 DOI: 10.1007/s13755-017-0020-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 03/29/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Patient healthcare trajectory is a recent emergent topic in the literature, encompassing broad concepts. However, the rationale for studying patients' trajectories, and how this trajectory concept is defined remains a public health challenge. Our research was focused on patients' trajectories based on disease management and care, while also considering medico-economic aspects of the associated management. We illustrated this concept with an example: a myocardial infarction (MI) occurring in a patient's hospital trajectory of care. The patient follow-up was traced via the prospective payment system. We applied a semi-automatic text mining process to conduct a comprehensive review of patient healthcare trajectory studies. This review investigated how the concept of trajectory is defined, studied and what it achieves. METHODS We performed a PubMed search to identify reports that had been published in peer-reviewed journals between January 1, 2000 and October 31, 2015. Fourteen search questions were formulated to guide our review. A semi-automatic text mining process based on a semantic approach was performed to conduct a comprehensive review of patient healthcare trajectory studies. Text mining techniques were used to explore the corpus in a semantic perspective in order to answer non-a priori questions. Complementary review methods on a selected subset were used to answer a priori questions. RESULTS Among the 33,514 publications initially selected for analysis, only 70 relevant articles were semi-automatically extracted and thoroughly analysed. Oncology is particularly prevalent due to its already well-established processes of care. For the trajectory thema, 80% of articles were distributed in 11 clusters. These clusters contain distinct semantic information, for example health outcomes (29%), care process (26%) and administrative and financial aspects (16%). CONCLUSION This literature review highlights the recent interest in the trajectory concept. The approach is also gradually being used to monitor trajectories of care for chronic diseases such as diabetes, organ failure or coronary artery and MI trajectory of care, to improve care and reduce costs. Patient trajectory is undoubtedly an essential approach to be further explored in order to improve healthcare monitoring.
Collapse
Affiliation(s)
- Jessica Pinaire
- Biostatistics, Epidemiology and Public Health Department, Nîmes University Hospital, Place R Debré, 30 029 Nîmes, France
- UPRES EA 2415, Clinical Research University Institute, 641 av du Doyen Gaston Giraud, 34 093 Montpellier, France
- LIRMM, UMR 5506, Montpellier University, 860 rue de Saint Priest – Bât 5, 34 095 Montpellier Cedex 5, France
| | - Jérôme Azé
- LIRMM, UMR 5506, Montpellier University, 860 rue de Saint Priest – Bât 5, 34 095 Montpellier Cedex 5, France
| | - Sandra Bringay
- LIRMM, UMR 5506, Montpellier University, 860 rue de Saint Priest – Bât 5, 34 095 Montpellier Cedex 5, France
- AMIS, Paul Valéry University, Montpellier, France
| | - Paul Landais
- Biostatistics, Epidemiology and Public Health Department, Nîmes University Hospital, Place R Debré, 30 029 Nîmes, France
- UPRES EA 2415, Clinical Research University Institute, 641 av du Doyen Gaston Giraud, 34 093 Montpellier, France
| |
Collapse
|
9
|
Madronio CM, Armstrong BK, Watts CG, Goumas C, Morton RL, Curtin A, Menzies SW, Mann GJ, Thompson JF, Cust AE. Doctors' recognition and management of melanoma patients' risk: An Australian population-based study. Cancer Epidemiol 2016; 45:32-39. [PMID: 27689254 DOI: 10.1016/j.canep.2016.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 09/12/2016] [Accepted: 09/17/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Guidelines recommend that health professionals identify and manage individuals at high risk of developing melanoma, but there is limited population-based evidence demonstrating real-world practices. OBJECTIVE A population-based, observational study was conducted in the state of New South Wales, Australia to determine doctors' knowledge of melanoma patients' risk and to identify factors associated with better identification and clinical management. METHODS Data were analysed for 1889 patients with invasive, localised melanoma in the Melanoma Patterns of Care study. This study collected data on all melanoma diagnoses notified to the state's cancer registry during a 12-month period from 2006 to 2007, as well as questionnaire data from the doctors involved in their care. RESULTS Three-quarters (74%) of patients had doctors who were aware of their risk factor status with respect to personal and family history of melanoma and the presence of many moles. Doctors working in general practice, skin cancer clinics and dermatology settings had better knowledge of patients' risk factors than plastic surgeons. Doctors were 15% more likely to know the family history of younger melanoma patients (<40years) than of those ≥80 years (95% confidence interval 4-26%). Early detection-related follow-up advice was more likely to be given to younger patients, by doctors aware of their patients' risk status, by doctors practising in plastic surgery, dermatology and skin cancer clinic settings, and by female doctors. CONCLUSION Both patient-related and doctor-related factors were associated with doctors' recognition and management of melanoma patients' risk and could be the focus of strategies for improving care.
Collapse
Affiliation(s)
- C M Madronio
- Cancer Epidemiology and Prevention Research, Sydney School of Public Health, The University of Sydney, Australia.
| | - B K Armstrong
- Cancer Epidemiology and Prevention Research, Sydney School of Public Health, The University of Sydney, Australia
| | - C G Watts
- Cancer Epidemiology and Prevention Research, Sydney School of Public Health, The University of Sydney, Australia
| | - C Goumas
- Melanoma Institute Australia, The University of Sydney, North Sydney, Australia
| | - R L Morton
- NHMRC Clinical Trials Centre, The University of Sydney, Australia
| | - A Curtin
- School of Public Health, Rural Health Northern Rivers, Lismore, Australia
| | - S W Menzies
- Discipline of Dermatology, Sydney Medical School, The University of Sydney, Australia; The Sydney Melanoma Diagnostic Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - G J Mann
- Melanoma Institute Australia, The University of Sydney, North Sydney, Australia; Centre for Cancer Research, Westmead Institute for Medical Research, The University of Sydney, Australia
| | - J F Thompson
- Melanoma Institute Australia, The University of Sydney, North Sydney, Australia; Central Clinical School, The University of Sydney, Australia
| | - A E Cust
- Cancer Epidemiology and Prevention Research, Sydney School of Public Health, The University of Sydney, Australia; Melanoma Institute Australia, The University of Sydney, North Sydney, Australia
| |
Collapse
|
10
|
Evaluation of a skin self examination attitude scale using an item response theory model approach. Health Qual Life Outcomes 2014; 12:189. [PMID: 25539671 PMCID: PMC4305258 DOI: 10.1186/s12955-014-0189-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 12/10/2014] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The Skin Self-Examination Attitude Scale (SSEAS) is a brief measure that allows for the assessment of attitudes in relation to skin self-examination. This study evaluated the psychometric properties of the SSEAS using Item Response Theory (IRT) methods in a large sample of men ≥ 50 years in Queensland, Australia. METHODS A sample of 831 men (420 intervention and 411 control) completed a telephone assessment at the 13-month follow-up of a randomized-controlled trial of a video-based intervention to improve skin self-examination (SSE) behaviour. Descriptive statistics (mean, standard deviation, item-total correlations, and Cronbach's alpha) were compiled and difficulty parameters were computed with Winsteps using the polytomous Rasch Rating Scale Model (RRSM). An item person (Wright) map of the SSEAS was examined for content coverage and item targeting. RESULTS The SSEAS have good psychometric properties including good internal consistency (Cronbach's alpha = 0.80), fit with the model and no evidence for differential item functioning (DIF) due to experimental trial grouping was detected. CONCLUSIONS The present study confirms the SSEA scale as a brief, useful and reliable tool for assessing attitudes towards skin self-examination in a population of men 50 years or older in Queensland, Australia. The 8-item scale shows unidimensionality, allowing levels of SSE attitude, and the item difficulties, to be ranked on a single continuous scale. In terms of clinical practice, it is very important to assess skin cancer self-examination attitude to identify people who may need a more extensive intervention to allow early detection of skin cancer.
Collapse
|
11
|
Health-care delay in malignant melanoma: various pathways to diagnosis and treatment. Dermatol Res Pract 2014; 2014:294287. [PMID: 24516469 PMCID: PMC3913342 DOI: 10.1155/2014/294287] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 10/13/2013] [Accepted: 10/14/2013] [Indexed: 11/28/2022] Open
Abstract
We aimed to describe and compare patients diagnosed with malignant melanoma (MM), depending on their initial contact with care and with regard to age, sex, and MM type and thickness, and to explore pathways and time intervals (lead times) between clinics from the initial contact to diagnosis and treatment. The sample from northern Sweden was identified via the Swedish melanoma register. Data regarding pathways in health care were retrieved from patient records. In our unselected population of 71 people diagnosed with skin melanoma of SSM and NM types, 75% of patients were primarily treated by primary health-care centres (PHCs). The time interval (delay) from primary excision until registration of the histopathological assessment in the medical records was significantly longer in PHCs than in hospital-based and dermatological clinics (Derm). Thicker tumors were more common in the PHC group. Older patients waited longer times for wide excision. Most MM are excised rapidly at PHCs, but some patients may not be diagnosed and treated in time. Delay of registration of results from histopathological assessments within PHCs seems to be an important issue for future improvement. Exploring shortcomings in MM patients' clinical pathways is important to improve the quality of care and patient safety.
Collapse
|
12
|
|
13
|
Grange F, Barbe C, Mas L, Granel‐Brocard F, Lipsker D, Aubin F, Velten M, Dalac S, Truchetet F, Michel C, Mitschler A, Arnoult G, Buemi A, Dalle S, Reuter G, Bernard P, Woronoff A, Arnold F. The role of general practitioners in diagnosis of cutaneous melanoma: a population‐based study in France. Br J Dermatol 2012; 167:1351-9. [DOI: 10.1111/j.1365-2133.2012.11178.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- F. Grange
- Service de Dermatologie, Hôpital Robert Debré, Université de Reims‐Champagne‐Ardenne, avenue du général Koenig, 51092 Reims Cedex, France
| | - C. Barbe
- Unité d’Aide Méthodologique, Hôpital Maison Blanche, Reims, France
| | - L. Mas
- Service de Dermatologie, Hôpital Robert Debré, Université de Reims‐Champagne‐Ardenne, avenue du général Koenig, 51092 Reims Cedex, France
| | - F. Granel‐Brocard
- Service de Dermatologie, Hôpital Brabois, Vandoeuvre les Nancy, France
| | - D. Lipsker
- Clinique Dermatologique, Hôpital Civil, Strasbourg, France
| | - F. Aubin
- Service de Dermatologie, Hôpital Saint Jacques, Besançon, France
| | - M. Velten
- Registre des Cancers du Bas‐Rhin and Réseau Français des Registres de Cancers FRANCIM, Strasbourg, France
| | - S. Dalac
- Service de Dermatologie, Hôpital du Bocage, Dijon, France
| | - F. Truchetet
- Service de Dermatologie, Hôpital Beauregard, Thionville, France
| | - C. Michel
- Service de Dermatologie, Hôpital du Moenschberg, Mulhouse, France
| | - A. Mitschler
- Service de Dermatologie, Hôpital Louis Pasteur, Colmar, France
| | - G. Arnoult
- Centre de Recherche et d’Investigation Clinique, Hôpital Maison Blanche, Reims, France
| | - A. Buemi
- Registre des Cancers du Haut‐Rhin and Réseau Français des Registres de Cancers FRANCIM, Mulhouse, France
| | - S. Dalle
- Service de Dermatologie, Hôpital de l’Hôtel‐Dieu, Lyon, France
| | - G. Reuter
- Cabinet de Dermatologie, Strasbourg, France
| | - P. Bernard
- Service de Dermatologie, Hôpital Robert Debré, Université de Reims‐Champagne‐Ardenne, avenue du général Koenig, 51092 Reims Cedex, France
| | - A.S. Woronoff
- CHU de Besançon and Réseau Français des Registres de Cancers FRANCIM; Registre des Tumeurs du Doubs, Besançon, France
| | - F. Arnold
- Association Départementale des Professions de Santé pour le Dépistage des Cancers, Reims, France
| |
Collapse
|
14
|
Choosing to biopsy or refer suspicious melanocytic lesions in general practice. BMC FAMILY PRACTICE 2012; 13:78. [PMID: 22873705 PMCID: PMC3526551 DOI: 10.1186/1471-2296-13-78] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 07/24/2012] [Indexed: 11/21/2022]
Abstract
Background General practitioners (GPs) are involved in the management of most melanocytic skin lesions in Australia. A high quality biopsy technique is a crucial first step in management, as it is recognized that poor techniques can mislead, delay, or miss a diagnosis of melanoma. There has been little published on the biopsy decisions and techniques of GPs. This study aims to describe the current management choices made by GPs for suspicious melanocytic skin lesions and to compare their choices with the best practice guidelines. Methods An anonymous survey of GPs presented with three clinical scenarios with increasing complexity of melanoma in which a referral or biopsy decision was specified. Results 391 mailed surveys with a 76.3% response rate. Mean biopsy experience was 4.14 biopsies per GP per month. The rates of choosing to refer among the three scenarios were 31%, 52% and 81% respectively, with referral to surgery being the most common choice (81%). Most biopsy techniques (55%) were chosen according to best practice guidelines, although non-guideline biopsy techniques chosen included shave (n = 10), punch biopsy (n = 57), wide excisions (n = 65), and flaps (n = 10). The few GPs (n = 5) who identified themselves as skin specialist GPs were no more likely to adhere to guidelines than their colleagues. Conclusion A majority of referrals and biopsies were chosen by GPs according to best practice guidelines, but concern remains for the high proportion of GPs making non-guideline based choices. How GPs choose to biopsy or refer needs further training, audit, and research if Australia is to improve the outcome of melanoma management in general practice.
Collapse
|
15
|
Lipworth AD, Park JM, Trefrey BL, Rubin KM, Geller AC, Sober AJ, Tsao H. Urgent access to a specialty care melanoma clinic is associated with a higher rate of melanoma detection. J Am Acad Dermatol 2011; 64:1060-7. [PMID: 21453985 DOI: 10.1016/j.jaad.2010.08.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2010] [Revised: 08/12/2010] [Accepted: 08/20/2010] [Indexed: 11/24/2022]
Abstract
BACKGROUND As melanoma rates increase, and the supply of dermatologists remains suboptimal to meet demand for services, detection of early melanoma has become an increasingly difficult challenge. Some authors advocate for shifting dermatologic resources from routine appointments to urgent visits for those with lesions concerning for melanoma. OBJECTIVE We sought to investigate the potential of an urgent access track (UAT) embedded within a pigmented lesion clinic to improve early melanoma detection. METHODS We conducted a retrospective review of patient records from a tertiary care hospital's pigmented lesion clinic and the associated UAT. Results of procedures for all 4495 patient visits to the routine track and all 316 visits to the UAT during the 21-month study period were included, as were detailed chart reviews of all UAT patient visits. RESULTS UAT visits were more than 4 times as likely (4.1% vs 1.0%) to yield a diagnosis of melanoma as routine track visits (odds ratio 4.24; 95% confidence interval 2.28-7.88; P < .0001), and almost 25 times as likely (2.2% vs 0.1%) to yield a diagnosis of metastatic melanoma (odds ratio 25.4; 95% confidence interval 7.4-87.4; P < .0001). LIMITATIONS This was a preliminary analysis with only limited data extracted from the routine track pigmented lesion clinic patient visits. CONCLUSION This initial analysis of UAT strategy suggests that UATs have potential to detect patients with earlier melanomas; further research is needed to specifically delineate how resources should be best allocated between routine surveillance and urgent care to maximize melanoma early detection and survival.
Collapse
Affiliation(s)
- Adam D Lipworth
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
| | | | | | | | | | | | | |
Collapse
|